Description of the condition

Disruptive or non‐compliant behaviours are a common manifestation of dental fear, anxiety, or phobia in children (Winer 1982). Dental fear is a normal emotional reaction to one or more specific threatening stimuli in the dental situation. Dental anxiety indicates a state of apprehension that something dreadful is going to happen in relation to dental treatment, and it is usually coupled with a sense of losing control. Dental phobia denotes a severe type of dental anxiety, and is characterised by marked and persistent anxiety in relation to either clearly discernible situations or objects (e.g. drilling, injections) or to the dental situation in general (New Reference; Klingberg 2007). According to the Diagnostic and Statistical Manual of Mental Disorders (DSM–V), the criteria for diagnosis of a specific phobia are: (i) marked and out of proportion fear within an environmental or situational context to the presence or anticipation of a specific object or situation, (ii) exposure to the phobic stimulus provokes an immediate anxiety response, which may take the form of a situationally bound or situationally predisposed panic attack, (iii) the person recognises that the fear is out of proportion, (iv) the phobic situation(s) is avoided, or else is endured with intense anxiety or distress, and (v) the avoidance, anxious anticipation, or distress in the feared situation(s) interferes significantly with the person's normal routine, occupational (or academic) functioning, social activities, or relationships, or there is marked distress about having the phobia (AMA 2013). In addition to the criteria for a specific phobia, the general criteria for a mental disorder, which is common to all Axis I diagnoses, also has to be met. This definition includes the criterion disability (i.e. impairment in one or more important areas of functioning). Therefore, for a diagnosis of phobia, dental fear or anxiety must result in the individual avoiding the necessary dental treatment completely, or enduring treatment only with dread, and in an adjusted treatment situation (e.g. specialist paediatric dentistry; Klingberg 2008).

The term 'dental fear and anxiety' (DFA) is often used to refer to strong negative feelings associated with dental treatment among children and adolescents, whether or not the criteria for a diagnosis of dental phobia are met. Conversely, dental behaviour management problems (DBMP) are defined by the dentist’s experience when treating the patient. It is a collective term for unco‐operative and disruptive behaviours, which result in delay of treatment or render treatment impossible, regardless of the type of behaviour or its underlying mechanism (Klingberg 1994).

Based on a review of prevalence studies between 1982 and 2006, Klingberg 2007 reported the prevalence of both DFA and DBMP to be approximately 9% for children in normal populations in Australia, Canada, Europe, and the USA. Recently, higher DFA and DBMP prevalence estimates, ranging from approximately 6% to 29%, have been reported for children in low‐ and middle‐income countries (Abu‐Ghazaleh 2011; Akbay Oba 2009; Dogan 2006; Folayan 2004; Paryab 2013; Salem 2012). Given the wide variation in both DFA and DBMP prevalence estimates among children in different geographical areas and settings, it should be recognised that these estimates may be influenced by different measures and cut‐off points used by investigators to distinguish between those who are and are not anxious. Nevertheless, girls exhibit DFA and DBMP more frequently than boys (Klingberg 2007). Dental fear and anxiety and DBMP have been related to general fear, and both internalising and externalising behavioural problems (Arnrup 2002; Klingberg 1995; Ten Berge 1999), although these relationships are ambiguous, and the development of these problems has been attributed to several psychological factors (Locker 2001).

Dental treatment frequently involves invasive treatment, multiple injections, and the use of sharp, high‐speed cutting instruments, often extended over several visits. Children and adolescents vary considerably in competence, maturity, personality, intellectual capacity, temperament and emotions, experience, oral health, family background, parenting styles, and culture. All of these aspects influence the child’s ability to cope with dental treatment, and can pose a great challenge to the treating dentist. It is difficult, if not impossible, to carry out any required clinical or preventive care if a child’s behaviour cannot be managed. Therefore, the dentist should identify the factors, both within and outside of the dental setting that may influence DFA and DBMP, so they may select the most appropriate behaviour management interventions, either non‐pharmacological or pharmacological, to minimise DFA and DBMP, and deliver high‐quality dentistry, whilst also helping the the child develop a positive attitude towards dental health and treatment.

Fear of dental treatment and anxiety about dental procedures have an impact on quality of life and the quality of the dental treatment performed (Milgrom 2010). Delay in seeking treatment because of dental anxiety often means that conservative treatment options are not viable. The choice of an appropriate non‐pharmacological intervention is based on the levels (low, moderate, high or phobic) of dental anxiety exhibited by the child. For children presenting with low levels of DF or DA, approaches that can be adopted include: tell‐show‐do, voice control, distraction, modelling, memory reconstruction, positive reinforcement, relaxation training, magic tricks, and positive images. Children with moderate levels of DF or DA may require more intensive interventions, such as providing them with information on coping strategies, while children who exhibit DP could benefit from the complementary use of pharmacological and psychological approaches, especially cognitive behavioural therapy (Newton 2012).

Behaviour management needs to be flexible and individualised for each child (Feigal 2001). Most behaviour management techniques require an understanding of the cognitive, emotional, and social development of the child and aim to develop communication between the child, dentist, and parent, where possible (Feigal 1995; Rosenberg 1974). To date, there are few studies that have evaluated the effectiveness of various non‐pharmacological interventions for managing dental anxiety in children. One Cochrane review explored the effectiveness of hypnosis (with or without sedation) for behaviour management in children receiving dental treatment, and reported that there was insufficient evidence to support the benefits of hypnosis for behaviour management in children (Al‐Harasi 2010). Our review aims to assess the effectiveness of all non‐pharmacological interventions in reducing dental anxiety in children.

Description of the intervention

Several non‐pharmacological techniques have been proposed for use with children, including:

• Voice control;

• Tell‐show‐do;

• Positive reinforcement;

• Distraction;

• Non‐verbal communication;

• Hand‐over‐mouth technique (HOM);

• Hand‐over‐mouth with airway restriction (HOMAR);

• Physical restraint;

• Contingent distraction;

• Contingent escape;

• Modeling;

• Relaxation training;

• Hypnosis;

• Systematic desensitisation and graded exposure;

• Cognitive behavioural therapy;

• Visual pedagogy;

• Memory reconstruction; and

• Others (e.g. magic tricks, positive images, environmental change).

Despite the range of non‐pharmacological intervention currently available, they are rarely used in isolation; for instance, tell‐show‐do, a basic desensitisation technique, is nearly always immediately followed by some form of praise (reinforcement). If this is used as an approximation to an eventual co‐operative behaviour, the technique could be termed ‘behaviour shaping’ (Roberts 2010).

Enhancing control or temporary escape allows the patient to have some degree of control over their situation, and the ability to communicate when they require a rest, are in pain, or need the dentist to stop. Voice control is the modulation of tone, volume, pace, and pitch of voice to control and guide behaviour. Contingent or non‐contingent distraction shifts the patient’s attention, allowing the dentist to decrease negative perceptions of treatment and avert negative or avoidance behaviour. Modeling relies upon the theory that behaviours are learned from observing and imitating others. By observing a model, a child is able to learn complex behaviour patterns to cope and approach dental treatment without fear (Roberts 2010; Ten Berg 2008).

Cognitive behaviour therapy (CBT) is an example of a brief psychological therapy, which uses both behaviour modification techniques and cognitive restructuring procedures to change disruptive beliefs and behaviours. Behavioural aspects of CBT include learning relaxation skills, conducting mini‐experiments, systematic desensitisation, and graded exposure. This aims to reduce anxiety through the gradual presentation of anxiety or fear‐inducing stimuli while the child is either in a relaxed state, or in the presence of a neutral or positive stimulus, thus modifying child’s response (Gordon 1974; Ten Berg 2008).

Protective stabilisation is defined as restriction of a patient’s freedom of movement, with or without the patient’s permission, to decrease risk of injury while allowing safe completion of treatment (AAPD 2015‐2016). Controversy surrounds the use of protective stabilisation, due to the risks of respiratory compromise, loss of dignity, and potential induction of psychological trauma (Roberts 2010).

Suggestion, visualisation, and hypnosis strategies train patients to be placed, or to place themselves into a level of focused consciousness, so suggestions can be easily adopted. The magic trick, or similar method of gaining a child’s attention and admiration, may make a child feel at ease in an unfamiliar scenario, as well as build rapport, and ultimately, lead to positive behaviour.

Regardless of the technique used, its effectiveness greatly depends on how it is applied, including the empathic skills shown by the dental practitioner.

How the intervention might work

Major consequences of a child’s unco‐operative behaviour in a dental setting include delays or early termination of treatment, or decreased quality of care (Allen 1988). The above‐mentioned non‐pharmacological interventions have been proposed in an attempt to help the child overcome DFA and DBMP, and learn about and understand dental procedures in a way that minimises their anxiety (Allen 1987; Allen 1992; Kuhn 1994; Peretz 1996a; Peretz 1996b; Peretz 1999). The use of these basic psychological techniques during dental treatment has been found to be effective in reducing children’s dental anxiety, which could potentially facilitate their acceptance of what may occur in the dental environment (Folayan 2003). This may be by gradually exposing them to potentially anxiety‐inducing experiences, helping them feel more in control by providing them with communication strategies, gaining their attention or distracting them, providing positive or negative reinforcement to minimise disruptive behaviour and strengthen desired behaviours, and focusing on building a more trusting relationship with their dentist and the dental team. Reducing a child's anxiety without using a pharmacological intervention means less threat to their general health, less obstruction to the delivery of timely dental health care in the present, and the likelihood of better compliance with clinical advice and preventive care in the future. Therefore, non‐pharmacological interventions are recommended by paediatric dental organisations (AAPD 2015‐2016; Roberts 2010).

Non–pharmacological interventions, can be theoretically grouped into: (i) communication skills, rapport, and trust building, (ii) behaviour‐modification techniques, (iii) cognitive behavioural therapy, and (iv) physical restraints (Appukuttan 2016).

Why it is important to do this review

Cochrane Oral Health undertook an extensive prioritisation exercise in 2014 to identify a core portfolio of titles that were the most clinically important ones to maintain on the Cochrane Library (Worthington 2015). The paediatric dentistry expert panel identified this review topic as a priority (Cochrane Oral Health priority review portfolio).

Children should be able to enjoy the benefits of dental treatment without experiencing unnecessary distress. Dental fear and anxiety and DBMP may have major and long‐lasting implications for children and their families, which are as follows.

• They exhibit a higher caries experience compared to children with low levels of dental anxiety (Nicolas 2010; Rantavuori 2004; Townend 2000; Versloot 2004).

• They are difficult to treat and require more time, resulting in a stressful and unpleasant experience for the child, parent and the treating dentist (Moore 2001).

• They are much more likely to resist, delay, or avoid dental visits, which is an important influencing factor for parents who fail to take their children to the dentist, thus resulting in failed or missed appointments (Hallberg 2008).

• There are financial implications for providing dental treatment to these children (Weinstein 2008). Dental practices, which operate on a fee‐per‐service basis, may be reluctant to treat these children, hence referring them to secondary or tertiary dental care services (Harris 2008). This results in longer waiting times, potentially leading to more extensive dental problems. They may eventually require more complex treatment with the aid of pharmacological interventions, namely, intravenous sedation, conscious sedation, or general anaesthesia (Armfield 2013).

• This results in neglected dental care and increased unmet need in adulthood (Berggren 2001). They are more likely to be symptomatic, rather than proactive, users of dental services in adulthood (Poulton 2001).

It is important that non‐pharmacological interventions delivered by dentists are evidence based; therefore, this review could help identify the specific interventions that are effective for the different levels of dental anxiety in children. Furthermore, this could help in developing guidelines and training dental practitioners in such techniques.