MANAGEMENT OF DENTAL ANXIETY IN PEDIATRIC PATIENTS

Dental fear/anxiety (F/A) in children can often lead to uncooperative behaviors that pose challenges for dentists in the clinical setting.  Studies have found that girls generally exhibit more dental anxiety than boys. Other proposed etiologic factors include socioeconomic status, culture, parental anxiety, negative experiences from dental treatments, and temperament of the child. Clearly, dental F/A is a multidimensional construct influenced by biology and the environment.

Behavior management is fundamental in dealing with children’s F/A in the clinical setting. Nearly one in four children seen by pediatric dentists present with management difficulties.

There are currently 14 Behaviour management therapy described by American Academy of Pediatric Dentistry (AAPD).

These include:

Basic behavior guidance techniques, such as positive pre-visit imagery, direct observation, tell-show-do (TSD), ask-tell-ask, voice control (VC), nonverbal communication (NC), positive reinforcement and descriptive praise (PR), distraction (Dis), memory restructuring, parental presence/absence (PP/A), and nitrous oxide/oxygen inhalation (NO); and advanced behavior guidance techniques, such as protective stabilization (PS), sedation (Sed), and general anesthesia (GA).

For children who are unruly and defiant, dentists resort to more invasive techniques, such as hand-over mouth (HOM), VC, and active and passive stabilization, to obtain the attention of the child and gain cooperation for treatment.7 When non-pharmacological techniques are ineffective or not accepted by parents, pharmacologic BMTs may be considered.

Positive pre visit imagery:-  The functional inquiry-  a functional inquiry, from a behavioral viewpoint, also should be conducted. During the inquiry, there are two primary goals: (1) to learn about patient and parental concerns and (2) to gather information enabling a reliable estimate of the cooperative ability of the child. Functional inquiries are conducted in two ways: (1) by a paper and pencil questionnaire completed by the parent and (2) by direct interview of child and parent.

Pre-appointment behavior modification:- It can be performed with live patient models such as siblings, other children, or parents. To see the experience of small patient many pedodontist allow parents into their working place. Because the observing child likely will be initiated into dental care with a dental examination, a parent's recall visit offers an excellent modeling opportunity. After seeing their parents in the chamber the patient become cooperative and sits in the dental chair on his/her own. These previews should be selected carefully.

Tell show do (TSD):  For pediatric dentists, euphemisms or word substitutes are like a second language. Examples of word substitutes that can be used to explain procedures to children are rubber dam as rubber raincoat

Sealant as tooth paint

Air syringe as wind gun

Water syringe as water gun

Suction as vacuum cleaner

Voice control: Sudden and firm commands are used to get the child's attention or to stop the child from whatever is being done. Another form of voice control is a slow and deliberate cadence that can function like music set to a mood. In both cases, what is heard is more important because the dentist is attempting to influence behavior directly, not through understanding.

Non verbal communication: nonverbal messages also can be sent to patients or received from them. Body contact can be another form of nonverbal communication. The dentist's simple act of placing a hand on a child's shoulder while sitting on a chairside stool conveys a feeling of warmth and friendship. Greenbaum and colleagues found that this type of physical contact helped children to relax, especially those 7 to 10 years of age.

Positive reinforcement:- Giving gifts to children has become a fact of commercial life in North America. There is general agreement on the merit of this practice in the dental office; gift can be given as prize after the patient allows a successful treatment. The gifts can be of dental use like a toothbrush kit. In these gifts are add-on to the dental health.  

HOME (Hand over mouth exercise):- The technique fits the rules of learning theory: maladaptive acts (screaming, kicking) are linked to restraint (hand over mouth), and cooperative behavior is related to removal of the restriction and praising can be used as positive reinforcement. It is important to stress that aversive conditioning is not used routinely but as a method of last resort, usually with children 3 to 6 years of age who have appropriate communicative abilities

To add, Cultural factors affecting behavioral guidance require the upmost attention in today’s increasingly diversified world. All practitioners encounter patients of a different culture daily and, in certain instances, may experience difficulty or barriers in communicating treatment objectives and expectations.