Armfield Et Al-2013-Australian Dental Journal

Australian Dental Journal
The official journal of the Australian Dental Association

Australian Dental Journal 2013; 58: 390–407
doi: 10.1111/adj.12118
Management of fear and anxiety in the dental clinic:

a review
JM Armfield,* LJ Heaton†
*Australian Research Centre for Population Oral Health, School of Dentistry, The University of Adelaide, South Australia, Australia.
†Department of Oral Health Sciences, School of Dentistry, The University of Washington, Seattle, Washington, USA.
ABSTRACT
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 man-
agement 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.
Keywords: Dental anxiety, management, treatment, review, non-pharmacological.
Abbreviations and acronyms: ART = atraumatic restorative treatment; CARL = Computer-Assisted Relation Learning; IDAF-4C+ =
Index of Dental Anxiety and Fear; GA = general anaesthesia; MDAS = Modified Dental Anxiety Scale.
(Accepted for publication 30 July 2013.)
who delay dental visiting for a prolonged time, even if
INTRODUCTION
experiencing considerable pain, might have extensive
High dental fear affects approximately one in six Aus- problems that require more complex and complicated
tralian adults1,2 and this prevalence figure is similar to treatment.
that of many Western countries around the world.3–7 If patients are not managed appropriately, it is quite
Among some sub-groups of the population, such as possible to establish what has been referred to as a
middle-aged women, the prevalence of high dental vicious cycle of dental fear.14,15 Patients avoid making
fear may be as high as one in three individuals.1 The dental visits because of their fear, which results in a
impact that this relatively high level of dental fear in worsening of problems, requiring more intensive and
the community can have is appreciable. First, people potentially traumatic treatment, which then reinforces
with high dental fear are much more likely to delay or exacerbates the fear, which leads to continued
or avoid dental visiting,1,8–10 and a number of fearful avoidance.16 In Australia, estimates suggest that about
people regularly cancel or fail to show for appoint- 40% of people with high dental fear fit the vicious
ments. Second, people with high dental fear, children cycle profile.17 In this scenario, the patient, the dental
and adults, may prove difficult to treat, require more practitioner and the dental care system all lose out.
time, and present with behavioural problems which Given the negative impact of dental fear for all con-
can result in a stressful and unpleasant experience for cerned, it is important that patients with dental fear
both the patient and treating dental practitioner. are managed correctly. Like many countries, Australia
Research indicates that trying to manage patients with does not have an established referral pathway for
dental fear is a source of considerable stress for many patients identified with dental fear. Certainly,
dentists.11 Finally, dentally anxious individuals, the needs of some patients with high levels of dental
because of their avoidant behaviours, often have fear might best be met if they first receive psychologi-
poorer dental health.12,13 In particular, those people cal treatment in a non-dental setting. Additionally,
390 © 2013 Australian Dental Association
Management of fear and anxiety in the dental clinic
referral to a dental practitioner who specializes or has person’s dental fear, and these are discussed in more
an interest in treating fearful patients might be an detail below.
option which could be discussed with the patient.
Often, however, it is the treating dental practitioner
The nature of dental fear
who is solely responsible for managing their anxious
patients. Fortunately, there are numerous non-phar- Before making any decision regarding the use of spe-
macological practices which might be adopted within cific anxiety management approaches, it is important
a clinic or surgery in order to assist fearful individuals to be aware of the nature of a person’s dental anxiety
better progress through their dental care requirements. and fear because this can be a crucial determining
factor in managing the problem. While it has
generally been regarded that the underlying cause of
Fear, anxiety, phobia and pain
anxiety is the result of direct negative dental
This paper will mostly use the terms ‘fear’ and ‘anxi- experiences,25 the nature of dental anxiety is more
ety’ interchangeably, and they are very much related, complicated than what is commonly presumed. For
but it is worth noting that there are conceptual example, it has been proposed, and evidence suggests,
differences between these two terms. While there is that how a person perceives the dental environment is
considerable variability in their usage in the literature, a considerably more important determinant of dental
we refer to anxiety as an emotional state which pre- fear and avoidance than having had a previous dis-
cedes an encounter with a feared object or situation, tressing experience at a dental visit.25–27 Avoidance of
whereas fear refers to the actual, or ‘activated’, dental care might also be an aspect of some other
response to the object or situation. It is generally the condition, such as fear of social evaluation (as in
case, however, that a person will have a fear response social phobia), fear of germs (as in obsessive
to something that they experience anxiety about. Both compulsive disorder) or fear of being away from the
fear and anxiety can involve physiological, cognitive, safety of home (as in panic disorder with or without
emotional and behavioural components, although agoraphobia). Other psychological conditions, such as
how these are expressed may well vary from one depression, might also be related to reduced dental
person to another. In contrast to fear and anxiety, a visiting and increased dental need.28,29 Current evi-
phobia is more narrowly defined by a diagnosis from dence indicates that people considered to have dental
an appropriately trained psychologist or psychiatrist anxiety are also much more likely to have various
as a mental disorder comprising a marked fear or other comorbid psychological conditions.30–32 There
avoidance of a specific object or situation which either is also an observed association between dental anxiety
significantly interferes with a person’s functioning or and having been the victim of past sexual abuse.33,34
which causes considerable emotional distress.18 While All these various factors might be indirectly or directly
many people experience some anxiety and fear of implicated in a patient’s dental-related anxiety and
going to a dental practitioner along a continuum from should be determined when appropriate.
very mild to extreme, only a relatively small Dental anxiety and fear might also focus on various
percentage of people will have a clinically diagnosed aspects of the treatment experience, and specific
condition. concerns might be independent of other possible
The relationship between fear and pain is highly rel- concerns. The source of a patient’s anxiety might be
evant to dental practitioners. While pain is cued by a in relation to fear of gagging or choking, fear of injec-
physiological process it also has a strong cognitive tion, or a strong aversion to the sight or thought of
component, and people with dental anxiety can have blood. Patients might have concerns about perceived
both exaggerated pain expectancies and pain percep- problems with getting numb, might have a low pain
tions.19–21 Clinicians need to be aware that managing threshold or might have issues with trusting dental
patient pain is not the same as managing patients’ practitioners. And there will be differences in the
anxiety and fear. First, the actual act of administering willingness of different patients to talk about these
local anaesthesia by intraoral injection is, for many issues. Good communication skills and establishing
anxious people, one of the most stressful and fear- rapport with the patient are critical in these
evoking aspects of the dental experience.22 Second, circumstances (and are dealt with below).
while it appears that dentally fearful people do report More generally, dental practitioners should be
increased fear of pain,23 the extent of this varies from aware that the process of providing a dental examina-
person to person and there are numerous additional tion and carrying out treatment combines a host of
fear-evoking aspects of a dental visit unrelated to potentially aversive situations.26 Patients are generally
pain.2,24 There are also more general issues, such as placed in a reclined position, increasing their sense of
lack of control and the unpredictability of the dental powerlessness, and are afforded little control over the
experience, which may be central to the aetiology of a situation. Often the clinician’s probing, scraping and
© 2013 Australian Dental Association 391
JM Armfield and LJ Heaton
drilling are unpredictable from the patient’s perspec- allergic to or having had a ‘reaction’ to local anaes-
tive, who is unable to see into their own mouth, and thetics, particularly those that contain epinephrine or
this can heighten their perceived lack of control. In similar vasoconstrictor. They may also report
addition, the dental practitioner is literally inside the concerns that they will not be able to breathe with a
oral cavity of the patient which represents both an rubber dam in place, or that they may choke if too
intrusion into the patient’s personal space and a sig- many instruments are placed in their mouths at once.
nificant concern for people with heightened disgust In the case of a ‘reaction’ to local anaesthetic, the
sensitivity. And, despite considerable advancements in patient may have felt symptoms of autonomic arousal,
dental techniques and the modern idea of pain-free consistent with increased epinephrine levels (e.g. heart
dentistry, a recent Australian study found that 85% palpitations, shortness of breath, etc.). Patients (and
of the adult population are still at least a little anx- some well-meaning dentists) may interpret these
ious about painful or uncomfortable procedures when symptoms as an ‘allergy to the anaesthetic’. At the
they make a dental visit.2 These inherent aspects of next appointment in which anaesthetic is used, the
the current approach to delivering dental care might patient is likely to feel increased anxiety in anticipa-
help to explain the relatively high prevalence of dental tion of having another ‘reaction’. The autonomic
anxiety in the population. arousal associated with this anxiety is compounded
with any sensations brought about by the epinephrine,
leading the patient to feel as though the ‘reaction’ is
Typologies of dental anxiety and fear: guidelines for
worsening over time. Patients in this category will
management approaches
often ask dentists not to use anaesthetic with epineph-
Several typologies have been put forward to explain rine, increasing the risk of inadequate anaesthesia and
the different types of dental anxiety which might be pain during treatment. Ultimately, patients end up
seen in the clinic. Different levels, types and character- feeling as though they have no choice but to endure
istics of dental anxiety and fear will dictate different painful dental treatment because of their ‘allergy’ to
management approaches by the dental practitioner. At anaesthetic.
perhaps the most basic level, dental anxiety varies In addressing this type of fear, taking a full medical
across a continuum, from very mild anxiety to severe history, providing education and gradual exposure are
and debilitating dental phobia which might preclude a key. Although the prevalence of true allergies to local
person from dental visiting even when they are in anaesthetics is extremely small and most adverse
severe pain or discomfort. Milgrom and colleagues responses are ultimately determined to be anxiety-
have identified four different groups of fearful patients related,36 it is critical to take a thorough medical
who are argued to differ in terms of both their clinical history to determine if referral to an allergist is indi-
presentation and in the most appropriate treatment cated. Even in cases where it seems unlikely that a
approaches.25 This category system has been labelled patient has a true allergy to local anaesthetic, referral
‘The Seattle System’ and has been validated by Locker to an allergist to completely rule this out can be very
et al.35 effective in managing the patient’s anxiety. Patients
Individuals who are fearful of specific stimuli can with this fear do not respond well to vague reassur-
readily identify the aspect(s) of dentistry they find ances that ‘these allergies are really rare’ or ‘you’ll be
most aversive.25 While the most common of these fine’, but do respond well when dental practitioners
stimuli are typically injections, the sound/sight/smell take their concerns seriously. After ruling out an
of the drill or handpiece, and pain associated with allergy, education about the nature of epinephrine
dental treatment, fearful individuals may identify any and its effects can put the patient’s symptoms in con-
number of dental procedures or parts of the dental text. It can be helpful to explain that epinephrine and
setting as the one trigger for their dental fear. Treat- adrenaline refer to the same hormone secreted in the
ment for this type of fear involves gradually exposing body – many people can identify when they’ve felt an
the individual to the feared stimuli, encouraging the ‘adrenaline rush’ when they felt excited or scared in
patient to use relaxation strategies throughout to the past. As this is found naturally in the body, people
manage their anxiety levels. This method is called are not allergic to epinephrine, but some may feel
‘systematic desensitization’ and is discussed below. more sensitivity to its arousing effects (e.g. increased
Typically, once a patient in this category has a num- heart rate). After explaining the relationship between
ber of positive experiences with the feared stimuli, the anxiety and autonomic symptoms, the dentist may
fear extinguishes over time. then offer to inject a very small amount of anaesthetic
Individuals who are fearful of medical catastrophe with epinephrine to see how the patient feels. If the
fear that something will happen during treatment that patient feels increased autonomic arousal, the dentist
will cause a medical emergency, such as a heart should encourage the use of relaxation skills to slow
attack.25 Often, these patients will report being heart rate and breathing. As the patient learns to
control his or her autonomic arousal, the fear of a over on me’. They also worry about dentists and den-
dangerous reaction gradually extinguishes. For tal staff perceiving them in a negative light, and may
patients who fear choking or suffocating, gradually use sarcasm or thinly veiled insults. For example, after
introducing the feared stimuli in the presence of relax- being presented with an expensive treatment plan, the
ation skills as described above is helpful, specifically distrustful patient may ‘joke’ that he is paying for the
focusing on having the patient practice breathing and dentist’s new car or holiday trip. While these patients
swallowing with the rubber dam and/or instruments do not present as fearful in a classic sense, they do
in place. fear a loss of control or self-esteem at the hands of
Patients with generalized dental anxiety experience the dental providers, leading them to present in a con-
significant anxiety in anticipation of dental treatment frontational way to regain control of the situation.
and are not typically able to identify one aspect of Patients in this final category respond best to
dental treatment that is difficult for them.25 In fact, information and requests for permission. The dental
when asked what about dentistry is difficult, many practitioner should ask the patient if they may tilt the
patients in this category will respond, ‘it’s all terrible’. patient back in the chair, use particular instruments,
Many individuals in this category will also report and do an examination. All steps in the process
other fears, such as heights, water, and/or flying. should be explained to the patient so that he or she
Patients with generalized dental anxiety will often knows what is happening throughout the appoint-
report difficulty sleeping the night before an appointment. Patients in this category may wish to watch the
ment and feeling physically and/or emotionally procedures using a hand mirror, although not all
exhausted after treatment. The key to this category is patients will wish to do so. When presenting a treat-
worry: patients will worry about the procedure itself; ment plan, all options should be presented verbally
their own behaviour during treatment and whether and in writing, with the emphasis on the patient’s role
they will be able to manage their own anxiety; what in ultimately deciding what treatment to pursue. Dis-
future dental treatment they may or may not need; trustful patients will respond well to offers to take the
and whether the dentist and dental staff are perceiving treatment plan (and radiographs, if possible) to
them in a negative light because of their fear and oral another dentist for a second opinion; this will provide
health. reassurance to the patient that the dentist is confident
Patients who fit the generalized dental anxiety cate- in the treatment plan and not simply trying to push
gory respond very well to reassurance before, during the patient into the most expensive treatment options.
and after the procedure to help alleviate their worry. Of course, all patients – regardless of fear – should be
As these patients will worry about the future, redirect- presented with clear treatment options, but distrustful
ing them to the present is valuable (e.g. ‘Let’s plan to patients will be most likely to want a thorough discus-
talk about the root canal after we’re finished today; sion with the dentist of all possible treatment options
for now, let’s focus on this one small filling. This is a and the consequences of each. If the treatment plan
very straightforward procedure, and I’m confident should need to change (e.g. instead of a large restora-
you’ll do really well and be very happy with the tion, an endodontic treatment is now needed), this
results’). Gradual exposure to the dental setting will should be explained to the patient as far ahead of
be helpful, particularly for patients who have avoided time as possible, rather than having to explain the
treatment in the past. Feedback from the patient change in plan in the middle of the procedure. How-
about what he or she considers to be an ‘easy’ ever, once trust is established between these patients
procedure or step will help guide the progress of the and their providers these patients are relatively
treatment plan. Patients in this category will set straightforward to treat.
unrealistic expectations for themselves, wanting to
‘push ahead’ with treatment before they are able to
Identification and assessment
cope with their anxiety. Training these patients in
relaxation strategies and maintaining a gradual To work successfully with a fearful dental patient, a
exposure to increasingly invasive procedures allows dental practitioner must first identify that an individ-
the patient to gain a sense of mastery over his or her ual is scared or nervous, and then adopt an appropri-
anxiety, although they may always describe ate treatment approach tailored to that patient’s
themselves as a ‘nervous patient’. concerns. Indeed, most dental practitioners will
Finally, patients who are distrustful of dental attempt to elicit information from their patients about
personnel may come across as argumentative or possible dental concerns, but the approach can be
suspicious of the dental practitioners’ motives.25 They highly variable between dentists and from one patient
are concerned about not being in control of their to the next. However, and despite longstanding rec-
treatment and often complain that prior dentists ‘just ommendations for the use of structured dental fear
treated me like a set of teeth’ or ‘tried to pull one questionnaires during clinical assessment,37 the use of
dental anxiety measures in general clinical practice is you of dentistry?’) allow for standardization and ensure
believed to be limited.38 For example, a study that patients have an opportunity to voice an initial
investigating the practices of UK practitioners with a concern. There is evidence that using dental fear scales
declared special interest in treating patients with does not raise anxiety in anxious or non-anxious
dental anxiety, found that only 20% used adult dental patients.49 Further, and even if a decision is made to
anxiety assessment questionnaires.39 This is surprising not formally assess dental anxiety, it is possible that the
as managing dental anxiety requires a tailored mere act of asking fearful dental patients to report their
treatment approach which firstly requires the dental level of dental fear prior to treatment may reduce the
practitioner to be efficient at detecting the presence of patients’ level of state anxiety.50
anxiety.40 While the identification of a fearful patient
can happen at various points, the earlier a dental
Matching anxiety management practices to identified
practitioner can determine that a patient is fearful, the
anxiety levels
greater the likelihood of success in working with the
patient.25 It is generally considered to be the case that when a
The UK-based study by Dailey et al.39 is the only patient exhibits only mild anxiety and they present
published paper reporting the use of dental fear without other complications they can be helped by
screening questionnaires by dentists. In Australia, establishing a trusting relationship and by providing
there is as yet no evidence of their use or non-use realistic information about the dental treatment.51
among dental practitioners. In terms of addressing the Relatively simple anxiety reduction strategies can also
widespread dental fear in the community, this knowl- be employed, such as providing the patient with a
edge gap is problematic. Adding to the issue is a sense of control and predictability in relation to
concern that chairside assessments of patient anxiety treatment. These various management approaches are
and fear might be inadequate or inaccurate. Evidence discussed in more detail below.
out of the US indicates that a dentist’s assessment of Either greater anxiety or increased treatment
patient anxiety has only a small-to-moderate correla- need may necessitate other anxiety management
tion with the patient’s self-reported anxiety using approaches.51 Those people with mild or moderate
several different dental fear scales.38 anxiety but with greater or more acute treatment need
The proper screening of dental anxiety and fear by may require specific pharmacological support (such as
dental practitioners will determine which treatment nitrous oxide or oral sedation) in addition to the use of
approaches to adopt and is a fundamental first step in strategies such as distraction, relaxation, or the devel-
managing patient anxiety. As stated above, it is recom- opment of better coping strategies. High levels of anxi-
mended that a structured, psychometrically valid scale ety may necessitate some form of cognitive-behavioural
be used in addition to the dental practitioner’s ques- intervention (perhaps via referral to a psychologist)
tions for the patient. There are several instruments such as systematic desensitization, cognitive restructur-
which are freely available for this purpose, useable for ing or hypnosis. These more complicated approaches
both adults and children.41–43 For example, the Modi- involve treating the anxious patient using well-devel-
fied Dental Anxiety Scale (MDAS) contains five items, oped psychological practices and might require addi-
is reliable, and is quick to administer.44 Another scale, tional training in order to be successfully employed.
the Index of Dental Anxiety and Fear (IDAF-4C+), con- Where the urgency of treatment need is high, in
tains an eight-item module measuring the physiologi- addition to high levels of anxiety, possible approaches
cal, cognitive, emotional and behavioural components to patient management might involve intravenous
of dental fear and an additional 10-item stimulus mod- sedation, conscious sedation or general anaesthesia
ule designed to assess possible areas of specific con- (GA). Because of the absence of training in and
cern.45 The scale compares favourably to other scales, availability of these approaches in many dental
is short enough to be used for effective screening of surgeries, such cases will often necessitate referral to
dental anxiety, and is flexible enough to allow addi- someone equipped to provide such services. Surgery
tional investigation of specific concerns if that is under GA should be regarded as the last treatment
deemed to be warranted. For children, special scales option as there is no evidence that this provides any
have been developed, such as the Modified Child Den- benefit to the highly anxious patient beyond meeting
tal Anxiety Scale46 and the Facial Image Scale,47 which their immediate treatment needs, but may have
use graphical representations of smiling and frowning negative repercussions such as increasing dental fear
faces to measure child anxiety. However, even simple and anxiety.52,53 However, in some instances,
single-item questions such as the omnibus item from especially if a patient is in severe pain or is suffering
the Dental Fear Survey25 (‘All things considered, how from oral malfunction due to considerably deterio-
fearful are you of having dental work done?’) or the rated oral status, a first dental treatment under
Dental Anxiety Question48 (‘Generally, how fearful are sedation may be indicated.54
Enhancing trust and control the ‘iatrosedative technique’, which involves a

systematic approach aimed at making the patient calm
Bernson and colleagues conducted interviews with
by the dental practitioner’s behaviour, attitude, and
dentally fearful individuals who were able to seek reg-
communicative stance.61,62 More simply, iatrosedation
ular dental care.55 When asked what skills they used
is a process of communication between the dental
to be able to complete treatment, two of the four key
practitioner and patient that creates a bond of under-
themes that emerged were ‘trust-filled interaction with
standing, trust and confidence.63 Ultimately, rapport,
staff’ and ‘striving for control’ (p. 375). Building trust
communication and trust form the backbone of any
in the staff included communicating and cooperating
anxiety management approach.
with members of the dental team. Developing a sense
of control, meanwhile, involved taking an active role
in one’s own care and communicating one’s wishes to Information
the dentist and staff. The overall theme that emerged
Providing patients with information about procedures
from these interviews was that fearful individuals see
can help correct misconceptions patients may have
receiving dental care as a mutual effort on the part of
about treatment, such as what sensations can be
both the patient and the dental practitioner, and that
expected and the anticipated length of treatment. Such
both parties need to make efforts to make the treat-
information is also helpful in increasing a sense of pre-
ment proceed smoothly. Below, we describe several
dictability during the procedure. The usefulness of pro-
techniques that both dental staff and patients may use
viding information often relies on the type of
to facilitate the dental treatment process.
information given, when it is given, and patients’ pref-
erences for information.64 A distinction should be
made between the types of information given to
Rapport and communication
patients. Sensory information tells patients what they
Early research in dental fear focused on dentist can expect to feel (e.g. pressure, vibrations) while pro-
characteristics associated with patient satisfaction and cedural information tells patients the order in which
anxiety reduction. Corah and colleagues surveyed parts of the procedure will happen (e.g. administration
patients and found that patient satisfaction was of the local anaesthetic, followed by placement of the
associated, in part, with the rapport patients felt with rubber dam, then use of the handpieces). Some patients
their dentists.56 Specifically, dentists’ friendliness and prefer to know about the procedure generally at the
providing patients with moral support were important start of the appointment, while others may prefer a
factors in patients’ satisfaction with care. With regard ‘play-by-play’ description of the treatment as the
to reducing anxiety, patients were most concerned appointment progresses. Dentists are well-served by
with their dentists’ explicit statements about prevent- asking patients prior to the start of the procedure what
ing pain.57 Interviews with dentally fearful patients type of information they would prefer and when, so
revealed that dentists’ understanding and acceptance that the correct amount of information is provided at
of patients’ needs and concerns were more important the appropriate time.
than their technical competence.58
Communication between the dental practitioner and
Providing control
patient is crucial for a productive working relation-
ship that results in competent clinical care. Hamasaki Tell-show-do
and colleagues found that patients who felt positively One way of reducing uncertainty and increasing pre-
about their communication with their dentists had dictability is to use the ‘tell-show-do’ technique. This
better outcomes related to satisfaction and lower fear involves an explanation of what is about to happen,
than those who felt less positively about their dentists’ what instruments will be used and the reasons for this
communication.59 (the ‘tell’ phase), followed by a demonstration of the
There now exists a considerable body of writing on procedure (the ‘show’ phase). The ‘do’ phase is then
dentist communication skills22,25,60 and it is beyond initiated by carrying out the procedure. Despite its
the scope of this article to adequately cover this popularity amongst dental practitioners65,66 and its
material. However, essential elements of good widespread acceptance by paediatric patients and
communication involve establishing an effective two- parents in several countries around the world67–70 the
way interaction, genuinely acknowledging (rather than ‘tell-show-do’ technique has not received very much
dismissing) patient concerns, attending to non-verbal research into its effectiveness.64 One study conducted
cues, effective listening and accurate reflection of what in Venezuela found that children assigned to a tell-
the patient says, demonstrating empathy, and using show-do condition had no evidence of increased blood
appropriate voice and tone. Related to the develop- pressure in comparison to the increase experienced by
ment of good communication is what has been called the no-psychological treatment group.71 Tell-show-do
has been shown to be efficacious in reducing anticipa- or restless. This may involve checking in briefly with
tory anxiety in new child patients although it is less another patient or staff member, or just allowing the
useful for children with previous dental experience.72 patient to stand up or use the bathroom.
Despite the limited available evidence, it has been Regardless of who initiates the rest break, the idea
recommended for use with any patient and has no is to pause the procedure prior to the patient
specified contraindications.73 becoming too anxious to proceed. Whether dental
Although the ‘tell-show-do’ technique was originally practitioners are encouraging their patients to signal
developed for use with children, it can also be applied for a rest break or scheduling breaks in advance,
to anxious adults where it can foster a sense of both pausing the procedure allows patients to calm
control and predictability. One variation reportedly themselves and proceed with treatment. If dental prac-
used with adults is ‘explain-ask-show-do’, which aims titioners wait to pause the procedure until their
to establish a situation of mutual cooperation.74 In this patients are too anxious to proceed, the patients may
variation, each key stage involves explaining what the be unable to calm themselves and the procedure may
dental practitioner would like to happen or suggesting be terminated prematurely, potentially compromising
a next step in the patient’s care, answering any ques- the quality of care.
tions that the patient might have and then, once the
patient receives all the information that they need, ask- Signalling
ing permission to proceed to the ‘show’ and ‘do’ stages. Being able to signal for the dentist, therapist or
This process attempts to balance the fears and phobias hygienist to stop treatment is a key component of
of the patient against the desire to make progress while building communication and trust between the patient
simultaneously respecting where the patient is currently and dental practitioner. Many dentally fearful individ-
at, both physically and emotionally. However, there uals recall experiences in which they felt their dentists
has been no known research into the effectiveness of did not know they wanted to stop treatment (e.g. if
this approach. they felt pain), or did not respond to the patients’
requests to stop. By giving the patient a means to
Rest breaks communicate with the dental practitioner during the
Either the dental practitioner or patient may initiate procedure (to which the dental practitioner is sure to
breaks during a procedure. Many dentally fearful respond), the patient’s sense of control and trust
individuals feel the need to continue with a proce- increases. A signal can be as simple as a raised hand
dure until they ‘can’t bear it any longer’, at which to notify the dental practitioner that the patient would
time it is more difficult for patients to calm them- like to stop the procedure. Specific signals can be
selves down enough to continue with the procedure. determined ahead of time; e.g. a raised hand means
When the patient initiates a rest break (usually stop, while a raised index finger may ask the assistant
through signalling, as discussed below), being able to to use the suction device (an alternative is that the
pause the procedure can increase the patient’s sense patient is allowed to control their own suction). Singh
of control over treatment. Dental practitioners should and colleagues provided patients with an electronic
be sure to communicate to their patients at the start communication system that allowed patients undergo-
of appointments that they (the patients) are able to ing endodontic therapy to communicate that they: (a)
indicate that they would like a break at any time in were feeling pain; (b) were feeling giddy or light-
the procedure. headed; (c) needed additional suction; (d) were feeling
Dentist-initiated rest breaks are particularly helpful tiredness in their jaws from prolonged mouth opening;
when treating patients who are not assertive or want or (e) wanted to know how much longer the proce-
to ‘push through’ an appointment as quickly as possi- dure would take.75 Patients using this system reported
ble. Some patients do not wish to request a rest break, significantly lower dental fear scores after treatment
for fear of appearing to be a ‘difficult’ patient. Dental than patients being treated in a usual manner. While
practitioners can plan the rest breaks in advance; such the signalling technique may be as simple or complex
as telling the patient they will work for five minutes, as is desired by the dental practitioner or patient, the
then take a one-minute break. This increases the key component to signalling is to facilitate communi-
patient’s sense of predictability and control over the cation and to enhance the patient’s trust that the clini-
procedure, as he or she can watch the clock and antic- cian will respond appropriately to their signal.
ipate the upcoming break. As an alternative, patients
can be allowed short breaks (involving closing their
Other psychological approaches to managing dental
mouth and resting) whenever there is a pause in treat-
anxiety
ment for some reason. Dental practitioners should
also take an unscheduled break in procedures if they In addition to the relatively simple techniques such as
feel their patients are becoming increasingly anxious providing information, tell-show-do and signalling,
there are several psychological approaches to manag- Positive reinforcement

ing dental anxiety and fear which can be used in the
Particularly in relation to children, but also for adults,
clinic. These range in complexity from those that are
positive reinforcement in terms of small tangible
relatively easy to carry out to others requiring
rewards or verbal acknowledgement might provide a
specialized training.
useful incentive for cooperation or appropriate behav-
iour. In relation to children, it is believed that it is not
Distraction possible to have too much reinforcement, although
the clinician should attempt to be genuine in their
There is evidence that focusing attention on specific
offering.85 Positive reinforcement, and positive
alternative visual or auditory stimuli in the dental
feedback in particular, is considered to be a univer-
clinic might be beneficial for patients with mild to
sally accepted behaviour management technique when
moderate dental anxiety. While several options are
providing dental care to children86 and is based on
available for the clinician, ranging from background
longstanding psychological principles that have been
music to television sets to computer games to 3D
consistently demonstrated to be effective.87 Many
video glasses for watching movies, there is currently
dental practitioners are encouraged to use positive
mixed evidence regarding the effectiveness of these
reinforcement to obtain cooperation with dental pro-
distraction practices in the dental clinic. For example,
cedures. However, the effect of positive reinforcement
while a meta-analysis of 19 randomized clinical trials
in relation to dental self-care behaviours, or behaviour
found that music therapy reduces pain and anxiety for
when visiting a dental professional, has received little
children undergoing medical or dental procedures,76 a
scientific evaluation.88
recent study of adults undergoing third molar
A related anxiety management procedure makes use
extraction found only small reductions for a music-
of the often powerful motivation of anxious individu-
treated group in interoperative anxiety and no differ-
als to ‘escape’ the fear-inducing situation. In this tech-
ence in pain perceptions compared to a non-music
nique, which is similar to signalling, brief periods of
control group.77 The results of an early study by
‘escape’ from ongoing dental treatment are provided
Corah and colleagues indicated that musical pro-
to a person contingent upon cooperative or appropri-
grammes, at best, resulted in a placebo effect.78
ate behaviour. Positive verbal reinforcement and a
A more recent study of German dental patients found
brief period of escape (5–10 seconds) are rewarded
that although music distraction reduced dental anxiety
for the patient lying still and being quiet, while dis-
significantly compared to a control group, the effect
ruptive behaviour delays escape until cooperation is
was significantly less than that produced by a brief
regained.89
relaxation method and that it worked only for mildly
anxious patients, having no clinical relevance for
highly anxious patients.79 Nonetheless, given the ease
Diaphragmatic or relaxation breathing
of introducing music distraction into the clinic, and
the absence of any known deleterious effects, the One exercise which is believed to be of benefit to almost
potential for positive outcomes and stated patient every fearful patient is relaxation through paced
preference would recommend it for more systematic breathing.25 The physiologic changes accompanying
and widespread use. relaxation breathing, or diaphragmatic breathing, effec-
Both visual and auditory distraction is now avail- tively form a counterpart to, and are therefore incom-
able through the use of goggles capable of showing patible with, the emergency ‘fight or flight’ reaction
2D and 3D vision accompanied by surround sound. characterizing anxious individuals.90 It is difficult to be
While immersive virtual reality goggles have been tense and to breathe from your abdomen at the same
found to reduce blood pressure, pulse rate and pain time.91 Because of this, relaxation breathing has been
ratings in patients undergoing periodontal scaling and used effectively across a wide range of situations to
root planing procedures,80,81 another series of studies combat anxiety. However, while it is believed that
by Benson and colleagues found that video glasses did relaxation breathing can also be effective in reducing
not alter perceived pain intensity of either restorative perceived pain,92 the evidence has been more equivocal
dental treatment82 or dental scaling.83 More research than that for anxiety reduction. While a systematic
is required to explore whether the effectiveness of this review covering the period 1996–2005 found no associ-
type of distraction is perhaps dependent on patient- ation between rhythmic breathing relaxation and pain
related factors, such as personality attributes related relief in a single identified study,93 one recent study has
to desire for predictability or control. There is shown that relaxation breathing does appear to lower
evidence, however, that audiovisual distraction might both anxiety and perceived pain.94 This is, perhaps, not
be beneficial for children who are anxious or uncoop- surprising as the association between greater anxiety
erative in the clinic.84 and increased pain perception is now well established
in the dental literature.95–98 Anxiety is known to upre- 1–2 weeks), in order to master the technique.25 There
gulate the sympathetic nervous system which, in turn, are several specific muscle sequences that can be used
is believed to decrease the pain threshold.99 for practising progressive muscle relaxation but,
There are several variations on relaxation breathing. regardless of the sequence, each muscle is tensed to
For example, Milgrom et al. describe a procedure approximately 75% of full tension, held for between
whereby patients are taught to take slow, deep breaths, 5 to 10 seconds, and then relaxed for about 10 sec-
holding each breath for approximately 5 seconds, before onds, with attention focused on the feeling of tension
slowly exhaling.25 Slow, steady breathing for 2–4 min- and then the specific sensations of muscle relaxa-
utes is regarded as effective in reducing a patient’s heart tion.106 Even if the full sequence of steps are not used,
rate and making anxious patients noticeably more com- smaller or fewer steps may still produce benefits such
fortable. Ackley, on the other hand, advises that patients that teaching the patients and using this technique at
should be asked to breathe so slowly that if a feather the clinic is worth trying.
was under their nose it would not move.100 These
breathing techniques can be taught quite easily at the
Guided imagery
dental clinic and can be practised at home by the patient
prior to an initial examination. Physiological monitoring Sharing similarities with distraction, guided imagery
of breathing via a heart rate monitor or some other bio- involves patients mentally taking themselves to a
feedback device might be useful for both the patient and pleasant or relaxing place. This technique removes the
dental practitioner,25 and has demonstrated effective- focus on the dental procedure and can usefully be
ness in reducing dental anxiety and negative feelings combined with relaxation techniques. To train the
regarding a dental injection.101 patient to use imagery, patients should practice in an
office and should be encouraged to sit quietly, slow
their breathing, relax their muscles and then to picture
Progressive muscle relaxation
a place of peace and relaxation that they find to be
Progressive muscle relaxation is a systematic tech- particularly pleasant for them. The dental practi-
nique initially developed several decades ago102 and tioner, using a calm and relaxed manner, guides the
subsequently standardized for use by therapists patient through the scene, attempting to engage as
and researchers.103 The procedure has been widely, many of the patient’s senses (sight, sound, touch,
and successfully, used to manage and treat a variety smell) and memories as possible. Once this technique
of anxiety disorders.104 In addition, it has been shown is mastered, it can then be used while the patient is in
to be effective when treating people with dental anxi- the dental chair with the dental practitioner again
ety. For example, in comparison to a cognitive ther- guiding the patient through the imagined scene.
apy, progressive muscle relaxation has been found to
result in a more significant reduction in dental fear
Cognitive restructuring
and general anxiety.105
The process of progressive muscle relaxation is While distraction and guided imagery aim to shift a
based on the basic principle of muscle physiology, patient’s attention away from the fear-evoking situa-
that when a muscle is tensed, releasing the tension tion, cognitive restructuring aims instead to alter and
then causes relaxation in the muscle. Further, a mus- restructure the content of a person’s negative cogni-
cle that is tensed and then relaxed does not merely tions as well as to enhance the individual’s control
return to its pretension state, but becomes even more over such thoughts. The process involves identifying
relaxed, especially if it is allowed to rest. The basic the misinterpretations and catastrophic thoughts often
process of progressive muscle relaxation requires the associated with dental fear, challenging the patient’s
patient to focus on specific voluntary muscles and, in evidence for them, and then replacing them with more
sequence, tense and then relax the tension in that realistic thoughts. Evidence for the potential effective-
muscle. As the tensing and relaxing sequence ness of cognitive restructuring in dental fear has
progresses, other aspects of the relaxation response mostly come from studies of dental patients seeing
also naturally occur: breathing becomes slower and clinical psychologists105,107 but there is some evidence
deeper, heart rate and blood pressure declines, and that the skills required to carry out cognitive restruc-
vasodilatation in the small capillaries of the extremi- turing are within the reach of dental practitioners,
ties may occur, creating a subjective sense of calmness through special training and supervision.108
and ease.106
The procedure used in progressive muscle relaxation
Systematic desensitization
is relatively simple but will require an investment of
time, firstly to teach the patient and then for the Systematic desensitization involves gradually exposing
patient to practice at home (once or twice per day for a fearful individual to the aspect of dentistry they find
frightening while encouraging them to use relaxation perceptions, feelings, thinking and behaviour by
strategies to reduce their anxiety. For example, for a asking them to concentrate on ideas and images in
patient who is fearful of injections, the dental practi- order to evoke an intended effect.114 During hypnosis
tioner may first show him or her the syringe and a person enters into a particular frame of mind char-
explain its parts and purpose (e.g. most dental syringes acterized by focused attention and dis-attention to
are long and thin to allow access to the rear of the extraneous stimuli which is not entirely dissimilar to
mouth) until the patient is able to view and hold the that experienced when a person is lost in thought, in
syringe with little to no anxiety. Next, the dental prac- a daydream, or being absorbed in a book.115 While
titioner may place the syringe with the needle capped in hypnosis can be used for a large number of dental
the patient’s mouth to simulate the injection, holding issues, its benefit for managing dental anxiety is that
the syringe in place for the length of a typical injection. ‘suggestions’ can be made to a patient which result in
The patient should be encouraged to use relaxation behavioural, cognitive or emotional change.
strategies to manage the inevitable anxiety caused by Specifically, it can be used to understand why dental
this exercise, and this step is repeated until the patient anxiety developed, resolve feelings about past experi-
expresses little to no anxiety. The dental practitioner ences, rehearse and help desensitize future treatments,
may then place the syringe with the needle uncapped, overcome embarrassment, and can be used to comple-
reassuring the patient that they will not move ahead ment local anaesthetics.115 While hypnosis has been
with the injection without the patient’s permission. demonstrated to be effective it needs to be matched to
Similar to the ‘cap-on’ step, the patient practices relax- the right patient and, if used inappropriately, can lead
ation skills and the step is repeated until the patient to a loss of confidence in the dental practitioner and
feels little to no anxiety. Finally, the dental practitioner the treatment process.116 In addition, hypnosis
– with the patient’s permission – may proceed with the requires specialized training and experience beyond
injection, replicating the location and length of time that provided in a standard university curriculum.117
demonstrated in the previous steps. For those dental practitioners who are interested in
Systematic desensitization has been shown to be incorporating hypnosis into their clinical practice,
effective. For example, Hakeberg and colleagues training opportunities through local dental societies or
found that dentally fearful patients completing a sys- universities should be sought.
tematic desensitization programme showed greater
fear reduction and an improvement in mood after
Clinical practice and treatment approaches for
receiving dental treatment compared to those patients
managing dental anxiety
pre-medicated with diazepam prior to dental treat-
ment; these results remained consistent at 10-year fol-
The clinic environment
low-up.109 The process of exposure can be further
systematized by using video-based exposure. As an Some patients are believed to associate the distinctive
example, a computer-based systematic desensitization sights, sounds, smells and sensations of the dental
programme named CARL (Computer-Assisted Relaxa- environment with feelings of anxiety and anticipation
tion Learning) has been developed to help reduce fear of pain.118 It has been suggested that reducing these
of dental injections.110,111 Individuals view a series of stress-triggers is an effective procedure for managing
video segments in which a fearful patient is taught anxious patients.119,120 Indeed, studies have found
coping skills (including diaphragmatic breathing and that changing aspects of the clinic environment,
progressive muscle relaxation, as described above) including appearance and odour, can have an effect
and then taken through the gradual steps of a dental on perceived anxiety. For example, a randomized-con-
injection. In a randomized clinical trial, individuals trolled trial carried out in the UK found that dental
completing the CARL programme showed greater fear patients exposed to a lavender scent while waiting for
reduction than individuals receiving an informational a scheduled appointment exhibited lower state anxiety
pamphlet about dental injections,112 and fearful than did control patients.121 This study is consistent
patients have found CARL to be an acceptable way to with the results of earlier studies using lavender or
reduce their dental injection fear.113 Whether done in orange scent in dental waiting rooms.122–124
person or via computer, systematic desensitization Altering the physical environment may also affect
allows patients to learn to reduce their anxiety while anxiety. For example, a study of dentally anxious
taking ‘baby steps’ through procedures. students found a stated preference for offices
with adorned rather than bare walls and for a slightly
cooler temperature.125 In a more extensive environmen-
Hypnosis
tal change involving a partially dimmed room with
Hypnosis has been defined as an interactive process lighting effects, vibroacoustic stimuli and consistent
whereby a hypnotist attempts to influence a person’s body pressure (a so-called Snoezelen environment),
greater relaxation resulted than in a standard operatory vibrations, and that it avoided local anaesthetic injec-
for children undergoing a scale and polish by a dental tion and continued numbness, which have been found
hygienist.118 It should be noted, however, that the liter- to be sources of considerable anxiety.135
ature in this area is sparse and considerably more
research is required before specific recommendations
Treatment planning
can be made in relation to altering the clinic environ-
ment in order to reduce dental anxiety. It is strongly recommended that treatment planning
for highly anxious people be both flexible and intro-
duced to the patient in phases.25 The important ele-
Alternative methods for tooth preparation
ment here is not to overwhelm anxious individuals
It has been argued that newer methods of restorative who may already be catastrophizing about the dental
dentistry, such as atraumatic restorative treatment visit, including the extent of treatment required.136
(ART), air abrasion, and infrared lasers, may reduce Phasing treatment also allows time for the patient to
some of the painful or uncomfortable aspects of learn and practise some of the behavioural strategies
dentistry, therefore reducing anxiety and fear of pain suggested in this article. The sequence and timing of
during treatment.119,120 This makes intuitive sense, treatment phases needs to be flexible. This means that
given that the ‘drill’ has long been listed as one of the should a patient begin to show high levels of stress or
most anxiety provoking items in the dental office.126,127 fear during a treatment session, it may be advisable to
More recently, a study by Oosterink and colleagues halt treatment and set mutual and more realistic goals
found that ‘dentist drilling your tooth or molar’ was for future appointments.117
the seventh most anxiety-provoking stimuli out of a list It is recommended that the treatment sequence com-
of 67 potentially anxiety-provoking stimuli.24 mence with techniques that are the least fear-evoking,
While the effectiveness of ART has received much painful and traumatic.117 The initial treatment phase
research attention, results for the role of ART in should be restricted to procedures designed to increase
reducing anxiety have so far yielded inconclusive the patient’s ability to tolerate treatment and desensi-
results. While two studies of 6–7-year-old children tize the patient to the dental environment, helping to
have found no difference in anxiety between children build trust with the dental professional. One example
undergoing ART and those undergoing traditional is the common practice of undertaking tooth cleaning
restorative treatment for caries,128,129 a study of chil- coupled with oral medication and other effective pain
dren and adults in South Africa concluded that ART control. More extensive or complex procedures, such
leads to lower dental anxiety in contrast to traditional as tooth extraction or root canal treatment, is better
restorative techniques.130 Similarly, while one review left to the second or third phase of treatment.25
of the literature on ART suggests ‘that it is a suitable Using a phased treatment planning approach, con-
approach to be used in children, the elderly, special siderable care must be taken to assist the patient
needs patients, or patients who demonstrate fear and complete treatment. A study among highly anxious
anxiety towards dental treatment’ (p. e672),131 UK patients referred for sedation at a special treat-
another review concludes that the association between ment clinic found that while attendance for treatment
different restorative procedures and dental anxiety, planning and initial treatment was high, only 33% of
pain and discomfort is contradictory and requires fur- the referred individuals ended up completing treat-
ther investigation.132 ment.137 Given the significant reluctance of anxious
For people who feel anxiety in relation to the noise, individuals to attend a dentist, it is important to lower
vibration, discomfort or pain of a standard rotary the perceived barriers to treatment. This might mean
drill, air abrasion offers another worthwhile alterna- determining management approaches such as proceed-
tive. In addition, it reduces the need for anaesthesia, ing slowly, having rest breaks, applying muscle relax-
which is a source of concern for many anxious chil- ation, or using some form of distraction.25 Also
dren and adults. As a result, using air abrasion is important, given the often significant concerns regard-
highly marketable by clinical practices.133 Again, ing the cost of dental treatment,9 is that the estimated
although air abrasion is assumed to be anxiety reduc- costs and insurance coverage for the initial treatment
ing because of its operational properties, little phase is openly and realistically discussed and agreed
research has been conducted to test this assumption. on by the patient.
However, one paper from the UK did find that air
abrasion produced appreciably less pain and anxiety
Scheduling appointments
than the use of local anaesthetic and drill.134 The
study reported that the most welcome aspect of air It is generally recommended that fearful individuals
abrasion was that it was pain-free, quick, avoided schedule appointments for a time when they are not
unpleasant aspects of the drill such as the noise and rushed or stressed. Early in the morning is often a good
time because it circumvents a patient stressing about Distraction

the visit all day and avoids the likelihood that there will
Although distraction techniques have been discussed
be a delay in being seen when the patient arrives at the
in relation to adults, there are several additional meth-
clinic. It might be worthwhile for the anxious patient to
ods of distraction that might be employed with chil-
bring a close friend or relative along to the first
dren. For example, if the child is playing with a toy in
appointment, to act as both an advocate and social sup-
the waiting room, it is possible that the toy might also
port for them. In between appointments, it is worth-
serve to distract the child in the dental chair.85 Engag-
while that additional contact be made in order to
ing with a child in a discussion about a pleasant topic,
support the patient in committing to attending the next
asking the child to visualize a pleasant experience, or
scheduled appointment. It should be noted, however,
giving the child a counting task might be beneficial di-
that while these recommendations relating to schedul-
stracters.85 In a 1991 study of dentists who were
ing appointments might make intuitive sense there is
members of the Australian and New Zealand Society
currently no empirical research which establishes the
of Paediatric Dentistry, relatively high percentages
effectiveness of appointment scheduling practices on
indicated that they furnished play materials in waiting
either dental anxiety or appointment cancellation.
areas (63%) or let the child hold a toy, mirror etc.
Therefore, there remains a need for considerable
(53%) as an approach to managing anxious or diffi-
research effort in order to establish an evidence base in
cult children.65 While the effectiveness of these indi-
this area of dental anxiety management.
vidual anxiety management approaches has not been
assessed, a study which gave children the option to
Management of dental fear and anxiety in children choose between a range of audio distractions (e.g.
music, soundtracks, audio stories) had significantly
Much of the preceding discussion of non-pharmacolog-
fewer uncooperative and more satisfied children than
ical management approaches for dental fear and anxi-
in the control group.143 Other studies have demon-
ety is as applicable to children as it is to adults.
strated benefits for using contingent distraction, where
However, children also present their own set of unique
access to a distracter, such as a personal music player,
challenges for the clinician. Also, the effectiveness of
is dependent upon cooperative behaviour and is
some of the abovementioned approaches will be greater
removed (negative reinforcement) for uncooperative
or lesser when working with children. In this regard,
behaviour.144,145 These studies found decreased levels
the developmental level of the child might be of critical
of disruptive behaviour compared to either a non-con-
relevance. In particular, reinforcement and distraction
tingent distraction group, or control group. It is worth
might work well for all children while providing more
noting, however, that these studies are now three dec-
information about the treatment procedures might be
ades old and that replication of these results among
less valuable depending upon the age and interest of
today’s children is necessary to assess their continued
the child. There are also behaviour management
validity.
approaches which are particularly suitable for children
rather than adults, and these shall be discussed below.
Cognitive restructuring
Modelling
There is evidence that information provided about a
The idea behind modelling is that one person’s behav- medically-relevant event, after the event has occurred,
iour can be altered as a result of them observing may influence both the memory of that event and the
another person performing a given behaviour.138 Mod- future.146,147 Only one study has so far been carried
elling in other health settings has been well studied139 out in a dental setting, which aimed to restructure
and research has demonstrated that children can also fear and pain memories of 6–7-year-old children
benefit from viewing other children or their parents receiving restorative treatment.148 In that study, an
undergoing dental treatment, without fear reactions or intervention comprising four components attempted
aversive consequences.139–141 It has also been sug- to alter cognitions around a dental experience. At the
gested that modelling might be particularly efficacious beginning of the second visit of a course of care, chil-
as a preventive measure with children who have not dren were: (1) shown pictures of themselves smiling
had previous exposure to dental treatment.142 Model- during the first visit two weeks prior; (2) asked to ver-
ling can be easily presented for viewing on televisions, balize to their parents how brave they had been previ-
computers or handheld devices or can be done live ously; (3) provided with concrete examples of their
using a parent or significant other person in the child’s previous positive behaviours; and (4) provided a sense
life. Filmed modelling can be considered a particularly of accomplishment for their past effort. After the sec-
economical approach as it does not require extensive ond visit, children in the intervention group had
chairside time.86 decreased memory of fear and pain at the first visit
and had appreciably improved behaviour. It is sug- of parents in Brazil157 and Israel,158 for example, have
gested that such an approach is easily adaptable to found strong support for the use of voice control,
clinical practice and can be used both as a preventive studies in the US67 and Saudi Arabia159 found voice
behaviour management technique and also as a control to be one of the least accepted techniques by
backup in case of a failure of traditional behaviour parents. Also relevant is how children feel about voice
management techniques.148 control. One study of children in England found not
only low acceptability (29%), but relatively high
unacceptability (29%), and children with higher fear
Restraint
were the least accepting of the technique.160 Given
There are several behavioural management techniques the importance of trust when managing children with
which involve the forced restriction of a child’s move- dental fear, it is important to weigh up not only the
ment, also somewhat euphemistically called ‘protec- estimated effectiveness of the technique and its accept-
tive stabilization’.86 These include mechanical ability to parents, but also assess what effect voice
restraints such as the ‘papoose board method’ and control might have on the larger issue of the child’s
physical restraints such as the hand-over-mouth exer- level of trust with the dental practitioner. Certainly,
cise, or holding the child down by the dental practi- some adults with dental phobia express concerns
tioner or parent. It should be noted that all restraint regarding social powerlessness associated with embar-
methods are considered controversial and are not uni- rassment or distrust of dentist behaviours often stem-
formly accepted.129 While the American Academy of ming from being poorly treated by a past dentist.161 If
Pediatric Dentistry, for example, recommends the use using a raised voice works in the short term to gain
of restraint only in instances where safety might be a compliance in the dental chair, but leads to lasting
concern and when ‘no other alternatives are avail- feelings of resentment and distrust in the child, the
able’, there is a contrary opinion that unless the situa- process may do more harm than good when it comes
tion is potentially life-threatening, the process is to managing dental anxiety. Certainly, more research
entirely unacceptable, perhaps even inhumane.149 In is needed in this area before definitive recommenda-
Australia, while the use of hand-over-mouth to con- tions can be made.
trol serious behavioural disturbances in children has
not been practised for decades, there has been greater,
CONCLUSIONS
albeit only occasional use, of gentle restraint or get-
ting parents to restrain their children.65 Leaving aside The preceding discussion demonstrates that there is a
the professional, legal and ethical issues of forced broad range of techniques that may be applicable for
restraint, there is no evidence that any form of this the non-pharmacological management of dental fear
procedure is beneficial for children with dental fear. and anxiety. Ideally, these techniques should not be
Indeed, physical restraint by a dentist has been impli- applied in a ‘cookbook’ fashion, but should be inte-
cated as a significant cause of dental anxiety.150,151 grated into a broader and more comprehensive
approach to patient management. Some dental practi-
tioners may find that many people with low or moder-
Voice control
ate fear can be effectively managed with good
Voice control is a punishment technique involving a con- communication skills, empathy, careful treatment and
trolled alteration of voice volume, tone, or pace which, some basic non-pharmacological approaches such as
more specifically, equates to issuing commands in a loud relaxation or distraction. More fearful individuals may
voice in order to reduce a child’s disruptive behav- require more time and effort, employing different tech-
iour.152 The American Academy of Pediatric Dentistry niques, before they are prepared to undergo treatment
recommends voice control as an approach to influencing and then successfully return to receive treatment in the
and directing children’s behaviour.73 This is consistent future. While not covered in this article, some patients
with findings from both the UK, indicating that many may find the use of sedation to be desirable and effec-
dentists are comfortable using voice control153 and use tive in managing their fear, at least in the short term.
it frequently,154 and evidence from US dentists indicat- Ultimately, the choice of anxiety management
ing that voice control is preferred as the first alternative approaches to learn and practice must be left to the
to the now unacceptable hand-over-mouth exercise as a dental practitioner. However, such choices should
behaviour management technique.155 always be based on an understanding of the particular
While there is some evidence indicating the patient, their particular history, their particular
effectiveness of voice control,156 changing societal concerns, and their particular capacity for change.
expectations about how children can be acceptably This deeper understanding requires first identifying
treated may mitigate against its use. Clearly, cultural the patient’s concerns and anxieties, then exploring
issues might be relevant in this regard. While studies the bases for them, and then working with the patient
to manage their fears so that a phased treatment plan 6. Enkling N, Marwinski G, Johren P. Dental anxiety in a repre-
sentative sample of residents of a large German city. Clin
can be successfully carried out. Oral Investig 2006;10:84–91.
While many of the anxiety management techniques
7. Lahti S, Vehkalahti MM, Nordblad A, Hausen H. Dental fear
and practices described here have an established evi- among population aged 30 years and older in Finland. Acta
dence base, others have received either little or mixed Odontol Scand 2007;65:97–102.
research support. Some techniques rely on dated 8. Schuller AA, Willumsen T, Holst D. Are there differences in
research and others rely on findings in other medical oral health and oral health behavior between individuals with
high and low dental fear? Community Dent Oral Epidemiol
settings which may or may not be generalizable to 2003;31:116–121.
dentistry. There is a great need for further scientific 9. Armfield JM. The avoidance and delaying of dental visits in
assessment of a number of anxiety management prac- Australia. Aust Dent J 2012;57:1–5.
tices and for a quantification of the extent of any ben- 10. Pohjola V, Lahti S, Vehkalahti MM, Tolvanen M, Hausen
efit provided. Of course, in a dental setting, it is also H. Association between dental fear and dental attendance
among adults in Finland. Acta Odontol Scand 2007;65:224–
the case that what works for one patient might not 230.
work for another. There is a need for flexibility when 11. Brahm CO, Lundgren J, Carlsson SG, Nilsson P, Corbeil J,
dealing with anxious individuals who, because of their Hagglin C. Dentists’ views on fearful patients. Problems and
unique backgrounds and concerns, will require a tai- promises. Swed Dent J 2012;36:79–89.
lored management and treatment approach. 12. Eitner S, Wichmann M, Paulsen A, Holst S. Dental anxiety –
an epidemiological study on its clinical correlation and effects
A number of the techniques recommended here for on oral health. J Oral Rehabil 2006;33:588–593.
dentally anxious people would be beneficial for all den-
13. Armfield JM, Slade GD, Spencer AJ. Dental fear and adult
tal patients, regardless of their level of anxiety. Such oral health in Australia. Community Dent Oral Epidemiol
basic procedures as good communication skills, estab- 2009;37:220–230.
lishing rapport and providing control, should be a stan- 14. Klepac RK, Dowling J, Hauge G. Characteristics of clients
dard approach for all patients and would be expected seeking therapy for the reduction of dental avoidance: reac-
tions to pain. J Behav Ther Exp Psychiatry 1982;13:293–
to contribute substantially to a mutually respectful den- 300.
tist-patient relationship and, ultimately, to enhanced 15. Berggren U, Meynert G. Dental fear and avoidance: causes,
patient satisfaction. While the practice of dentistry symptoms, and consequences. J Am Dent Assoc 1984;109:
entails the use of an array of clinical skills, varying 247–251.
from simple to very complex, at its heart dentistry is a 16. Armfield JM, Stewart JF, Spencer AJ. The vicious cycle of
dental fear: exploring the interplay between oral health, ser-
service industry involving an interaction between the vice utilization and dental fear. BMC Oral Health 2007;7:1.
dental professional and the patient. And while a patient 17. Armfield JM. What goes around comes around: revisiting the
has the reasonable expectation that their oral health hypothesised vicious cycle of dental fear and avoidance. Com-
problems will be competently and successfully munity Dent Oral Epidemiol 2013;41:279–287.
addressed, they are also entering into a relationship 18. American Psychiatric Association. Diagnostic and statistical
manual of mental disorders. 4th edn. Washington, DC: Amer-
with the dental provider with expectations that they ican Psychiatric Association, 2000.
will be treated in a caring and respectful manner. For
19. van Wijk AJ, Hoogstraten J. Anxiety and pain during dental
the dental practitioner, there is much job satisfaction to injections. J Dent 2009;37:700–704.
be had from successfully managing both a patient’s 20. van Wijk AJ, Makkes PC. Highly anxious dental patients
dental anxiety and their oral health. And for those peo- report more pain during dental injections. Br Dent J
ple with dental fear, given the strong association 2008;205:E7; discussion 142-143.
between anxiety and dental visiting, helping the patient 21. Maggirias J, Locker D. Psychological factors and perceptions
of pain associated with dental treatment. Community Dent
manage their anxiety will also be going some way Oral Epidemiol 2002;30:151–159.
towards helping them improve their oral health. 22. Weiner AA. The fearful dental patient: a guide to understand-
ing and managing. Ames: Wiley-Blackwell, 2011.
REFERENCES 23. van Wijk AJ, McNeil DW, Ho CJ, Buchanan H, Hoogstraten
J. A short English version of the Fear of Dental Pain question-
1. Armfield JM, Spencer AJ, Stewart JF. Dental fear in Australia: naire. Eur J Oral Sci 2006;114:204–208.
who’s afraid of the dentist? Aust Dent J 2006;51:78–85. 24. Oosterink FM, de Jongh A, Aartman IH. What are people
2. Armfield JM. The extent and nature of dental fear and phobia afraid of during dental treatment? Anxiety-provoking capacity
in Australia. Aust Dent J 2010;55:368–377. of 67 stimuli characteristic of the dental setting. Eur J Oral
3. McGrath C, Bedi R. The association between dental anxiety Sci 2008;116:44–51.
and oral health-related quality of life in Britain. Community 25. Milgrom P, Weinstein P, Heaton LJ. Treating fearful dental
Dent Oral Epidemiol 2004;32:67–72. patients: a patient management handbook. 3rd edn. Seattle,
4. Nicolas E, Collado V, Faulks D, Bullier B, Hennequin M. WA: Dental Behavioral Resources, 2009.
A national cross-sectional survey of dental anxiety in the 26. Armfield JM, Slade GD, Spencer AJ. Cognitive vulnerability
French adult population. BMC Oral Health 2007;7:12. and dental fear. BMC Oral Health 2008;8:2.
5. Chanpong B, Haas DA, Locker D. Need and demand for 27. Armfield JM. Towards a better understanding of dental anxi-
sedation or general anesthesia in dentistry: a national survey ety and fear: cognitions vs. experiences. Eur J Oral Sci
of the Canadian population. Anesth Prog 2005;52:3–11. 2010;118:259–264.

28. Heaton LJ, Mancl LA, Grembowski D, Armfield JM, Mil- 50. Dailey YM, Humphris GM, Lennon MA. Reducing patients’
grom P. Unmet dental need in community-dwelling adults state anxiety in general dental practice: a randomized con-
with mental illness: results from the 2007 Medical Expendi- trolled trial. J Dent Res 2002;81:319–322.
ture Panel Survey. J Am Dent Assoc 2013;144:e16–23. 51. De Jongh A, Adair P, Meijerink-Anderson M. Clinical man-
29. Okoro CA, Strine TW, Eke PI, Dhingra SS, Balluz LS. The agement of dental anxiety: what works for whom? Int Dent J
association between depression and anxiety and use of oral 2005;55:73–80.
health services and tooth loss. Community Dent Oral Epi- 52. Gazal G, Mackie IC. Distress related to dental extraction for
demiol 2012;40:134–144. children under general anaesthesia and their parents. Eur J
30. Locker D, Poulton R, Thomson WM. Psychological disorders Paediatr Dent 2007;8:7–12.
and dental anxiety in a young adult population. Community 53. Klaassen MA, Veerkamp JS, Hoogstraten J. Dental treatment
Dent Oral Epidemiol 2001;29:456–463. under general anaesthesia: the short-term change in young
31. Pohjola V, Mattila AK, Joukamaa M, Lahti S. Anxiety and children’s oral-health-related quality of life. Eur Arch Paediatr
depressive disorders and dental fear among adults in Finland. Dent 2008;9:130–137.
Eur J Oral Sci 2011;119:55–60. 54. Lundgren J, Wide Boman U. Multimodal cognitive behaviour-
32. Armfield JM, Pohjola V, Joukamaa M, Mattila AK, Suominen al treatment. In: Ost LG, Skaret E, eds. Cognitive behavioural
AL, Lahti SM. Exploring the associations between somatiza- therapy for dental phobia and anxiety. Oxford: John Wiley
tion and dental fear and dental visiting. Eur J Oral Sci & Sons, 2013:109–118.
2011;119:288–293. 55. Bernson JM, Hallberg LR, Elfstrom ML, Hakeberg M. ‘Mak-
33. Willumsen T. Dental fear in sexually abused women. Eur J ing dental care possible: a mutual affair’: a grounded theory
Oral Sci 2001;109:291–296. relating to adult patients with dental fear and regular dental
34. Dougall A, Fiske J. Surviving child sexual abuse: the relevance treatment. Eur J Oral Sci 2011;119:373–380.
to dental practice. Dent Update 2009;36:294-296, 298-300, 56. Corah NL, O’Shea RM, Bissell GD, Thines TJ, Mendola P.
303-294. The dentist-patient relationship: perceived dentist behaviors
35. Locker D, Liddell A, Shapiro D. Diagnostic categories of den- that reduce patient anxiety and increase satisfaction. J Am
tal anxiety: a population-based study. Behav Res Ther Dent Assoc 1988;116:73–76.
1999;37:25–37. 57. Corah NL. Dental anxiety. Assessment, reduction and
36. Gawkrodger DJ. Investigation of reactions to dental materi- increasing patient satisfaction. Dent Clin North Am 1988;
als. Br J Dermatol 2005;153:479–485. 32:779–790.
37. Milgrom P, Weinstein P. Dental fears in general practice: new 58. Liddell A, Ackerman C, Locker D. What dental phobics say
guidelines for assessment and treatment. Int Dent J 1993; about their dental experiences. J Can Dent Assoc 1990;
43:288–293. 56:863–866.
38. Heaton LJ, Carlson CR, Smith TA, Baer RA, de Leeuw R. 59. Hamasaki T, Soh I, Takehara T, Hagihara A. Applicability of
Predicting anxiety during dental treatment using patients’ self- both dentist and patient perceptions of dentists’ explanations
reports: less is more. J Am Dent Assoc 2007;138:188–195. to the evaluation of dentist-patient communication. Commu-
nity Dent Health 2011;28:274–279.
39. Dailey YM, Humphris GM, Lennon MA. The use of dental
anxiety questionnaires: a survey of a group of UK dental 60. Geboy MJ. Communication and behavior management in
practitioners. Br Dent J 2001;190:450–453. dentistry. Toronto: BC Decker, 1989.
40. Sharif MO. Dental anxiety: detection and management. 61. Friedman N. Iatrosedation: the treatment of fear in the dental
J Appl Oral Sci 2010;18:i. patient. J Dent Educ 1983;47:91–95.
41. Newton JT, Buck DJ. Anxiety and pain measures in dentistry: 62. Friedman N, Wood GJ. An evaluation of the iatrosedative
a guide to their quality and application. J Am Dent Assoc process for treating dental fear. Compend Contin Educ Dent
2000;131:1449–1457. 1998;19:434-436, 438, 440-432.
42. Armfield JM. How do we measure dental fear and what are 63. Melamed SF. Sedation: a clinical guide to patient manage-
we measuring anyway? Oral Health Prev Dent 2010;8:107– ment. 5th edn. St Louis: Mosby Elsevier, 2010.
115. 64. Kent G, Croucher R. Achieving oral health: the social context of
43. Porritt J, Buchanan H, Hall M, Gilchrist F, Marshman Z. dental care. 2nd edn. Oxford: Butterworth Heinemann, 1998.
Assessing children’s dental anxiety: a systematic review of 65. Wright FA, Giebartowski JE, McMurray NE. A national sur-
current measures. Community Dent Oral Epidemiol 2013; vey of dentists’ management of children with anxiety or
41:130–142. behaviour problems. Aust Dent J 1991;36:378–383.
44. Humphris GM, Morrison T, Lindsay SJ. The Modified Dental 66. Buchanan H, Niven N. Self-report treatment techniques used
Anxiety Scale: validation and United Kingdom norms. Com- by dentists to treat dentally anxious children: a preliminary
munity Dent Health 1995;12:143–150. investigation. Int J Paediatr Dent 2003;13:9–12.
45. Armfield JM. Development and psychometric evaluation of 67. Eaton JJ, McTigue DJ, Fields HW Jr, Beck M. Attitudes of con-
the Index of Dental Anxiety and Fear (IDAF-4C+). Psychol temporary parents toward behavior management techniques
Assess 2010;22:279–287. used in pediatric dentistry. Pediatr Dent 2005;27:107–113.
46. Howard KE, Freeman R. Reliability and validity of a faces 68. Kantaputra PN, Chiewcharnvalijkit K, Wairatpanich K, Mali-
version of the Modified Child Dental Anxiety Scale. Int J Pae- kaew P, Aramrattana A. Children’s attitudes toward behavior
diatr Dent 2007;17:281–288. management techniques used by dentists. J Dent Child (Chic)
47. Buchanan H, Niven N. Validation of a Facial Image Scale to 2007;74:4–9.
assess child dental anxiety. Int J Paediatr Dent 2002;12: 69. Luis de Leon J, Guinot Jimeno F, Bellet Dalmau LJ. Acceptance
47–52. by Spanish parents of behaviour-management techniques used
48. Neverlien PO. Assessment of a single-item dental anxiety in paediatric dentistry. Eur Arch Paediatr Dent 2010;11:175-178.
question. Acta Odontol Scand 1990;48:365–369. 70. Muhammad S, Shyama M, Al-Mutawa SA. Parental attitude
49. Humphris GM, Hull P. Do dental anxiety questionnaires raise toward behavioral management techniques in dental practice
anxiety in dentally anxious adult patients? A two-wave panel with schoolchildren in Kuwait. Med Princ Pract 2011;20:
study. Prim Dent Care 2007;14:7–11. 350–355.

71. Samra-Quintero PA, Bernardoni-Socorro C, Borjas AM, Fuen- 90. Benson H, Greenwood MM, Klemchuk H. The relaxation
mayor NR, Estevez J, Arteaga-Vizcaino M. Changes in blood response: psychophysiologic aspects and clinical applications.
pressure in children undergoing psychological treatment before Int J Psychiatry Med 1975;6:87–98.
dental procedures. Acta Odontol Latinoam 2006;19:9–12. 91. Bourne EJ. The anxiety and phobia workbook. 2nd edn. Oak-
72. Carson P, Freeman R. Tell-show-do: reducing anticipatory land: New Harbinger, 1995.
anxiety in emergency paediatric dental patients. Int J Health 92. Schaffer SD, Yucha CB. Relaxation and pain management:
Prom Educ 1998;36:87–90. the relaxation response can play a role in managing chronic
73. American Academy on Pediatric Dentistry. Guideline on and acute pain. Am J Nurs 2004;104:75–76, 78–79, 81–82.
behavior guidance for the pediatric dental patient. Pediatr 93. Kwekkeboom KL, Gretarsdottir E. Systematic review of
Dent 2008;30:125–133. relaxation interventions for pain. J Nursing Scholarsh
74. Hendrie F. Tell-show-do – It’s not just for children! Available 2006;38:269–277.
at: URL: ‘http://www.dentalfearcentral.org/help/psychology/ 94. Park E, Oh H, Kim T. The effects of relaxation breathing on
tell-show-do/’. Accessed May 2013. procedural pain and anxiety during burn care. Burns
75. Singh H, Meshram G, Warhadpande M, Kapoor P. Effect of 2013;39:1101–1106.
‘perceived control’ in management of anxious patients under- 95. Litt MD. A model of pain and anxiety associated with acute
going endodontic therapy by use of an electronic communica- stressors: distress in dental procedures. Behav Res Ther
tion system. J Conserv Dent 2012;15:51–55. 1996;34:459–476.
76. Klassen JA, Liang Y, Tjosvold L, Klassen TP, Hartling L. 96. Sanikop S, Agrawal P, Patil S. Relationship between dental
Music for pain and anxiety in children undergoing medical anxiety and pain perception during scaling. J Oral Sci
procedures: a systematic review of randomized controlled tri- 2011;53:341–348.
als. Ambul Pediatr 2008;8:117–128.
97. Sullivan MJ, Neish N. Catastrophic thinking and the experi-
77. Kim YK, Kim SM, Myoung H. Musical intervention reduces ence of pain during dental procedures. J Indiana Dent Assoc
patients’ anxiety in surgical extraction of an impacted mandibu- 2000;79:16–19.
lar third molar. J Oral Maxillofac Surg 2011;69:1036–1045.
98. Sullivan MJ, Neish NR. Catastrophizing, anxiety and pain
78. Corah NL, Gale EN, Pace LF, Seyrek SK. Relaxation and during dental hygiene treatment. Community Dent Oral Epi-
musical programming as means of reducing psychological demiol 1998;26:344–349.
stress during dental procedures. J Am Dent Assoc
1981;103:232–234. 99. Ayer W. Psychology and dentistry: mental health aspects of
patient care. New York: The Haworth Press, 2005.
79. Lahmann C, Schoen R, Henningsen P, et al. Brief relaxation
versus music distraction in the treatment of dental anxiety: a 100. Ackley DC. Dental fear. Aren’t you tired of it? Dent Today
randomized controlled clinical trial. J Am Dent Assoc 2003;22:96–102.
2008;139:317–324. 101. Morarend QA, Spector ML, Dawson DV, Clark SH, Holmes
80. Hoffman HG, Garcia-Palacios A, Patterson DR, Jensen M, DC. The use of a respiratory rate biofeedback device to
Furness T 3rd, Ammons WF Jr. The effectiveness of virtual reduce dental anxiety: an exploratory investigation. Appl Psy-
reality for dental pain control: a case study. Cyberpsychol chophysiol Biofeedback 2011;36:63–70.
Behav 2001;4:527–535. 102. Jacobson E. Progressive relaxation. 2nd edn. Chicago: Univer-
81. Furman E, Jasinevicius TR, Bissada NF, Victoroff KZ, Skilli- sity of Chicago Press, 1938.
corn R, Buchner M. Virtual reality distraction for pain con- 103. Bernstein DA, Borkovec TD. Progressive relaxation training:
trol during periodontal scaling and root planing procedures. a manual for the helping professions. Champaign: Research
J Am Dent Assoc 2009;140:1508–1516. Press, 1973.
82. Bentsen B, Svensson P, Wenzel A. Evaluation of effect of 3D 104. Conrad A, Roth WT. Muscle relaxation therapy for anxiety
video glasses on perceived pain and unpleasantness induced disorders: it works but how? J Anxiety Disord 2007;21:243–
by restorative dental treatment. Eur J Pain 2001;5:373–378. 264.
83. Bentsen B, Wenzel A, Svensson P. Comparison of the effect 105. Berggren U, Hakeberg M, Carlsson SG. Relaxation vs. cogni-
of video glasses and nitrous oxide analgesia on the perceived tively oriented therapies for dental fear. J Dent Res
intensity of pain and unpleasantness evoked by dental scaling. 2000;79:1645–1651.
Eur J Pain 2003;7:49–53.
106. Bracke PE. Progressive muscle relaxation. In: Weiner IB,
84. Ram D, Shapira J, Holan G, Magora F, Cohen S, Davidovich Craighead WE, eds. Corsini Encyclopedia of Psychology. 4th
E. Audiovisual video eyeglass distraction during dental treat- edn. Hoboken: John Wiley & Sons, 2010:1–2.
ment in children. Quintessence Int 2010;41:673–679.
107. de Jongh A, Muris P, ter Horst G, van Zuuren F, Schoenmak-
85. Efron LA, Sherman JA. Five tips for managing pediatric den- ers N, Makkes P. One-session cognitive treatment of dental
tal anxiety. Dent Today 2005;24:104–105. phobia: preparing dental phobics for treatment by restructur-
86. Roberts JF, Curzon ME, Koch G, Martens LC. Review: ing negative cognitions. Behav Res Ther 1995;33:947–954.
behaviour management techniques in paediatric dentistry. Eur 108. Willumsen T, Vassend O, Hoffart A. A comparison of cogni-
Arch Paediatr Dent 2010;11:166–174. tive therapy, applied relaxation, and nitrous oxide sedation in
87. Deci EL, Koestner R, Ryan RM. A meta-analytic review of the treatment of dental fear. Acta Odontol Scand
experiments examining the effects of extrinsic rewards on 2001;59:290–296.
intrinsic motivation. Psychol Bull 1999;125:627–668; discus- 109. Hakeberg M, Berggren U, Carlsson SG. A 10-year follow-up
sion 692–700. of patients treated for dental fear. Scand J Dent Res
88. Melamed BG, Williamson DJ. Programs for the treatment of 1990;98:53–59.
dental disorders: dental anxiety and temperomandibular dis- 110. Coldwell SE, Getz T, Milgrom P, Prall CW, Spadafora A,
orders. In: Sweet JJ, Rozensky RH, Tovian SM, eds. Hand- Ramsay DS. CARL: a LabVIEW 3 computer program for
book of clinical psychology in medical settings. New York: conducting exposure therapy for the treatment of dental
Plenum Press, 1991:539–566. injection fear. Behav Res Ther 1998;36:429–441.
89. Kuhn BR, Allen KD. Expanding child behavior management 111. Coldwell SE, Wilhelm FH, Milgrom P, et al. Combining
technology in pediatric dentistry: a behavioral science alprazolam with systematic desensitization therapy for dental
perspective. Pediatr Dent 1994;16:13–17. injection phobia. J Anxiety Disord 2007;21:871–887.

112. Heaton LJ, Leroux BG, Ruff PA, Coldwell SA. Computerized 132. Leal SC, Abreu DM, Frencken JE. Dental anxiety and pain
dental injection fear treatment: a randomized clinical trial. related to ART. J Appl Oral Sci 2009;17(Suppl):84–88.
J Dent Res 2013;92:37S–42S. 133. Rosenberg S. How to profit from … air abrasion: marketing
113. Boyle CA, Newton T, Milgrom P. Development of a UK ver- air-abrasion technology. Dental Econ, 1999.
sion of CARL: a computer program for conducting exposure 134. Rafique S, Fiske J, Banerjee A. Clinical trial of an air-abra-
therapy for the treatment of dental injection fear. SAAD Dig sion/chemomechanical operative procedure for the restorative
2010;26:8–11. treatment of dental patients. Caries Res 2003;37:360–364.
114. British Psychological Society. The nature of hypnosis. A 135. Armfield JM, Milgrom P. A clinician guide to patients afraid of
report prepared by a Working Party at the request of The dental injections and numbness. SAAD Dig 2011;27:33–39.
Professional Affairs Board of The British Psychological Soci-
ety. Leicester: The British Psychological Society, 2001. 136. Bernson JM, Elfstrom ML, Berggren U. Self-reported dental
coping strategies among fearful adult patients: preliminary
115. Gow MA. Hypnosis in dentistry. In: Weiner AA, ed. The enquiry explorations. Eur J Oral Sci 2007;115:484–490.
fearful dental patient: a guide to understanding and manag-
ing. Ames: Wiley-Blackwell, 2011:139–171. 137. Boyle CA, Newton T, Heaton LJ, Afzali S, Milgrom P. What
happens after referral for sedation? Br Dent J 2010;208:E22;
116. Holden A. The art of suggestion: the use of hypnosis in den- discussion 524-525.
tistry. Br Dent J 2012;212:549–551.
138. Bandura A. Social learning theory. Englewood Cliffs: Prentice
117. Logan H, Marek C. The anxious or fearful dental patient. In: Hall, 1977.
Stefanac SJ, Nesbit SP, eds. Treatment planning in dentistry.
St Louis: Mosby Elsevier, 2007:339–365. 139. Farhat-McHayleh N, Harfouche A, Souaid P. Techniques for
managing behaviour in pediatric dentistry: comparative study
118. Shapiro M, Melmed RN, Sgan-Cohen HD, Eli I, Parush S. of live modelling and tell-show-do based on children’s heart
Behavioural and physiological effect of dental environment rates during treatment. J Can Dent Assoc 2009;75:283.
sensory adaptation on children’s dental anxiety. Eur J Oral
Sci 2007;115:479–483. 140. Melamed BG, Weinstein D, Katin-Borland M, Hawes R.
Reduction of fear-related dental management problems with
119. Hmud R, Walsh LJ. Dental anxiety: causes, complications use of filmed modeling. J Am Dent Assoc 1975;90:822–826.
and management approaches. J Minim Interv Dent
2009;2:67–78. 141. Stokes TF, Kennedy SH. Reducing child uncooperative behav-
ior during dental treatment through modeling and reinforce-
120. Walsh LJ. Anxiety prevention: implementing the 4 S principle ment. J Appl Behav Anal 1980;13:41–49.
in conservative dentistry. Auxilliary 2007;17:24–26.
142. Greenbaum PE, Melamed BG. Pretreatment modeling. A
121. Kritsidima M, Newton T, Asimakopoulou K. The effects of technique for reducing children’s fear in the dental operatory.
lavender scent on dental patient anxiety levels: a cluster Dent Clin North Am 1988;32:693–704.
randomised-controlled trial. Community Dent Oral Epidemiol
2010;38:83–87. 143. Filcheck HA, Allen KD, Ogren H, Darby JB, Holstein B,
Hupp S. The use of choice-based distraction to decrease the
122. Lehrner J, Eckersberger C, Walla P, Potsch G, Deecke L. distress of children at the dentist. Child Fam Behav Ther
Ambient odor of orange in a dental office reduces anxiety 2004;26:59–68.
and improves mood in female patients. Physiol Behav
2000;71:83–86. 144. Ingersoll BD, Nash DA, Blount RL, Gamber C. Distraction
and contingent reinforcement with pediatric dental patients.
123. Lehrner J, Marwinski G, Lehr S, Johren P, Deecke L. ASDC J Dent Child 1984;51:203–207.
Ambient odors of orange and lavender reduce anxiety and
improve mood in a dental office. Physiol Behav 2005; 145. Ingersoll BD, Nash DA, Gamber C. The use of contingent au-
86:92–95. diotaped material with pediatric dental patients. J Am Dent
Assoc 1984;109:717–719.
124. Hainsworth JM, Moss H, Fairbrother KJ. Relaxation and
complementary therapies: an alternative approach to manag- 146. Bruck M, Ceci SJ, Francoeur E, Barr R. ‘I hardly cried when
ing dental anxiety in clinical practice. Dent Update I got my shot!’ Influencing children’s reports about a visit to
2005;32:90–92, 94–96. their pediatrician. Child Dev 1995;66:193–208.
125. Bare LC, Dundes L. Strategies for combating dental anxiety. 147. Chen E, Zeltzer LK, Craske MG, Katz ER. Alteration of
J Dent Educ 2004;68:1172–1177. memory in the reduction of children’s distress during repeated
aversive medical procedures. J Consult Clin Psychol 1999;
126. Gale EN. Fears of the dental situation. J Dent Res 67:481–490.
1972;51:964–966.
148. Pickrell JE, Heima M, Weinstein P, et al. Using memory
127. Milgrom P, Fiset L, Melnick S, Weinstein P. The prevalence restructuring strategy to enhance dental behaviour. Int J Pae-
and practice management consequences of dental fear in a diatr Dent 2007;17:439–448.
major US city. J Am Dent Assoc 1988;116:641–647.
149. Weaver JM. Why is physical restraint still acceptable for den-
128. Topaloglu-Ak A, Eden E, Frencken JE. Perceived dental anxi- tistry? Anesth Prog 2010;57:43–44.
ety among schoolchildren treated through three caries
removal approaches. J Appl Oral Sci 2007;15:235–240. 150. Barton DH, Hatcher E, Potter R, Henderson HZ. Dental atti-
tudes and memories: a study of the effects of hand over
129. de Menezes Abreu DM, Leal SC, Mulder J, Frencken JE. Pain mouth/restraint. Pediatr Dent 1993;15:13–19.
experience after conventional, atraumatic, and ultraconserva-
tive restorative treatments in 6- to 7-year-old children. Eur J 151. Brunt L, Wright B. Restrain or refer? Br Dent J 2006;200:2–3.
Oral Sci 2011;119:163–168. 152. Newton T, Asimakopoulou K, Daly B, Scambler S, Scott S.
130. Mickenautsch S, Frencken JE, van’t HM. Atraumatic restor- The management of dental anxiety: time for a sense of pro-
ative treatment and dental anxiety in outpatients attending portion? Br Dent J 2012;213:271–274.
public oral health clinics in South Africa. J Public Health 153. Crossley ML, Joshi G. An investigation of paediatric dentists’ atti-
Dent 2007;67:179–184. tudes towards parental accompaniment and behavioural manage-
131. Carvalho TS, Ribeiro TR, Bonecker M, Pinheiro EC, Colares ment techniques in the UK. Br Dent J 2002;192:517–521.
V. The atraumatic restorative treatment approach: an ‘atrau- 154. Newton T, Asimakopoulou K, Daly B, Scambler S, Scott S.
matic’ alternative. Med Oral Patol Oral Cir Bucal 2009;14: What’s new in anxiety management without drugs: an
e668–673. update. SAAD Dig 2012;28:3–7.

155. Oueis HS, Ralstrom E, Miriyala V, Molinari GE, Casamassimo 160. Davies EB, Buchanan H. An exploratory study investigating
P. Alternatives for hand over mouth exercise after its elimina- children’s perceptions of dental behavioural management
tion from the clinical guidelines of the American Academy of techniques. Int J Paediatr Dent 2013;23:297–309.
Pediatric Dentistry. Pediatr Dent 2010;32:223–228. 161. Moore R, Brodsgaard I, Rosenberg N. The contribution of
156. Greenbaum PE, Turner C, Cook EW 3rd, Melamed BG. embarrassment to phobic dental anxiety: a qualitative
Dentists’ voice control: effects on children’s disruptive and research study. BMC Psychiatry 2004;4:10.
affective behavior. Health Psychol 1990;9:546–558.
157. Ramos MM, Carrara CF, Gomide MR. Parental acceptance
of behavior management techniques for children with clefts. Address for correspondence:
J Dent Child (Chic) 2005;72:74–77. Dr Jason Armfield
158. Peretz B, Zadik D. Parents’ attitudes toward behavior man- Australian Research Centre for Population Oral Health
agement techniques during dental treatment. Pediatr Dent School of Dentistry
1999;21:201–204.
The University of Adelaide
159. Abushal MS, Adenubi JO. Attitudes of Saudi parents toward
behavior management techniques in pediatric dentistry. Adelaide SA 5005
J Dent Child (Chic) 2003;70:104–110. Email: [email protected]

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Management of fear and anxiety in the dental clinic:

Enhancing trust and control the ‘iatrosedative technique’, which involves a

there are several psychological approaches to manag- Positive reinforcement

time because it circumvents a patient stressing about Distraction

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