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Dental Anxiety Amongst Pediatric Patients’: How Can We Fix This?

Alexa Nurse

Dental Hygiene Department, South College Nashville

RDH 1430: Pain Management/ Anxiety Control and Medical Emergencies

Professor Sarah R. McKinney, BSDH

August 17, 2021

Dental Anxiety Amongst Pediatric Patients’: How Can We Fix This?

The purpose of these reviews is to better understand ways to decrease pediatric patients’

levels of anxiety in a dental setting. Dental anxiety is “characterized by a physical and/or

emotional response to a perceived threat. This threat does not always have to be physically

present, as the mere idea of an uncomfortable situation can provoke feelings of uneasiness and

apprehension” (White et al., 2017). When a patient is in a dental chair, they feel threatened. This

perceived threat can be anything from receiving injections, having to lie in the chair during a

lengthy appointment or feeling nervous about a procedure causing pain. It is important to

differentiate whether the patient is experiencing dental anxiety from a fear or phobia of the

dentist (White, et al.,2017). It is important to try and control the anxiety a child may be feeling in

the dental chair to keep the clinician and the patient safe.

Why Are Children So Afraid?

The articles reviewed provide up to date information regarding dental anxiety amongst

children when in a dental office setting. The three articles explain the significance of lowering

pediatric patients’ level of anxiety during routine or restorative procedures. Patients’ anxiety can

stem from previous experiences in the dental office. Going to the dentist has changed drastically

from what it used to be in the past. Now, you will find more up to date equipment and new

advances in the field that can make the experience of going to the dental office more enjoyable.

Most people associate the dentist with traumatic appointments they experienced in the past. Over

the years, dentists have learned how to lower the level of anxiety their patient experiences in

their office by using great bedside manner or distraction. This is just the beginning to the ever-

changing world of dentistry and the various advances the world has made to help with patients’

anxiety levels.
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Eye Movement Distraction

Tirupathi et al. (2019) explains how the use of eye movement distraction (EMD) can be

helpful in the dental office when treating pediatric patients with dental anxiety regarding local

anesthetic. EMD is based on a “theory that alternating bilateral stimulation or eye movement can

reduce the fear and anxiety” (Tirupathi et al., 2019). In this article, Tirupathi et al. (2019)

emphasized the importance of pediatric dental professionals using EMD in their practice due to

its effectiveness in reducing anxiety in children. After having 228 children in the study with

group 1 being given local anesthetic without EMD and group 2 being given local anesthetic with

EMD, the results were significant. The patients who received the injection while performing

EMD were told if they stopped, they would feel more pain. Each child receiving an injection did

so with the same provider regardless of which group they were in. The patients who participated

in the EMD while receiving local anesthetic showed lower signs of anxiety compared to the

children not doing EMD while receiving the injection. This is important for dental professionals

to know this form of distraction because this technique does not require any additional materials

and it is not technique sensitive. All in all, pediatric dentists and professionals might consider

administer this type of distraction in their practice when dealing with needle-phobic children.

Virtual Reality: Does it Work?

An article by Felemban et al. (2021) was not only about the anxiety experienced by

pediatric patients while receiving infiltration, but also about how the use of virtual reality

distraction can help calm the nerves of these nervous patients. Felemban et al. (2021) explains

how there have been many distractions that have been used over the years, but virtual reality

distraction is among the newest of techniques. It has been found that the administration of an

injection in the dental office can be the most stressful part of the visit. When a child is in the
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dental chair the use of “proper pain control and discomfort reduction during dental treatment,

especially among children, can maximize a child’s cooperation, overall satisfaction, build a good

dentist–patient relationship, and enhance patient compliance” (Felemban et al., 2021). The study

used was based on a test group and a control group of children. The test group was given local

anesthetic while watching a cartoon via virtual reality goggles and the control group was given

local anesthetic while watching cartoons on a screen. Virtual reality is a “new method in the

medical field with the aim of aiding in patient behavior management. It offers the advantage of

an immersive virtual experience blocking out external stimuli that may provoke a negative

attitude, especially in young patients” (Felemban et al., 2021). At the conclusion of the study,

patients who were younger and female had higher pain assessment scores over the other children;

this was regardless of what technique was used. The utilization of virtual reality goggles did not

have a large of an impact on the children over other screen distractions among the pediatric

patients. There needs to be more research on the effects of using virtual reality in the dental

office.

Internet-Based Cognitive Behavioral Therapy

Shahnavaz et al. (2018) focused their article on the importance of controlling dental

anxiety within pediatric patients using internet-based cognitive behavioral therapy (ICBT). ICBT

is an evidence-based method that helps treat patients with specific phobias. Shahnavaz et al.

(2018) believe that this type of therapy can help those children who feel anxiety weighing them

down when in a dental setting, such as, a patient that is needle phobic. However, access to this

type of method is difficult. The reason for this study was to “test the hypothesis that

psychologist-guided ICBT improves… children’s and adolescents’ ability to manage dental

anxiety by (1) decreasing avoidance and affecting the phobia diagnosis and (2) decreasing the
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dental fear and increasing the target groups’ self-efficacy” (Shahnavaz et al, 2018). The study

was used to test these patients at the baseline, posttreatment and then 1 year after the treatment

was given. The patients who participated in the study, were given modules of texts, animations,

videos related to dentistry and a package that included some dental instruments. The participants

of the study were given access to the treatment via an internet-based platform and received

guidance from a psychologist via the web along with treatments in a dental setting. Once the

study was completed, it was found that the patients who participated had decreased dental

anxiety and increased self-efficacy. Along with that, at their one year follow up, the participants

still displayed improvements regarding their dental anxiety. Before participating in ICBT, these

children displayed anxiety regarding intraoral injections. After ICBT, they were able to better

control their anxiety during their dental visits. The group of children who participated in this

study, showed improvement in all areas measured (Shahnavaz et al., 2018). All in all, having a

child see a licensed psychologist or psychotherapist for ICBT can be helpful when trying to

control a pediatric patient’s anxiety when in the dental chair; however, there was no control

group to measure how likely this outcome would be on other children. There need to be more

studies that can replicate this type of result before it can be integrated into dental practices. The

more dentists refer pediatric patients, the more likely there will be an increase in the accessibility

to this psychological treatment.

Conclusion

The dental professional needs to understand the importance of incorporating a form of

distraction in their practice when treating pediatric dental patients with anxiety. All three articles

mentioned the importance of utilizing a form of distraction –whether it be EMD, VR or ICBT.

They all had one thing in common: How can we prevent children from being afraid of the
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dentist? When children feel safe, they are calmer and more willing to behave for outside sources.

This is important to dental professionals because it can help prevent an already stressful situation

from becoming more traumatic for the patient. The dental professional needs not be complacent

when it comes to protecting themselves and the patient. After all, when it comes to treating

children, phobia comes with the job. It is important to do everything in your power to help this

patient in order to give treatment to keep the patient in health.

References

Felemban, O. M., Alshamrani, R. M., Aljeddawi, D. H., & Bagher, S. M. (2021). Effect of

virtual reality distraction on pain and anxiety during infiltration anesthesia in pediatric

patients: a randomized clinical trial. BMC Oral Health, 21(1), 1-10.

https://doi.org/10.1186/s12903-021-01678-x

Tirupathi, S., Krishna, N., Rajasekhar, S., & Nuvvula, S. (2019). Eye movement distraction: a

new distraction technique for management of dental anxiety during intraoral local

anesthesia administration in children. International Journal of Clinical Pediatric

Dentistry, 12(6), 507–509.

https://doi.org/10.5005/jp-journals-10005-1690

Shahnavaz, S., Hedman-Lagerlöf, E., Hasselblad, T., Reuterskiöld, L., Kaldo, V., & Dahllöf, G.

(2018). Internet-based cognitive behavioral therapy for children and adolescents with

dental anxiety: Open Trial. Journal of Medical Internet Research, 20(1), e12.

https://doi.org/10.2196/jmir.7803

White, A. M., Giblin, L., & Boyd, L. D. (2017). The prevalence of dental anxiety in dental

practice settings. Journal of Dental Hygiene: JDH, 91(1), 30-34.

https://www.proquest.com/scholarly-journals/prevalence-dental-anxiety-practice-

settings/docview/1880407764/se-2?accountid=30659