consists of a simple 40-point scale, with children rating their level of anxiety in regard to eight specific questions on a scale of 1-5. Scores of 27-40 indicate severe dental anxiety or phobia.3 Guidelines produced by the British Society of


Paediatric Dentistry describe a full range of behaviour management techniques and suggested situations for use in dental anxiety.2


Te chosen


management technique should be based on individual circumstances; no single method will be applicable in all situations.


Mild to moderate anxiety Fear of the unknown can oſten be easily diminished with good rapport building and empathy. Te following techniques can be useful: Positive reinforcement. Use stickers, colouring


sheets or simply verbal praise to reward the child when they co-operate well. Keep praise and rewards specific: “Well done for keeping your mouth open so well” is more effective than “good boy”. Asking the child how they are doing during treatment, communicating with thumbs up, has been shown to be more effective than reassurance. Tell-show-do. Although requiring time at the


initial treatment appointment, this technique is an excellent way to introduce patients to new experiences, increasing the chance of future co-operation. Tis might include using the three-in-one on the child’s hand prior to drying teeth or demonstrating the slow-speed on a finger-nail prior to caries removal. Should the child ask to see the local anaesthetic prior to injection, show them the individual components and emphasise how fine and thin the needle is and how little of it needs to touch the gum. Voice control. Tis is especially helpful with


young children who respond better to tone of voice rather than actual words, switching to a different, slightly sterner tone when necessary to improve attention, compliance and establish authority. Distraction. Short-term distracters are useful, for


example chatting and pulling the lip taut to distract from the sensation of local anaesthetic (and always dry mucosa before using topical, allowing four minutes for it to work!). If facilities allow, playing a cartoon on a ceiling television screen during treatment has been demonstrated as being effective. Giving control. Be honest with the child. If you


set up a stop-signal, promising that you will stop if the patient indicates for this to happen, you must adhere to it. Not doing so can have disastrous consequences with the breakdown of trust between patient and dentist.


More severe cases of anxiety If it becomes clear during the initial appointment that the patient has more severe anxiety, additional strategies will be necessary. Tese might include conscious sedation, general anaesthetic or non- pharmacological techniques such as cognitive behavioural therapy or hypnosis. It may be


AUTUMN 2016


appropriate to refer the patient to the local public dental service or paediatric dental department for further assessment.


Other points for consideration Avoidance. Consider when treating children that your aim is not only to prevent and treat dental disease but also to avoid treatment-induced anxiety. Consider the holistic needs of the child when treatment planning. For example, a child with pulpitis in one primary molar may well have a number of other carious teeth that also need to be taken into consideration. Take appropriate radiographs and consider how other carious teeth will be managed. Prioritise prevention of caries in permanent molars and where possible avoid carrying out an extraction at the first dental appointment. Parent in or out? Some dentists prefer one-to-one


interaction with a child without the parent/carer present. Research suggests, however, that co- operation is widely unaffected by having a parent present in the surgery or not. In the case of pre-school children, however, behaviour tends to be better when a parent is with them. Watch your language. Take care with your choice


REFERENCES


1 Prevention and Management of Dental Caries in Children. Scottish Dental Clinical Effectiveness Programme. Dundee 2010 http://www.sdcep.org.uk/ published-guidance/caries-in- children/ (accessed 3.7.16)


2 Campbell C, Soldani F, Busuttil-Naudi A, Chadwick B. Update of Non- pharmacological behaviour management guideline. Clinical Guidelines in Paediatric Dentistry


http://bspd.co.uk/Portals/0/ Public/Files/Guidelines/ Non-pharmacological%20 behaviour%20 management%20.pdf (accessed 3.7.16)


3 Freeman R. An evaluation of the PALS after treatment modelling intervention to reduce dental anxiety in child dental patients. 2009 International Journal of Paediatric Dentistry 19(4):233-42


4 Children and Young People (Scotland) Act 2014 http://www.legislation.gov. uk/asp/2014/8/contents/ enacted (accessed 3.7.16)


of words. “Don’t be scared, I’m not going to hurt you” will unfortunately do little to alleviate anxiety. Negatives like “Don’t” and “not” tend to be bypassed by the mind – a little like telling a child not to look out the window, it becomes the first thing that they do! Focus instead on positives: “You will manage this just fine” and “liſt up your hand if you need a break and I’ll stop”. Failed appointments. Dental anxiety is oſten


cited as a reason for not attending dental appointments. However, children deserve access to dental care and require a responsible adult to get them there. It can help by explaining via letter or telephone that the first visit is for assessment and planning only. If a parent or guardian is repeatedly failing to bring their child to their scheduled appointment or only bringing the child when they are in pain, discuss your concerns with an appropriate colleague. All concerns should be fully documented and local health board protocol followed.4 Check out www.dental.llttf.com for valuable


downloadable resources aimed at dental practitioners, young people and their parents on coping with dental anxiety, including leaflets on how to prepare children for their dental visit. Te website was produced by a team of researchers in the UK, experienced in research and treatment regarding anxious young people. Treating children can certainly bring its


challenges, but careful planning and management can go a long way towards easing the stress for patient and dentist alike.


n Fiona Hogg is a specialty registrar in paediatric dentistry at Glasgow Dental Hospital and the Royal Hospital for Children, Glasgow


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