THE management of the paediatric patient in dental practice is a challenge faced by general dental practitioners on a daily basis. Treating children can be particularly rewarding but like all aspects of dentistry it requires good communication skills, clinical knowledge and a degree of practice!
Children account for a significant proportion of the population and developing a rapport at an early age will help establish a good long-term practitioner-patient relationship and hopefully result in a healthy, functional, stable and attractive dentition. This is not achieved without a degree of effort and here we offer an overview of both the non-pharmacological and pharmacological techniques that can be utilised to help tiny terrors become pleasant patients.
First it is essential to have a good understanding of the factors affecting anxiety in children. Often for children this is a fear of the unknown. The dental surgery is full of unfamiliar people and strange objects that often produce frightening noises and can induce a ‘fight-or-flight’ response.
Guidance from The Royal College of Surgeons of England suggests that the behaviour of children in clinical situations can be categorised in three ways:
• Co-operative: the child is able to participate in dental care.
• Potentially co-operative: the child may be able to participate in dental care with the adjunct of appropriate behaviour management techniques.
• Lacking co-operative ability: the child is pre-co-operative, for example, very young children.
It is essential that the clinician takes time to evaluate the child’s stage of development in order to appropriately plan the overall management strategy. This involves setting achievable goals and working with children and their parents towards attaining these goals.
Below are a number of communication-based techniques used to manage the anxious child patient.
Tell-Show-Do This technique is extremely popular and is helpful in acclimatising children to the dental surgery and treatment. There are three phases: initially an explanation of the equipment or procedure, followed by a demonstration (e.g. polishing the child’s nail) before proceeding with the treatment.
Positive reinforcement This technique involves acknowledgement, praise and reward for positive behaviour (whilst ignoring negative behaviour). For example, stickers or bravery certificates.
Distraction Changing the focus of the child’s attention away from the anxiety-causing factor can be effective. A useful example of distraction is having the child choose the music played in the surgery. The band One Direction is increasingly popular in my surgery at the minute!
Non-verbal communication These are non-verbal signals and cues which can help to reassure the child and provide a sense of control to the patient. A particularly effective example is the use of stop signals. A signal is agreed between dentist and patient to indicate that he or she would like to stop treatment. It is essential that if this technique is used the clinician does stop when requested, as often the child will test the ‘deal on offer’ before committing to treatment.
Modelling This is a particularly useful technique for an anxious child with a cooperative sibling/parent. The child can watch the ‘model’ taking part in treatment and feel reassured by a positive experience. Often this can remove a fear of the unknown.
Relaxation Simple relaxation techniques using breathing exercises or progressive muscular relaxation can be useful but require a degree of co-operation. This technique may be more useful in teenage or adult patients.
Systematic desensitisation This is a four-step technique to reduce the anxiety associated with a specific stimulus.
1. Identify the stimulus and any factors that contribute to anxiety.
2. Utilise relaxation techniques.
3. Establish a hierarchy of fear – patient scores experiences out of 10. For example seeing the LA syringe may cause an anxiety score of 4/10 whereas having LA administered may give a score of 10/10.
4. Over a period of weeks the patient then uses relaxation techniques to progress through the hierarchy. It is essential the patient completes one stage while maintaining a relaxed mindset before proceeding.
Hypnosis This can be an extremely useful technique if the case is selected appropriately. Some controversy exists in relation to the effectiveness of hypnosis for behaviour management in children. A Cochrane review published in 2010 concluded that on the basis of the studies that met the inclusion criteria there was not yet enough evidence to suggest beneficial effects.
Conscious sedation techniques can be used with great effect to reduce fear and anxiety in children. Guidance from the Scottish Dental Clinical Effectiveness Programme defines conscious sedation as “a technique in which the use of a drug or drugs produces a state of depression of the central nervous system enabling treatment to be carried out, but during which communication is maintained and the modification of a patient’s state of mind is such that the patient will respond to command throughout the period of sedation.”
Inhalational sedation or relative analgesia (RA) This technique has a wide margin of safety and is generally viewed as the first port of call of the pharmacological techniques. A mixture of nitrous oxide and oxygen is used to achieve relaxation, sedation and a level of analgesia. The level of nitrous oxide is titrated until the patient is confident to start treatment. It is essential that the gas mixture is used alongside verbal support and reassurance from the operator. A degree of hypnotic suggestion can help the child to feel at ease and progress well with treatment. Breathing 100 per cent oxygen for two minutes after the completion of treatment reverses the effects of RA sedation. Patient selection plays an important role in achieving clinical success as well as the experience of the operator in providing the correct communicative support.
Intravenous sedation IV sedation involves the administration of drugs directly into the venous blood stream via a cannula. Most commonly the drug of choice is the benzodiazepine, midazolam, which provides the useful effects of sedation, anxiolysis muscle relaxation and anterograde amnesia. But midazolam is also a central nervous system depressant and the patient must be carefully monitored throughout sedation. IV sedation should only be provided by suitably trained practitioners. It has the disadvantage of involving a needle to introduce the cannula and it is generally reserved for adolescent and adult patients.
Transmucosal sedation This involves administrating a sedative across a mucous membrane, such as sublingual and intranasal membranes. It is useful particularly with needle phobic patients. The use of midazolam by a transmucosal route is off licence and thus patients and their parents/guardians must be given this information in order to provide informed consent.
General anaesthesia (GA)
Although there are a range of techniques available for the management of the anxious child it is unfortunate that some patients will still require GA in order to co-operate with treatment. GA must be carried out by an anaesthetist in a hospital setting. The national UK Guideline for the Use of General Anaesthesia (GA) in Paediatric Dentistry provides a number of situations in which GA is indicated including:
• severe pulpitis
• acute soft tissue swelling requiring removal of infected tooth/teeth
• surgical drainage of acute infection
• single or multiple extractions in a young child unsuitable for conscious sedation.
The decision to use GA should not be taken lightly and the small but catastrophic risk of death must be highlighted in order to gain informed consent. As a result of this risk, all other avenues of anxiety management should be considered before referral for GA. Treatment planning for GA will involve the removal of any teeth of questionable long-term prognosis in order to prevent a repeat GA.
In conclusion, there are a range of techniques that can be utilised effectively to assist the anxious child in co-operating with treatment and developing a positive outlook to holistic dental care. Careful assessment by an experienced clinician and referring when appropriate are essential. Well-considered treatment planning with a long-term overall oral health strategy focusing on prevention and achieving oral health is paramount.
Mr Stuart Davidson is a dentist and Mr Michael Dhesi a VDP at the Clyde Dental Group (www.clydedental.com), which takes referrals for RA and IV sedation in anxious children
Non-Pharmacological Behaviour Management Clinical Guidelines – The Royal College of Surgeons of England.
Non-Pharmacological Approaches to Behaviour Management in Children – J. Tim Newton et al – Dent Update 2003; 30L 194-199.
Managing Anxious Children: The use of Conscious Sedation in Paediatric Dentistry – M.T. Hosey – International Journal of Paediatric Dentistry 2002; 12: 359-372