By: Abbass El-Outa, BDS, DES Clinical Management 
Contact the autor: @abbasstbh 
 
Traditionally, dental fear and the associated psychological difficulties have long been a problem in adults as well as children. As a result, highly anxious patients may procrastinate in their care, cancel appointments, have problems in tolerating procedures while in the dental chair and even shun dental care at all. For that, dental fear is reported as being the greatest difficulty faced by dentists in terms of managing their patients. 
 
In children, researchers suggest that around eight per cent need special care due to the fear of treatment. It is suggested that dental anxiety effects in those patients persist in adulthood and may lead to oral health deterioration as a result of their avoidance of care. 
Dental management of the anxious paediatric patient may include many modalities starting with behavioural management to pharmacologic and conscious sedation in highly uncooperative children. Such interventions are reserved for the minority of anxious and fearful children with whom the behavioural and psychological attempts fail. The need for psychological interventions in dentistry is supported by guidelines. Recently, parental role became an important element in the psychological management of children present for dental care. 
 
1. Factors influencing anxiety in children 
Although dental anxiety is common, not all children exhibit it. It is a widely-accepted assumption that a negative dental experience leads to dental anxiety. However, anxiety may be present in patients without prior visits to the dentist; furthermore, those with previous unpleasant experiences in the dental surgery may become compliant and happy. Therefore, dental anxiety aetiologies are not clear-cut. 
 
Factors associated with dental anxiety include: 
Parental attitude toward dental treatment. 
Past medical and dental experiences of the child. 
Siblings’ and friends’ dental experiences and opinions. 
Home preparation of the child preceding dental visit. 
Own perception of the child that something is wrong with his or her teeth. 
 
1.1. Parental attitude 
Maternal anxiety influence has long been recognised (for over 100 years), and the relation between child behaviour and maternal anxiety is well-documented. This effect is greatest in very young children (under four years of age). In other words, parents anxious of dental treatment tend to have children who are anxious as well. 
 
1.2. Medical and dental experience 
Many of the uncooperative or anxious children in dental settings turn out to have previous negative and traumatic experiences in the past. Nevertheless, not all of those with a painful past dental treatment become anxious. The key determinant variable in the anxiety development is the dentist, as studies show; a caring and friendly dentist with an empathic approach may overcome pain effects on the long run. 
 
Unpleasant past medical experiences as well may affect a child's ability to accept dentistry. Children with positive medical experiences may be less worried in the dental settings. Therefore, pain experienced during medical appointments may influence child’s behaviour in the dental office. 
 
1.3. Vicarious learning: the influence of dental experiences of others 
Many adults as well as children, despite not having had injections in the dental surgery before, expect such experience to hurt. Particularly, children may be strongly influenced by what their friends say or what they hear in their environment. Therefore, just as parents’ anxiety affects their children by what is known psychologically as modelling, friends and siblings’ opinions may deeply affect children’s perception of dental care in the dental office as well. I recall one young patient I had a couple of years ago who required extensive behavioural approach prior to extracting a non-restorable primary tooth after his friends told him the story of someone who lost the ability to talk after extracting a tooth for the rest of his life. 
 
2. Importance of the first visit 
The importance of the first visit cannot be emphasized enough. Usually, it is recommended that by the age of 1, or even as soon as the first tooth has erupted, regular visits to the dentist should start. This first visit and the subsequent regular ones serve to establish a friendly image of the dentist, given that these visits are often procedure-free. In addition to being an opportunity for screening and dental check-up (even if the child only has one tooth inside his mouth), such visits play an important role for the child to establish a friendly view of the dental setting and the dentist. 
 
3. Parents inside dental surgery: to remain to not to remain? 
The issue of whether a parent should be present or not during child dental treatment has long been a debate. Many dentists tend to have firm views on this matter. Nevertheless, the majority of parents prefers to be present in the surgery during treatment. Primarily, dentists who prefer that parents not be present beside their child during treatment are concerned that parents may show anxiety themselves or disrupt treatment with inappropriate communication. 
 
Literature suggests that children’s behaviour is unaffected whether a parent is present or not in the dental surgery, with the exception of very young children (under the age of 4 years) due to “separation anxiety”. In such patients (under 4 years old) treatment often necessitates the presence of their parents, and their physical involvement sometimes. In these cases, parents should follow dentists’ guidance to have the desired conditions for the child’s management and treatment. 
 
4. Parental tips for best psychological preparation of your child 
Be informed of detailed treatment plan of your child and ask whatever questions you have; however, limit discussion and questioning with the dentist in front of the child. 
Strictly avoid using dental treatment as a threatening tool: “I’ll tell the dentist to pull your tooth or you give you an injection if you do not comply.” 
Use the same non-threatening vocab as the dental team (“tickle” as a substitute for “hurt”, “put the tooth to sleep” for “anaesthetise the tooth”, “pudding” for “alginate”, “water gun” for “water syringe”, “tooth paint” for “sealant” …) 
Encourage the child to improve her/his readiness by “playing dentist” on a doll or with the parent. 
Hide own dental anxiety in front of the child, or, if not possible, have the child accompanied by an adult who is not anxious. 
Avoid using unhelpful reassurance and giving false hope that will, on the contrary, raise child’s anxiety, such as: “The dentist won’t hurt you,” or “There is no need to worry.” Besides, expressions such as, “Everything will be fine,” and “You won’t feel a thing,” often lead to child’s disappointment and loss of trust in both the parent the dentist as such expressions are often not precise. 
Do not insist that the dentist starts with a relatively major dental procedure in the child’s first couple of visits to the dental office. Let the child have the most pleasant first experience with minimal intervention. 
Follow the dentist’s advice on home preparation of the child and your attitude in the office and cooperate with her/him as much as possible for the best management. 
Eventually, it is very normal for a child present to a strange environment to cry and refuse being inspected by a stranger. Consequently, choose a dentist you trust and who is competent in paediatric dentistry, cooperate with her/him, and be a positive model for your child in order for him to have the most pleasant dental experience that would, hopefully, last a lifetime. 
 
Useful oral health resources for parents 
About the Author 
 
Lebanese dental surgeon practicing in Beirut, Lebanon.  
Private practice comprises general dental care including paediatric dentistry, specialized public programmes and community dentistry, aesthetic dentistry and others. 
Currently, pursuing post-graduate studies at the Lebanese University School of Dental Medicine. 
Published and ongoing research projects. 
E-mail address: abbass@abbass.org 
Twitter: @abbasstbh 
References 
Ayer, William A. Psychology and Dentistry - Mental Health Aspects of Patient Care. 1st ed. New York: Haworth Press, 2005. 
Buchanan H, Hainsworth J. Clinical Psychology in Dentistry: A Guide to Commissioners of Clinical Psychology Services - Issue 11 of Briefing paper. Leister: British Psychological Society; 2009. 
Enneking D, Milgrom P, Weinstein P, Getz T. Treatment outcomes for specific subtypes of dental fear: preliminary clinical findings. Special Care in Dentistry. 1992;12(5):214-8. 
Greenbaum PE, Melamed BG. Pretreatment modeling. A technique for reducing children's fear in the dental operatory. Dental Clinics of North America. 1988;32(4):693-704. 
Hosey, Marie Thérèse, Barbara L Chadwick, and Nairn H. F Wilson. Child Taming: how to manage children in dental practice. 1st ed. London: Quintessence, 2003. 
McDonald, Ralph E, David R Avery, and Jeffrey A Dean. Mcdonald And Avery's Dentistry For The Child And Adolescent. 9th ed. Maryland Heights, Mo.: Mosby/Elsevier, 2010. 
Weiner, Arthur A. The Fearful Dental Patient. 1st ed. Ames, Iowa: Wiley-Blackwell, 2011. 
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