People who are highly anxious about undergoing dental treatment comprise approximately one in seven of the population and require careful and considerate management by dental practitioners. This paper presents a review of a number of non-pharmacological (behavioural and cognitive) techniques that can be used in the dental clinic or surgery in order to assist anxious individuals obtain needed dental care. Practical advice for managing anxious patients is provided and the evidence base for the various approaches is examined and summarized. The importance of firstly identifying dental fear and then understanding its aetiology, nature and associated components is stressed. Anxiety management techniques range from good communication and establishing rapport to the use of systematic desensitization and hypnosis. Some techniques require specialist training but many others could usefully be adopted for all dental patients, regardless of their known level of dental anxiety. It is concluded that successfully managing dentally fearful individuals is achievable for clinicians but requires a greater level of understanding, good communication and a phased treatment approach. There is an acceptable evidence base for several non-pharmacological anxiety management practices to help augment dental practitioners providing care to anxious or fearful children and adults.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/adj.12118

Management of fear and anxiety in the dental clinic: a review

Update on bispectral index monitoring.

Background. A new version of the Modified Child Dental Anxiety Scale (MCDAS) was formed by adding a faces rating scale to the original numeric form.

Aims.  To describe the psychometric properties of the faces version of the Modified Child Dental Anxiety Scale (MCDASf), and to provide normative data for dental anxiety for children using the MCDASf.

Design.  To determine the test–retest reliability, 287 schoolchildren aged 8–10 years completed the MCDASf on two separate occasions 17 weeks apart. To determine the criterion validity, 207 schoolchildren aged 10–12 years completed the MCDASf and the CFSS-DS at the same sitting. Construct validity was assessed using a cohort of 206 consecutive child dental patients and their parents.

Results.  The MCDASf showed good test–retest reliability (intraclass correlation coefficient = 0.80) and internal consistency (Cronbach's alpha = 0.82). The MCDASf significantly correlated with the CFSS-DS (r = 0.80, P < 0.001). Dental anxiety assessed using the MCDASf was related to the dmft (t = −2.17, P = 0.03), DMFT (t = −4.19, P < 0.001), and dental general anaesthetic experience (t = −4.46, P < 0.01). The mean MCDASf score for the normative sample (n = 475) was 19.81 (95% CI: 19.20, 20.43).

Conclusions.  The MCDASf is a reliable and valid measure of dental anxiety in children aged 8–12 years.

Reliability and validity of a faces version of the Modified Child Dental Anxiety Scale

Dental anxiety: An understudied problem in youth

Method. The aim of the study was to assess the effectiveness of i.v. midazolam in a randomized, controlled, cross-over trial. Children aged 12‐16 yr (ASA I and II), requiring two appointments for equivalent but contralateral dental extractions for orthodontic purposes, were recruited. Conscious sedation with either i.v. midazolam titrated at 0.5 mg min ‐1 ,t o a maximum of 5 mg, or nitrous oxide/oxygen titrated to 30%/70% inhalation sedation was used at the first visit, the alternative being used at the second visit. Vital signs including blood pressure, arterial oxygen saturation and ventilatory frequency, as well as sedation levels and behavioural scores, were recorded every 2 min. Results. Forty patients, mean age 13.2 yr (range 12‐16 yr), participated in the trial. A mean dose of midazolam 2.8 mg was administered in the test group. The median time to the maximum level of sedation was 8 min for midazolam compared with 6 min for nitrous oxide (P<0.001). Vital signs for both treatments were comparable and within acceptable clinical limits and communication with the patient was maintained at all times. The median (range) lowest arterial oxygen saturation level recorded for midazolam was 97 (91‐99)% compared with 97 (92‐100)% for nitrous oxide. The mean (range) recovery time for midazolam was 51.6 (39‐65) min and 23.3 (20‐34) min for nitrous oxide (P<0.0001). Fifty-one per cent said they preferred i.v. midazolam, 38% preferred nitrous oxide, and 11% had no preference. Conclusion. I.V. midazolam sedation (0.5 mg min ‐1 to a maximum of 5 mg) appears to be as

Randomized, controlled, cross-over clinical trial comparing intravenous midazolam sedation with nitrous oxide sedation in children undergoing dental extractions

Summary. Objective. To examine the validity of a scale that uses faces as an indicatorof children’s dental anxiety. Setting. Department of Child Dental Health waiting room, Newcastle Dental Hospital. Subjects and methods. 100 children (aged 3–18 years) completed the Facial ImageScale (FIS) and the Venham Picture Test (VPT) in the dental hospital waiting room. Results. A strong correlation (0·7) was found between the two scales, indicating goodvalidity for the FIS. Findings also showed that a small, but signiﬁcant, number of childrenare anxious in the dental context.Conclusion. The ﬁndings suggest that the FIS is a valid means of assessing child dentalanxiety status in a clinical context. Introduction Dental anxiety in children has been recognized asa problem in patient management for many years.Furthermore, the effects of this anxiety have beenshown to persist into adulthood, which can oftenlead to dental avoidance [1] and the subsequentdeterioration of oral health [2]. It is important thatdentists are able to assess dental anxiety in childpatients as early as possible so that they may identifypatients who are in special need with regards to theirfear. For this purpose, formal assessment measuresare essential. Upon reviewing the literature, it isclear that there are many different assessmentmethods available for this purpose (see Aartman andcolleagues [3,4] for comprehensive reviews). Whenconsidering the usefulness of an assessment measure,however, there are essentially three important factorsto take into account: 1 The validity of the instrument used must be con-sidered. This can be problematic, especially whenthe measure is indirect. For example, the use ofphysiological methods has been criticised on thegrounds that anxiety may be evoked due to the natureof the equipment used, and not because the child isdentally anxious [5]. In addition, projective techniquessuffer from questionable reliability and validity dueto difﬁculties in the interpretation of stories and thestandardization of scoring; 2 The assessment measure must be appropriate foruse with children. Indirect measures overcome thisto a certain degree as they mostly rely on observationsand reactions of the child by others. Techniques thatrely on some form of verbal-cognitive self-report(e.g. questionnaires) can be problematic, however.Questioning children directly about their dental anxietyis reasonably straightforward, but verbal methodsemployed with young children can have limitationsdue to comprehension and intellectual ability [4]; 3 It is important to consider whether an assessmentmeasure is of practical use to the dental practitioner,an issue that is rarely addressed in the literature.Techniques such as projective tests and behaviouralobservation are not designed for everyday use by theclinician. Projective techniques, such as the Children’sDental Fear Picture Test [6], require expertise in carry-ing out interviews and administering (and scoring)tests. Similarly, physiological methods often require

Validation of a Facial Image Scale to assess child dental anxiety.

Summary. Objective. To investigate the extent to which dentists report their encouragement to dentally anxious children to blunt (distract from the procedure) or monitor (give information about the procedure) during treatment.

Setting. British Society of Paediatric Dentistry conference.

Subjects and methods. One hundred and two of 155 delegates (66% response rate) completed a Monitor Blunter Treatment Checklist (MBTC), which was included in their conference pack. Participants were asked to tick all of the 10 statements (five monitoring and five blunting) that reflected how, in general, they would treat a dentally anxious child.

Results. Dentists chose significantly more monitoring than blunting statements. Treatment strategies relating to explaining procedures were endorsed by the majority of dentists, while distraction was chosen by less than a third.

Conclusion. Dentists tend to use monitoring strategies that adhere generally to the principles of the Tell-Show-Do technique. This may have implications if the anxious child has a ‘blunting’ coping style.

N. Niven

Papers

Validation of a Facial Image Scale to assess child dental anxiety.

Self-report treatment techniques used by dentists to treat dentally anxious children: a preliminary investigation.

Further evidence for the validity of the Facial Image Scale