The effect of psychological management on dental anxiety in children

The effect of psychological management on dental anxiety

in children

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MO Folayan* / D. Ufomata** / CA Adekoya-Sofowora*** / OD Otuyemi**** / E. Idehen*****

The aim of this study was to determine the effect of using of psychological management techniques on
the level of anxiety in Nigerian children during dental management. The Short Form of the Dental
Anxiety Survey Schedule was administered to 81 children who were attending a suburban dental clinic
for the first time. This schedule was re-administered again two weeks later when they came for a follow
up visit. The age of the patients was recorded. The types as well as number of psychological techniques
employed during treatment were also noted. The overall mean dental anxiety level of the children
decrease from an average of 15.23±5.03 before treatment to 13.40+4.13 after treatment (p < 0.001).
However, the mean dental anxiety score in children in whom no psychological technique was
employed during treatment increased after treatment. On the other hand, there was also a statistically
significant decrease in the mean dental anxiety level of children treated using either a single psycho-
logical technique or combined psychological techniques after treatment. Better results were obtained
when combined psychological techniques where used than when only a single technique was used. It
was concluded that psychological techniques used in the management of dental anxiety in children are
highly effective in decreasing dental anxiety levels. Better results are obtained when a number of
techniques are combined effectively.
J Clin Pediatric Dent 27(4): 365-370, 2003

INTRODUCTION would facilitate the ability of the child to ultimately

D
ental anxiety is a worldwide problem and a accept care, protect the self esteem of the child and to
barrier to oral health care services. This foster a positive attitude towards oral care for the child.
necessitates the need to manage dental anxiety Moreover, it enhances the work quality and efficiency
in children because of the vicious cycle that may arise of the dental personnel.2
from unmanaged cases. One of this is the deteriorating There are various techniques used in the manage-
dental health that arises as a complication of the ment of anxiety of the patient. A number are directed
anxiety. This exposes them to invasive dental at preventing the development of dental anxiety, while
procedures, which may be unpleasant and further others are used in its treatment. Prevention of dental
reinforce fears for dental procedures.1 Also, the anxiety anxiety development in children often entails the effec-
may persist into adulthood and some of these children tive use of psychological management techniques,
could grow up to become parents with dental anxiety, which is aimed at enhancing trust, the lack of which can
which they pass on to their children. exacerbate anxiety. It also helps to enhance the feeling
Methods of managing dental behavior of children of control and the development of coping skills in
are aimed at avoiding unpleasant and unproductive patients.3 This starts from the very first contact the
confrontations and to create an environment that patient makes with the dental environment,4,5 which
should be such that encourages the patient to be
relaxed and promote easy interaction between the
child and the dental team.
* Dr. M.O. Folayan, Department of Preventive Dentistry, Other psychological management techniques aimed
Obafemi Awolowo University, Ile-Ife, Nigeria. at getting the child to relax include the use of audio-
** Professor D. Ufomata visual products. This exposes the child to tape-slide
*** Dr. C.A. Adekoya-Sofowora scenes before the first dental examination with the
**** Professor O.D. Otuyemi
***** Dr. E. Idehen
product giving an explanation about a first dental visit
so that the child may not view the appointment, dentist
Send all correspondence to Dr. M.O. Folayan, Department of and dental staff as a serious threat.4,6
Preventive Dentistry, Obafemi Awolowo University, Ile-Ife, Nigeria.
During treatment, other forms of psychological
E-mail: [email protected] management techniques are used to prevent the

The Journal of Clinical Pediatric Dentistry Volume 27, Number 4/2003 365
The effect of psychological management on dental anxiety in children

development of anxiety. This includes the use of one of A variation to the above is the desensitization
the old techniques, which is still much talked about technique. This technique is effective for children, who
today and encouraged. This is the “Tell-Show-Do” tech- have developed dental anxiety. It entails gradual
nique developed by Addelston in 1959.7 It entails giving exposure of the child to dental treatments for short periods
the child a very careful explanation of a procedure and of time starting from the non-invasive procedures such
equipment before the procedure is done and the equip- as simple polishing. The dentist only moves up to the
ment used. next grade of treatment when the child has become

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The need to demonstrate the use of an instrument comfortable with a level of treatment. This way, the child
before the actual procedure so that the child may is gradually helped to confront whatever is the source of
understand what is been said. For example, running a dental anxiety and thereby, overcome it. It is a time
prophy cap on operator’s thumb nail would be a ‘do’ consuming technique, but very rewarding as the child
type of activity.6 Hoist and Ek9 study reported that the eventually becomes comfortable with dental procedures.7
use of this method throughout dental treatment for Psychological management of dental anxiety is
children in general dentistry resulted in an increase in encouraged in all normal children with cooperative
positive acceptance of all treatment steps encountered ability. For resource-poor African countries, where capital
and the time spent per child diminished compared with intensive projects such as the purchase of relative
the period before the approach was introduced.10 analgesia machines or trained personnel experienced in
There is the modeling technique of behavior modifi- the safe use of pharmacological agents for management
cation. Here, the child-patient learns about dental of dental anxiety are scarce, the need to be conversant
experience by viewing other children receiving dental in the use of psychological techniques in managing the
treatment. It involves either live or filmed models and dentally anxious child becomes imperative.
has been used in several investigations and reported to This paper aimed at evaluating the effect of
be effective in preventing anxiety development.10-15 employed psychological management strategies on
Distraction is also a psychological strategy in helping dental anxiety in children, who are attending a subur-
people cope with brief stressors. This skill is almost un- ban African dental hospital and thus make appropriate
teachable. It entails skillful communication with the recommendation of its use in African children.
dentist talking in a stream fashion with the aim of
diverting the attention of the patient from noxious MATERIALS AND METHODS
stimuli and to manipulate the perceptions and expecta- The study was conducted at the Paediatric Dental Unit
tions of the child. It is very useful in children with a of the Dental Hospital in the Obafemi Awolowo
short attention span.2 This points to the need for the University Teaching Hospital Complex (OAUTHC)
dentist to develop good communication skills.19 lle-lfe, Nigeria. The unit provides tertiary dental health
Physical contact in the form of patting and stroking, services in South Western Nigeria, for an estimated
also tended to be effective in reducing anxiety that may population of over 9.2 million people of which 40-45%
accompany dental care.3,20 However, a touch given with- are children.25
out accompanying verbal statements can be perceived All consecutive new patients between the ages of
as threatening or unfriendly21 especially amongst eight and thirteen years and who were attending a
children from low income families.22 This may be dental clinic for the first time over an eleven month
because these low income children live lives that may period were considered eligible for inclusion in the
be more frequently characterized by instability and study population. Those with past medical history of
insecurity. They may be sensitized to strangers, who major mental disorder or present physical disorder
may be less benign than those encountered by high were excluded from the study. Ethical clearance was
income children.22 received from the institution for the study to be
There is also a place for letting the child hold toys, conducted. Also, verbal consent was received from the
mirror, etc. during treatment, permitting the child to parents of the children, who participated in the study
raise a hand, press a buzzer and so forth to stop treat- after the purpose of the study was explained to them.
ment. Allowing parents stay with the child in the A Short Form of the Dental Subscale of the Child
operatory especially when they help to get the patient Fear Survey schedule (DFSS-SF) described by Carson
to be relaxed in the new environment as part of this and Freeman26 was administered to the children. This
technique.23 A technique found to be effective in scale was completed, while the children were in the
preventing dental anxiety developing in a child, who waiting hall on the first day of attendance and before
has a potential to do so is the use of positive any form of dental procedure was performed. The
reinforcement. Here, the child is praised and given psychometric scale requires the children to rate dental
gifts when he shows acts of cooperation. The child is anxiety on a 5 point scale from 1, corresponding to “no
further encouraged to continue to cooperate by fear,” to 5, corresponding to “very frightened,” in
coaxing, petting and use of persuasion when the child relation to eight dental treatment situations. The
shows signs of poor cooperation.19,24 questions included range from “meeting the dentist” to

366 The Journal of Clinical Pediatric Dentistry Volume 27, Number 4/2003
 The effect of psychological management on dental anxiety in children

“having teeth extracted”. This questionnaire assesses Table I. Number of times the technique was used during patient
management
the level of anxiety before treatment.
All patients were thereafter, managed by dentists. Tell-Show- Positive Physical Distraction Permit The Spend Restraint
During treatment, the number and types of psychologi- Do Reinforcement Contact
And Coaxing
Child To Time With
Raise The Child
cal management strategy employed for each child was Hand To
Stop
Outside
The
recorded. Treatment Operatory

All the patients were then recalled two weeks after 67 16 3 1 6 1 2

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the initial dental management. The DFSS-SF was re- (82.72%) (19.75%) (4.94%) (1.23%) (7.14%) (1.23%) (2.47%)
administered during this second visit. The re-evaluation
was done to assess the dental anxiety level of the
patients after receiving some form of dental treatment.
The professional status of the dentist-operator was Table II. Mean of dental anxiety levels per number of techniques
used
also recorded. The use of psychological techniques per
professional status was analyzed. No technique single technique Combined techniques
The pre-treatment and post-treatment anxiety score Employed during
Treatment
Employed during
Treatment
Employed during
Treatment
of the patients were entered into a desktop computer
using Epi info version 6 software and was analyzed Pre treatment 15.4 14.96 16.54
anxiety level
using SPSS (for Windows) version 6. The data obtained
from the children on the first and second visits were Post treatment 16.5 12.85 13.92
compared using t-test. Also compared where the dental anxiety level
anxiety level changes when no psychological tech- Number of 10 47 24
niques was employed, when only one technique was Patients
employed and when more than one technique was
employed. A statistical significance was regarded to
exist where the p-value was less than 0.05.
Table III. Analysis technique used
RESULTS
No % Single % Combine %
Eighty-one children were recruited for the study during technique technique technique
the period of data collection. Their mean age was 10.98
No. Children 10 100 47 100 24 100
years (SD=1.73).
The mean value of the anxiety level of the children No. Children
before treatment was 15.225±5.029. With increased
Dental Anxiety
The various types of psychological techniques used score 6 60.0 12 25.5 2 8.3
during treatment were the “Tell-Show-Do” in 67
(82.72%) child patient and positive reinforcement and No Children
With decreased
coaxing in 16 (19.75%) child patients. Also distraction Dental anxiety
was used in 0.1(1.23%) patient, physical contact in 3 Score 3 30.0 28 59.6 18 75.0
(4 children, permitting the child to raise hand to stop
No. Children
treatment in 6 (7.41%) children and spending time with With no
the child outside the operatory before the commence- Change in
ment of treatment in 1 (1.23%) child. Restraint was Dental anxiety 1 10.0 7 14.9 4 16.7
used in 2 (2.47%) children. (see Table I).
In ten (12.3%) children, no form of psychological
technique was employed during treatment, while in
47(58.1%), a single psychological technique was used. be highly significant (p <0.001) meaning that the
In 24 (29.6%) children, two or more techniques were anxiety of the child-subject decreased significantly
used in combination simultaneously (see Table II). between the pre-treatment and the post treatment.
The most common technique used when only a single Also, analysis of the mean dental anxiety score of
psychological technique was employed during the dental the children (see Table II) showed that there was an
treatment of the child was the “Tell-Show-Do” tech- increase in the mean anxiety score increased in children
nique. This was employed in 44 (93.6%) of the 47 in which no technique was employed during treatment
children. Positive reinforcement and coaxing was though this was not found statistically significant
employed in 2 (4.3%) of the children, while the child was (p = 0.22). However, there was a statistically significant
permitted to raise hand to stop treatment in 1 (2.1%) child. decrease in the mean anxiety level of children treated
The mean anxiety score of the children after treat- using a single psychological technique (p = 0.00001)
ment was found to decrease from an average of and in those managed using combined psychological
15.23±5.03 to 13.40±4.13. This difference was found to technique (p = 0.0002).

The Journal of Clinical Pediatric Dentistry Volume 27, Number 4/2003 367
The effect of psychological management on dental anxiety in children

Although the mean dental score of the children The use of sedation is thus, only advised when behav-
managed without any form of psychological technique ioral management strategies have failed.
increased, that of 3 of the 10 children actually All the children in this study were treated successfully
decreased, while that of 1 did not change. Likewise, 12 through the use of various forms of psychological tech-
of the 47 children managed using a single psychological niques. This is because these children were able to
technique increased, while that of 7 did not change. comprehend, accept and comply with instructions and
Also, 2 children managed using combined technique could respond on their own to actions, both expressed and

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increased, while that of 4 children did not change unexpressed, of the dentist. Although these psychological
(Table III). A look at the table also shows that more techniques entail spending more time in the operatory
children had the anxiety level decreased with the use of before and during treatment, the result is rewarding to
combined psychological techniques than otherwise and both the dentist and the child not only immediately, but
vice versa. also on the long term. This is because treatment can be
Further analysis showed that there was no statisti- done out with minimal disturbance to the dentist and the
cally significant difference between the mean of the child becomes more relaxed. Also, in the long run, you
pre-treatment dental anxiety score in children would have made a dental operatory friendly child, who
managed with no psychological techniques and those can willingly come into the clinic at all times with minimal
managed with either a single (p = 0.59) or combined anxiety.This is corroborated by Thom et al.28 study wherein
(p = 0.18) techniques. However, there was a statistically 70% of all the patients managed using psychological tech-
significant difference in the pre-treatment mean dental niques continued dental treatment for a long while
anxiety score of children managed with a single compared to 20% managed using pharmacological agents.
psychological technique and those with combined tech- The effectiveness of using psychological techniques to
niques (p = 0.0097). decrease the dental anxiety level of children was demon-
Also, there were statistically significant differences strated by the significant difference in the post-treatment
between the post treatment mean dental anxiety scores mean dental anxiety score of children in whom no
of children managed with no psychological technique and psychological technique was used when compared with
those managed with a single technique (p < 0.001) as well those in whom either a single or combined techniques are
as those managed with combined techniques (p = 0.002). used.There was a statistically significant decrease in dental
anxiety score when single or combined techniques were
DISCUSSION used when managing the child in comparison to when no
The highly statistically significant reduction of the technique was employed. The effectiveness of these tech-
anxiety level of the child post management when niques become more apparent when there was no statisti-
compared to the anxiety level before treatment shows cally significant differences established in the pre-
the high success that can be achieved through the use treatment mean dental anxiety score of the three groups.
of psychological management technique as an adjunct Also, a statistically significant difference was
to definitive therapy. established between the pre-treatment mean dental
Behavior management generally refers to the means anxiety score of children managed using a single tech-
by which, the dental health team efficiently and effec- nique and those in which combined psychological tech-
tively performs treatment for a child and at the same nique was use. Those in whom two or more techniques
time, instills positive dental behavior.27 These patients were used had a significantly higher dental anxiety score.
were exposed to non-invasive behavioral management Previous studies had reported that dentists tended to com-
strategies, thus, avoiding the possible side effects from municate more with children with high anxiety levels.17,30
pharmacological drugs, and that of analgesia and anes- Communication may entail the questioning of
thesia, while ensuring that the anxiety is adequately children for feeling and understanding, as this tends to
dealt with and possibly eliminated. Nathan2 noted in his make them more willing to trust the clinician.17 This
study that the use of pharmacological agents do not means employing more forms of psychological tech-
eliminate anxiety, but merely enhance patient accep- niques that entails communication. It is important to
tance of treatment by reducing arousal and modifying note that communication can also be used negatively as
anticipation of danger. the use of fear promoting words, coercion and coaxing
Thom et al.26 study further corroborated this by (threat of scolding), persuasion, rules and rhetorical
demonstrating that dental phobic patients treated with questions does nothing to alleviate anxiety in children.
pharmacological agents relapsed after dental treat- Rather, these signals show that the dentist is being
ment, whereas those managed by psychological tech- frustrated by the child and the child in turn, senses this.2
niques improved and continued to do so during the The effectiveness of using combined psychological
follow up management. So also did Aartman et al.29 techniques when compared with that of single
study, which demonstrated that a large proportion of technique is reflected in Table III. There were a higher
patients with high level of dental anxiety could be percentage of patients, who had dental anxiety level
treated with psychological technique alone successfully. decreased compared to when a single or no psychological

368 The Journal of Clinical Pediatric Dentistry Volume 27, Number 4/2003
 The effect of psychological management on dental anxiety in children

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370 The Journal of Clinical Pediatric Dentistry Volume 27, Number 4/2003