A short-term follow-up of treatment outcome in groups of uncooperative child dental patients.

AIM: To evaluate the short-term follow-up outcome in four subgroups of uncooperative child dental patients referred to a specialist paediatric dental clinic in Sweden. METHODS: Seventy children, classified into four groups (based on fear, temperament, behaviour and verbal intelligence), were followed-up at their public dental clinics after termination of specialist dental treatment. Questionnaire assessments of children's dental and general fear, parental dental fear, emotional stress, locus of control and parenting efficacy were made by parents pre and post treatment and at follow-up and were analysed within and between groups. At follow-up, parents rated their children's coping and procedure stress, while treatment acceptance was rated by the dentists. RESULTS: Decreases in child dental fear were maintained at follow-up, although a third of children still had moderate or high dental fear. For those children who had been classified into the externalising, impulsive group, an increased risk of non-acceptance (RR=3.7) was indicated. The risk of dental fear at follow-up was increased for the group of fearful, inhibited children (RR=3.8). For the study group as a whole a poorer follow-up outcome could be predicted by avoidance behaviour (OR 12.9-16.6) and moderate or high post treatment dental fear (OR 6.5- 21.3). CONCLUSIONS: Fearful, inhibited child dental patients may need, due to dental fear, extra attention even after successful dental treatment at a specialist clinic. Externalising, impulsive children constitute a special challenge for dentistry. The continued need for adjusted management after termination of specialist treatment can be predicted from avoidance behaviour and post treatment dental fear scores.     

Parental beliefs on the origins of child dental fear in The Netherlands

The aim of this study was to assess parental beliefs on the causes and prevention of child dental fear in the Netherlands. The parents of 123 children (67 high fearful and 56 low fearful children) were interviewed about the causes of their children's dental fears, and about factors contributing to the prevention of this fear. Parents attributed their child's dental fear to the following factors: invasive dental experiences (37 percent), medical problems (19 percent), child's temperament (16 percent), negative dentist behavior (13 percent) and social influences (5 percent). In the prevention of child dental fear, an empathetic dentist (34 percent) and parental guidance (30 percent) were mentioned most frequently. In conclusion, conditioning factors were reported to be highly important in the development of child dental fear. Some of the parents, however, indicated temperamental factors to have played a role, suggesting that subgroups of dentally fearful children exist. These temperamental or psychological factors seem also to contribute substantially to the development of dental fear. Possible differences in parental attributional style are discussed.     

Lack of cooperation in pediatric dentistry--the role of child personality characteristics

PURPOSE: This study aimed to investigate fear, temperament, behavioral symptoms and verbal intelligence in a study group of uncooperative child dental patients, partly in comparison with a reference group of ordinary child dental patients. A second aim was to explore a hypothesis of heterogeneity by searching for subgroups within the study group. METHODS: Parents of 86 study group children (36 aged 4-to 7- years and 50 aged 8- to 12-years) and 117 reference group children (8- to 12-years) answered a questionnaire concerning dental and general fear, temperament and general behavior. Study group children performed a vocabulary test to measure verbal intelligence. Data were analyzed with a variable-based and a person-based approach. RESULTS: In addition to dental fear, a higher level of impulsivity most clearly discriminated study group from reference group children. Cluster analyses revealed four different fear and personality subgroups within the study group. CONCLUSIONS: Uncooperative child dental patients constitute a heterogeneous group. Subgroups with different fear, temperament and behavior problem profiles can be identified. These subgroups could be presumed to benefit from different treatment regimens, which should be further investigated.     

Lachgassedierung in der Kinderzahnheilkunde

Inhalational sedation with nitrous oxide is a safe and effective method of managing fear and pain and it is widely used in pediatric dentistry. It is suitable for treating children with low-grade to moderate fear of dental treatment but cannot be used in extremely fearful or uncooperative patients. A modern generation of nitrous oxide equipment is easy to use and minimizes the risk of environmental exposure to the gas. By integrating suggestion and colorful, scented nasal hoods, children’s already high approval ratings for the method increases even further. Other benefits include rapid onset and offset of the sedative effect, precise control of the duration and depth of sedation and a short recovery period. Dentists can acquire all the necessary theoretical and practical knowledge for performing dental inhalation sedation in 2-day courses led by anesthesiologists.     

Cooperation during dental treatment: the Children's Fear Survey Schedule in Japanese children

Summary. Objective. The aim of this study was to evaluate dental fear and cooperation during dental treatment using the Children's Fear Survey Schedule – Dental Subscale (CFSS‐DS). Methods. From the behaviour assessment of regular patients of the Pediatric Dental Clinic in Niigata University Dental Hospital (aged 5–12 years old), the patients were classified into two groups: uncooperative and cooperative. CFSS‐DS questionnaires were sent to a total of 295 patients, 186 of which were returned, 61 from the uncooperative group and 125 from the cooperative group. Results. In the uncooperative and the cooperative groups, the CFSS‐DS mean total scores were 31·79 and 24·02 (P < 0·05), respectively, and the ratios of the patients whose scores were equal to or more than 35 were 36·1 and 11·2%, respectively. Fear of ‘injections’ and ‘the dentist drilling’ had high scores in both groups. Conclusions. The results indicated that there are many uncooperative patients with low dental fear and cooperative patients with high dental fear.     

The clinically related predictors of dental fear in Taiwanese children

Background. Dental fear has been singled out as one of the most troublesome problems facing paediatric dentistry today. Children with dental fear may avoid visiting dentists; therefore, their oral health protection is often compromised. However, the aetiology of dental fear is still not entirely understood. Objective. This study investigated the dental visiting habit, the previous dental experiences, the conditioning pathway, and the clinically related predictors of dental fear in children. Design. The dental history of 247 children (2–10 years old) was obtained when they came to a dental clinic for treatment. The level of dental fear in these children was assessed using the Children's Fear Survey Schedule–Dental Subscale (CFSS-DS). Observers rated the clinically anxious responses and uncooperative behaviour towards dental treatment in these children. Three stepwise regression analyses were performed to determine significant predictors of CFSS-DS score, clinically anxious responses, and uncooperative behaviour of children, respectively. Results. We found that the CFSS-DS score and clinical anxiety have different predictors, but age ≤ 3.99 years old and cooperativeness in the first dental visit were important predictors for both the CFSS-DS score and the clinical anxiety. Furthermore, the other predictors of the CFSS-DS score were maternal dental fear, unbearable pain during the first dental visit, and visiting dentists in a regular dental clinic; the other predictors of clinical anxiety were first-born, regular dentist, and CFSS-DS score. Finally, the only significant predictor for uncooperative behaviour was clinical anxiety. Conclusion. Children's dental fear and their anxious response during dental treatment were dynamic processes that consisted of many different factors. The direct conditioning of subjective experience of pain was more important than the objective pathway of child dental fear, and the indirect conditioning does not seem influential in this study sample.     

Child dental fear: cause-related factors and clinical effects

The relationship between child dental fear and clinical effects, and the importance of some etiological factors related to the development of dental fear in children, were studied in 3,204 urban Swedish children aged 4 to 6 and 9 to 11 yr. Information concerning child dental fear (as measured by the Dental Subscale of Children's Fear Survey Schedule), general fears, parental dental fear, parents' employment and native language was obtained through questionnaires. Data regarding dental health, behavior management problems (BMP) and modes of dental treatment were compiled from dental records. The results showed that child dental fear was associated with missing appointments and dental caries. A proportion of 27% of the children with BMP were dentally fearful, while 61% of the children with dental fear reacted with BMP. A model for stepwise regression analysis showed that general fears, maternal dental fear, and age were important etiological factors in the development of dental fear in children.     

Effects of a positive verbal presentation on parental acceptance of passive medical stabilization for the dental treatment of young children

PURPOSE: The purpose of this study was to investigate the impact of a positive verbal presentation on parental acceptance of passive medical stabilization of young dental patients needing dental treatment in the private setting. METHODS: Parents appearing for the treatment of their young, uncooperative child were informed regarding the use of passive medical stabilization (Papoose Board). The control group (CG) was given a neutral explanation regarding the use of the Papoose Board (PB), and the experimental group (EG) was given a positive verbal presentation. A video film depicting 2 children undergoing dental treatment with conscious sedation and PB and a third child undergoing dental treatment under general anesthesia was viewed. Next, a post-screening survey regarding parents' attitudes to the treatment modalities was given. RESULTS: Sixty parents completed the trial. EG parents were found to be significantly more receptive to PB use compared to CG parents (69% vs 10%; chi-squared = 19.48; P=.001). CG parents believed that active restraint by a parent would be just as successful as passive restraint. The majority of EG parents, however, voiced the opposite opinion. EG parents attributed a restrained child's crying while in a PB to the child's fear, while CG parents attributed it directly to the restraint. CONCLUSIONS: Parental acceptability of the PB, coupled with conscious sedation, is dependent on the way it is presented by the clinician. Positive explanation may result in more parents' acceptance of this form of treatment.     

Can parents and children evaluate each other’s dental fear?

Luoto A, Tolvanen M, Rantavuori K, Pohjola V, Lahti S. Can parents and children evaluate each other’s dental fear? Eur J Oral Sci 2010; 118: 254–258. © 2010 The Authors. Journal compilation © 2010 Eur J Oral Sci The aim of this study was to determine whether parents and their 11–16‐yr‐old children can evaluate each other’s dental fear. At baseline the participants were 11–12‐yr‐old children from the Finnish Cities of Pori (n = 1,691) and Rauma (n = 807), and one of their parents. The children and their parents were asked if they or their family members were afraid of dental care. Fears were assessed using single 5‐point Likert‐scale questions that included a ‘do not know’ option. Children and parents answered the questionnaire independently of each other. Background variables were the child’s and their parent’s gender. Parents’ and children’s knowledge of each other’s dental fear was evaluated with kappa statistics and with sensitivity and specificity statistics using dichotomized fear variables. All kappa values were < 0.42. When dental fear among children and parents was evaluated, all sensitivities varied between 0.10 and 0.39, and all specificities varied between 0.93 and 0.99. Evaluating dental fear among fearful children and parents, the sensitivities varied between 0.17 and 0.50 and the specificities varied between 0.85 and 0.94, respectively. Parents and children could not recognize each other’s dental fear. Therefore, parents and children cannot be used as reliable proxies for determining each other’s dental fear.     

Empirical evidence of the relationship between parental and child dental fear: a structured review and meta‐analysis

International Journal of Paediatric Dentistry 2010; 20: 83–101 Background. The relationship between parental and child dental fear has been studied for over a century. During this time, the concept of dental fear as well as methodological approaches to studying dental fear in children have evolved considerably. Aim. To provide an overview of the published empirical evidence on the link between parental and child dental fear. Design. A structured literature review and meta‐analysis. Results. Forty‐three experimental studies from across the six continents were included in the review. The studies ranged widely with respect to research design, methods used, age of children included, and the reported link between parental and child dental fear. The majority of studies confirmed a relationship between parental and child dental fear. This relationship is most evident in children aged 8 and under. A meta‐analysis of the available data also confirmed an association between parental and child dental fear. Conclusion. The narrative synthesis as well as the meta‐analysis demonstrate a significant relationship between parental and child dental fear, particularly in children 8 years and younger.     

Sedation in uncooperative children undergoing dental procedures: a comparative evaluation of midazolam, propofol and ketamine

Dentists usually face a common problem dealing with pediatric patients due to their high levels of anxiety and fear, associated with dental procedures. Such children are usually managed by various pharmacological methods. The efficacy and safety of conscious sedation, using intravenous short acting group of drugs (midazolam, propofol and ketamine) in uncooperative children, requiring oral rehabilitation was thus evaluated in this study. A total of 30 uncooperative children, aged 3-6 years, belonging to ASA I, II category formed the study group. The efficacy of the three group of drugs was evaluated on the basis of the onset of sedation, duration of action, side effects encountered, and the overall cooperative behavior of the child throughout the course of the procedure, after obtaining parental consent. Results showed that propofol was highly effective in terms of onset of sedation, although increased body movements and crying, pain on injection and intermittent cough was observed as the main side effects of the drug. Midazolam showed the longest duration of action, but was not very effective in terms of treatment completion due to increased movements and crying. Maximum cooperation during the procedure was obtained with ketamine and no adverse effects were encountered. We preferred ketamine from the results of our study and recommended future evaluation of ketamine in combination with other sedatives.     

Possible predictors of discontinuation of specialized dental treatment among children and adolescents with dental behaviour management problems

Gustafsson A, Broberg AG, Bodin L, Berggren U, Arnrup K. Possible predictors of discontinuation of specialized dental treatment among children and adolescents with dental behaviour management problems. Eur J Oral Sci 2010; 118: 270–277. © 2010 The Authors. Journal compilation © 2010 Eur J Oral Sci This study aimed to identify potential predictors of non‐attendance among children and adolescents with dental behaviour management problems (DBMP). A group of 179 patients, 7.5–19 yr of age, was grouped into 56 ‘non‐attenders’ (discontinued treatment, missed appointments, or ≥ 20% cancellations) and 123 ‘attenders’. In addition to data from an introductory interview and dental recordings, baseline data from psychometric measures of fear and other personal and parental characteristics were included in logistic regression analyses and tree‐based modelling. The non‐attenders had higher scores on impulsivity and sociability and lower socio‐economic status (SES) than the attenders, and they lived more often in single‐parent families. Logistic regression analyses and tree‐based modelling point to SES and parental anxiety as important predictors for non‐attendance within this group of children and adolescents. To predict, and possibly to prevent, non‐attendance among children and adolescents referred for specialized dental care because of DBMP, we must consider their lives and family situations as well as their personal characteristics and oral health status. Further research should focus on whether the observed associations between non‐attendance and factors such as personal characteristics, family and psychosocial factors, and previous dental experiences, also hold for those who remain in regular dental care.     

Emotional contagion of dental fear to children: the fathers' mediating role in parental transfer of fear

International Journal of Paediatric Dentistry 2012; 22: 324–330 Background. Dental fear is considered to be one of the most frequent problems in paediatric dentistry. According to literature, parents’ levels of dental fear play a key role in the development of child’s dental anxiety. Hypothesis or Aim. We have tried to identify the presence of emotional transmission of dental fear among family members and to analyse the different roles that mothers and fathers might play concerning the contagion of dental fear to children. We have hypothesized a key role of the father in the transfer of dental fear from mother to child. Design. A questionnaire‐based survey (Children’s Fear Survey Schedule‐Dental Subscale) has been distributed among 183 schoolchildren and their parents in Madrid (Spain). Inferential statistical analyses, i.e. correlation and hierarchical multiple regression, were carried out and possible mediating effects between variables have been tested. Results. Our results support the hypothesis that family members’ levels of dental fear are significantly correlated, and they also allow us to affirm that fathers’ dental fear is a mediating variable in the relationship between mothers and children’s fear scores. Conclusions. Together with the presence of emotional transmission of dental fear among family members, we identified the relevant role that fathers play as regards the transfer of dental fear from parents to children.     

Attitudes to dental care among parents of uncooperative vs. cooperative child dental patients

The aim of this cross-sectional questionnaire study was to investigate four aspects of parents' attitudes to dental care (knowledge, child's oral health behavior, priorities and responsibility). One study group (n = 50) of parents of uncooperative child dental patients (aged 8-12 yr) was compared to a reference group (n = 113) of parents of ordinary child dental patients of similar age, and to a second study group (n = 36) of parents of uncooperative younger child patients (aged 4-7 yr). Study group parents had significantly lower socio-economic status and a higher level of dental fear as compared to parents of ordinary child patients. We found indications of a poorer dental knowledge and a differing responsibility-taking profile among study group parents. Their children also had sweets more often. As compared to parents of younger children, the older study group parents had lower socio-economic status and showed a lower responsibility-taking related to the child's treatment refusal. In conclusion, parents of uncooperative children differ from parents of ordinary child dental patients, not only in socio-economic status and dental fear, but also in aspects such as dental knowledge and responsibility-taking. These differences were partly related to the child's age.     

Intra-nasal midazolam in conscious sedation of young paediatric dental patients

Summary. Objectives . To compare the effects of 3 different doses of intra-nasal midazolam in the conscious sedation of young paediatric dental patients and to compare the effectiveness of the sedation in the fasting and non-fasting child.
Design . Double blind random controlled trial.
Sample and Methods . Thirty-eight uncooperative young children aged 2–5 years (mean age 4·02 years) were randomly assigned to one of 3 groups. The groups and the doses of midazolam administered intra-nasally were A: 0·3 mg/kg, B: 0·4 mg/kg, and C: 0·5 mg/kg body weight. Each child in each group had two visits for restorative treatment: one without food (fasting) and the other with soft drink and light food (non-fasting) before treatment. Child behaviour and sedative effects were evaluated using the scoring system of Houpt. The vital signs were monitored continuously using a pulse oximeter and Dinamap machine.
Results . There was rapid onset of sedation with the maximal effect between 8 and 15 minutes. This sedation lasted for 25–40 minutes in Groups A and B and for 60 minutes in Group C. Conscious sedation and dental treatment were achieved in 79%, 96% and 100% of the children in Groups A, B and C, respectively. Consistently higher Houpt scores were seen in Groups B and C, with statistically significant differences between Groups A and C, and B and C (Tukey's range test, P < 0·05). There were no significant differences in the general behaviour of the child, the onset and the duration of sedation between the fasting and the non-fasting child (nonparametric anova P > 0·05). All the vital signs were within normal physiological limits and there were no significant adverse effects either with or without fasting.
Conclusions . All 3 doses of intranasal midazolam were effective in modifying the behaviour of the uncooperative child patient to accept dental treatment. This was irrespective of fasting.     

Some characteristics of children with dental behaviour problems. Five-year follow-up of pedodontic treatment

The aim of the study was to find out how 146 children with dental fear, aged 3-13 years and referred to a Pedodontic Clinic during 1 year, accepted dental treatment after five years. The main background variables causing dental fear were social factors in 45%, personality factors in 29%, and previous negative experience in 26%. Caries incidence was high in 71% of the patients. Most patients received up to three training sessions with the "tell-show-do" method. Conventional treatment was given in 48%, 25% needed conscious sedation, and 27%, were treated under general anaesthesia. Significantly more children with low caries incidence were treated conventionally. After five years, 78% of the children showed good acceptance of conventional dental treatment while 18% received conscious sedation and 4% general anaesthesia. Significantly more children referred at the age of 3-8 years showed good cooperation than did the older children. Good acceptance was also found significantly more often when conventional treatment had been given. Caries incidence had decreased in 41% and increased in 6% of the patients. The patients who continue to show negative acceptance should receive special attention in an attempt to change their attitude to dentistry in positive direction.     

Dose-responsive characteristics of meperidine sedation in preschool children

Using double-blind conditions, 60 uncooperative and fearful preschool children (24-66 months) received intramuscular injections of meperidine 0.25, 0.50, 1.00 mg/lb or placebo prior to restorative dental treatment. Behavior was assessed by the dentist and an independent observer during five specific treatment procedures. Behavioral ratings found meperidine to be an effective sedative, with 0.50 mg/lb and 1.00 mg/lb being significantly more effective than placebo (P less than 0.05, Kruskal-Wallis). Children receiving 1.0 mg/lb of meperidine had significantly more nausea and vomiting than patients receiving lower doses of the drug (P less than 0.05, Chisquare). Physiologic monitoring demonstrated that the highest dose of meperidine was associated with transient drops in arterial oxygen saturation. Meperidine sedation was found to be more effective for older children (37-66 months) and for children initially rated as being only moderately uncooperative and fearful.     

Temperamental reactivity and negative emotionality in uncooperative children referred to specialized paediatric dentistry compared to children in ordinary dental care

Background. Current treatment of children with dental behaviour management problems (DBMP) is based on the presupposition that their difficulties are caused by dental fear, but is this always the case? Objective. The aim of this study was to study temperamental reactivity, negative emotionality, and other personal characteristics in relation to DBMP in 8‐ to 12‐year‐old children. Methods. Forty‐six children referred because of DBMP (study group) and 110 children in ordinary dental care (reference group) participated. The EASI tempramental survey assessed temperamental reactivity and negative emotionality, the Child Behaviour Questionnaire internalizing and externalizing behaviour problems, and the Children's Fear Survey Schedule general and dental fears. Cluster analyses and tree‐based modelling were used for data analysis. Results. Among the five clusters identified, one could be characterized as ‘balanced temperament’. Thirty‐five per cent of the reference group compared to only 7% of the study group belonged to this cluster. Negative emotionality was the most important sorting variable. Conclusions. Children referred because of DBMP differed from children in ordinary dental care, not only in dental fear level, but also in personal characteristics. Few of the referred children were characterized by a balanced temperament profile. It is important to consider the dual impact of emotion dysregulation and emotional reactivity in the development of DBMP.     

Childhood dental fear in the Netherlands: prevalence and normative data

OBJECTIVE: This study aimed to present normative data on dental fear for the Dutch child population, by identifying not only highly fearful children but also children at risk for developing this high dental fear. METHODS: Fear distribution of samples of high and low fearful children was studied, using the Dutch parent's version of the Dental Subscale of the Children's Fear Survey Schedule (CFSS-DS). Total fear scores were calculated for both samples, for different age levels and for boys and girls separately. To establish cut-off scores, mean CFSS-DS scores were associated with dentists' clinical fear ratings and, in addition, were transformed into stanines. RESULTS: Scores between 32 and 38 were found to represent a borderline area for dental fear, and scores of 39 and higher to represent high dental fear. CONCLUSION: The results have shown 6% of the Dutch child population to be highly fearful, while another 8% may be at risk to develop high dental fear. By providing extra attention for these children, the development of high dental fear or phobia may be prevented.     

Parental presence versus absence in the dental operatory: a technique to manage the uncooperative child dental patient.

AIM: Societal changes have led to an increased parental presence in paediatric dental surgeries. The aim of this study was to assess the deliberate use of a parental presence/absence (PPA) intervention as a behavioural technique to manage very uncooperative children. STUDY DESIGN: This is a retrospective study of the PPA technique in a Greek paediatric dental practice. METHODS: Practice patient records were examined over a six year period, during which time Frankl behaviour ratings were made for each patient. At the initial dental visit, 85 otherwise normal healthy children were found to be very uncooperative (Frankl score of definitely negative); 46 female and 39 male, mean age 4.6+/-1.5 yrs (range 2.7-8.8). Their parents stepped out of the operatory and returned after the child became cooperative. These children were compared with 85 randomly selected cooperative children, matched for age and gender. STATISTICS: A one sample binomial test was used to assess the technique's success, while chi(2) and t-tests were used for between group comparisons of proportions and means, respectively. RESULTS: Seventy-four out of the 85 initially uncooperative children displayed Frankl positive behaviour as the initial appointment progressed, while 6 children remained uncooperative during the first appointment but were cooperative at following visits. The total technique success was 80/85 (94%, p<0.001). The two groups differed significantly with regards to control in caries scores (frequency 77.6% with 12.2 +/- 11.8 dmfs as opposed to 54.1% with 6.7 +/- 5.7 dmfs), and in parent's awareness of patient dental needs or symptoms (76 vs 52). There was no significant difference between groups with regards to completing the treatment planned (63/80 vs 75/85). There was no significant difference in the proportion of returning children who displayed uncooperative behaviour in subsequent visits. CONCLUSIONS: The PPA technique can be successful in gaining the cooperation of children displaying very negative behaviour, thus minimising the need for other more aversive techniques.