Prevention of Dental Fear and Anxiety with Behavior Management Techniques

Abstract

Dental fear and anxiety can have a significant effect on an individual, ultimately leading to a poor oral health-related quality of life. Many develop fear and anxiety due to an unfortunate experience at the dentist during their childhood. Dentists, with proper training, can treat children and provide behavior management techniques to complete treatment in a positive manner. These behavior management techniques focus on decreasing the fear and anxiety toward a dental procedure and assisting the child to develop the proper skills needed to cope with such procedures in the future.

Full text

Arch Psychiatry. 2024
Volume 2, Issue 1
e Archives of Psychiatry Short Communication
35
Arch Psychiatry. 2024;2(1):35-39.
Prevention of Dental Fear and Anxiety with Behavior
Management Techniques
Elizabeth Berry1,*
1Research Course Director, Bon Secours St Mary´s Hospital Program for Advanced Paediatric Dental Education, 6900 Forest
Ave, Suite 110, Richmond, Virginia, 23230, USA
*Correspondence should be addressed to Elizabeth Berry, ELIZABETH_BERRY@bshsi.org
Received date: June 28, 2024, Accepted date: July 22, 2024
Citation: Berry EJ. Prevention of Dental Fear and Anxiety with Behavior Management Techniques. Arch Psychiatry.
2024;2(1):35-39.
Copyright: © 2024 Berry EJ. is is an open-access article distributed under the terms of the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source
are credited.
Introducon
Dental fear or anxiety is very common amongst children and
adults. It can be characterized by a feeling of apprehension
or unease involving the dental eld and the procedures that
may occur at a dental oce [1]. Approximately 36% of the
population has the fear of the dentist with 12% having an
extreme fear [2]. Dental fear generally starts in childhood
and can be linked to traumatic dental experiences when
one is a child [3]. The onset of dental anxiety and fear was
found to have started in childhood [4]. Patients are less likely
to seek dental care after a poor experience at the dentist
and developing a fear resulting in low oral health-related
quality of life. Children that experienced more check-up visits
before they experienced their rst treatment have reported
lower levels of dental fear [5]. This shows the more positive
experiences a child has at the dentist, the more likely they are
not to develop a fear of the dentist and follow up with needed
oral health care. It is imperative to provide a level of care to
children that enables a child to grow to not be fearful of the
dentist, so they may seek future dental care leading to better
oral health outcomes.
Pediatric Dentists are trained in behavior guidance
techniques to provide a pleasant environment for children.
These techniques include communication guidance, direct
observation or modeling, tell-show-do, voice control, and
positive pre-visit techniques. More advanced techniques may
be used if the key techniques are not working, or the child has
a disability or is not old enough for these techniques to work
[6]. Overall, the author believes that an appointment should be
considered a failure if the child leaves in tears and develops a
fear of the dentist, even if the needed treatment is completed.
Key Techniques
Many behavior guidance techniques involve proper basic
communication guidance techniques. Reective/active
listening is a technique that establishes rapport with a patient
[7]. Listening takes eort; hearing is not the same. A dentist
must take what the patient is saying and reect on what is
said. This encourages the child to speak and feel heard during
treatment. Acknowledging a child’s feeling involves listening
to them quietly, acknowledging their feelings, giving a name
to their feelings, restating their feelings in the child’s own
words, and them summarizing the child’s emotions [8]. Bi-
directional communication also allows the child to feel as an
active participant in their care [6].
Abstract
Dental fear and anxiety can have a signicant eect on an individual, ultimately leading to a poor oral health-related quality of life. Many
develop fear and anxiety due to an unfortunate experience at the dentist during their childhood. Dentists, with proper training, can treat
children and provide behavior management techniques to complete treatment in a positive manner. These behavior management techniques
focus on decreasing the fear and anxiety toward a dental procedure and assisting the child to develop the proper skills needed to cope with
such procedures in the future.
Keywords: Fear, Anxiety, Pediatric, Dentistry, Oral health

Berry EJ. Prevention of Dental Fear and Anxiety with Behavior Management Techniques. Arch Psychiatry. 2024;2(1):35-
39.
Arch Psychiatry. 2024
Volume 2, Issue 1 36
Direct observation or modeling is another technique used
and is very useful for families of children when an older sibling
does well at the dentist. Allowing a younger sibling to watch
their older sibling during an appointment and ask questions,
can prevent the fear of a future visit. This allows the patient
to familiarize themselves with the dental settings and the
particular procedure [6]. This can also be done with lmed
modeling, a family member, or another patient.
‘Tell-show-do’ is a classic technique used throughout the
day of a pediatric dentist and has been proven to be eective
[9,10]. This desensitization technique involves explaining the
procedure rst, demonstrating how the procedure is done
in a nonthreatening manner, then carefully completing the
procedure [6]. An example would involve a simple cleaning
with a prophy angle. One would tell the patient all that is going
to be used including the “spin” toothbrush and the showing
the “toothpaste” that will be used. Next the technique can be
done on the nail of the patient to show how it does not hurt
and so they can experience from a visual, auditory, olfactory,
and tactile aspect the experience. Then the procedure would
be completed (Figure 1).
Voice control is also utilized, not in a threatening manner as it
may sound. This is a deliberate alteration of the voice volume,
tone or pace to inuence and direct the patient and their
behavior [6,11]. The type of intonation this author encourages
would be one such as a whisper. When one is having trouble
getting a patient to calm or listen, lowering the voice to
whisper and getting closer to the patient allows the patient to
focus on what the dentist is stating.
Positive reinforcement is one of the most common ways to
reward good behavior and encourage a child to want to return
to the dentist. This includes praise for particular behaviors and
reinforcing behavior with classic toys found in a dental oce
(Figure 2). Children love being rewarded with a toy at the
end of an appointment. A simple bouncy ball after getting a
restoration or lling completed can lead the child to having a
positive experience. Praising the child with what they did well
is important to encourage that behavior in the future [12].
Distraction is a technique where the patient’s attention is
diverted to avoid the actual procedure being completed [6].
Audio-visual distraction has been shown to be very eective.
For example, television as an audio-visual distraction is used
in many dental oces to distract a child from the dental
treatment. Another example would be audio distraction where
the provider is telling a story to divert the child’s attention to
the story and not the treatment, or having the child listen
to music [13,14]. These techniques are very eective in
decreasing anxiety [15,16].
Some patients may benet from positive pre-visit imagery
[6]. This involves looking at positive photographs or images
of dentistry prior to a dental appointment. The child can also
be given imaging preparing them for a dental procedure and
the instruments that will be used. By doing so, the child is
prepared for the visit and is not going into an appointment
with fear of the unknown. Dental instruments and materials
can look quite scary. Providing the child an explanation and
visual image of such items can reduce fear at the appointment.
For example, dental etchant is used to clean the tooth prior
to placing sealants, a common preventive technique used
around the age of 6-7 years old when the rst permanent
molars erupt. Dental etch comes in a syringe and looks like
a needle (Figure 3). By explaining that the blue material
simply comes out and is “painted” on the tooth like shampoo
and is then rinsed o the tooth, will assist the child in getting
through an appointment without fear.
Figure 1. Tell-show-do.

Berry EJ. Prevention of Dental Fear and Anxiety with Behavior Management Techniques. Arch Psychiatry. 2024;2(1):35-
39.
Arch Psychiatry. 2024
Volume 2, Issue 1 37
Figure 2. Common toys given at appointments.
Figure 3. Dental etchant used for sealants.
Parents or guardians also have a great inuence on the
child and how they do in the dental oce. If a parent has a
positive attitude toward oral health, then they are more
likely to establish a dental home for their child and therefore
provide more preventative care. This is more likely to lead to
prevention of caries and the child is less likely to experience
having to complete a more dicult restorative appointment
[6]. Parents also transmit their dental fear onto their child [6].
This makes it more challenging for a child to develop a positive
attitude toward the dentist. It is important to not only make
the experience for the child at each appointment positive, but
also the parent.
Advanced Techniques
The key techniques work for most children, however, at
times more advanced techniques are needed. Nitrous oxide,
sedation, and general anesthesia can additionally be used.
The “key techniques” should be considered prior to the
advanced techniques. Some children though may not be able
to cooperate due to emotional immaturity, a psychological
disability or medical disability [6].
Nitrous oxide inhalation is a technique that many dentists
use to provide dental treatment safely (Figure 4). It has

Berry EJ. Prevention of Dental Fear and Anxiety with Behavior Management Techniques. Arch Psychiatry. 2024;2(1):35-
39.
Arch Psychiatry. 2024
Volume 2, Issue 1 38
multiple mechanisms of action including an analgesic eect
and anxiolytic eect. Properties that make it an advanced
technique of choice is its rapid onset of action, ability to
titrate, and how eects are easy to reverse [17]. In children
these properties allow procedures that are not pleasant to be
completed, reducing pressure-induced pain and reaction time
[18].
Sedation can safely be provided for patients unable to
cooperate by well-trained dentists. This advanced technique
is typically indicated for patients with fear and anxiety where
the key techniques do not work or to protect the developing
psyche of a child that where the key techniques most likely
will not work [6]. This type of technique requires appropriate
training by the dentist to provide sedation safely.
General anesthesia allows safe, eective, and high-quality
care to patients that are unable to complete treatment in the
chair. This technique is considered in more complex cases,
including those that involved signicant surgical procedures
or to decrease the number of anesthetic exposures [6].
Additionally, it is considered for children that are very young,
have complex medical conditions, have emergency treatment
that is extensive, or patients with neurodevelopmental needs
[6,9]. General anesthesia when used, is typically completed
either in the hospital, ambulatory surgery center or oce
setting by an anesthesiologist with the dentist completing the
dental treatment.
Conclusion
Dental fear is highly prevalent in many adults worldwide. This
leads to poorer oral health outcomes due to the avoidance
of regular preventive visits and any dental treatment. By
incorporating techniques to provide a positive environment
starting at a very young age, dental fear can be greatly
reduced. The techniques described provide many ways to
assist a child to develop into an adult with less chance of fear
of the dentist due to a poor experience while young. The goal
is to protect the overall psyche of the child and encourage
them to continue to see a dentist when older and therefore
have good oral health.
Figure 4. Nitrous oxide being administered to a patient.

Berry EJ. Prevention of Dental Fear and Anxiety with Behavior Management Techniques. Arch Psychiatry. 2024;2(1):35-
39.
Arch Psychiatry. 2024
Volume 2, Issue 1 39
Conicts of Interest
Not applicable.
Funding Statement
Not applicable.
Acknowledgments
The author would like to thank Drs. John H Unkel and William
Piscitelli for their editing of this manuscript.
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