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Management of Pediatric Patients with Anxiety on Dental Care: A Systematic Review

Harun Achmad

Lecturer of Pediatric Dentistry, Department of Pediatric Dentistry, Faculty of Dentistry, Hasanuddin University, Indonesia

Corresponding Author: [email protected]

Abstract

Introduction:Emotional responses in the form of anxiety and a child's behavior towards dental care are serious problems for general dentists and pediatric dentists. Anxious, fearful or uncooperative behavior of the child can hinder the provision of efficient dental care and interfere with the quality of care provided. If not adequately addressed, persistent negative response patterns may appear and become a barrier to regular dental care. Thus this systematic review reviewed some literature on the pattern of handling anxiety in child patients in dentistry.

Methods: In this systematic review, article searches are conducted in Google Search, Pubmed, and Cochrane Library. The study was published from 2013 to 2020. 86 articles rated, including 86 articles from electronic databases, 0 from manual searches. 65 records filtered, 20 records excluded, 45 full-text articles rated for eligibility and 17 full-text articles included. Result:There are 17 articles on patterns of anxiety management in pediatric patients in dentistry. Broadly speaking, it consists of non-pharmacological and pharmacological approaches. Handling anxiety behavior in pediatric patients with a non-pharmacological approach includes communication, modeling, tell show do, ask-tell-ask, distraction, desensitation, voice control, reinforcement, hypnosis, sensory-adapted dental environments (SADE), and Animal- assisted therapy (AAT).

Meanwhile, when non-pharmacological approaches are not successful, pharmacological approaches can be applied in the form of sedation, general anesthesia, and nitrous oxide / oxygen inhalation. Or using a combination of the two to relieve anxiety in pediatric patients during dental treatment can be an option.Conclusion: Anxiety management can be a non- pharmacological approach and a pharmacological approach or a combination of the two. This pattern of treatment can be used to overcome children's anxiety towards dental care so that this systematic review can be used as a reference in the treatment of anxiety in children patients in dentistry.

Keywords:Anxiety, Child behavior management, Dentistry

Introduction

Anxiety is the most frequent and common problem in dentistry, especially pediatric dentistry because children who are very anxious about avoiding examinations and refusing dental care.1-4 One study reported the prevalence of anxiety in all age groups worldwide is 3-43% .5,6

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The prevalence children who are anxious when receiving dental care aged 4-18 years are 6-20%

.4,7 Studies reported by dentists say that child patients with anxiety are difficult to manage and treat so it is important for a dentist to treat children with anxiety , because anxiety is the cause of 75% failure of routine dental care.4,8 Anxiety about dental care can increase caries and score of Decayed, Missing or Filled Teeth (DMFT), and increase the use of analgesic antibiotics. The cognitive effects of anxiety include fear, crying, and aggression. Another problem caused by anxiety in dental care is reduced parental satisfaction with the treatments offered or planned so that the perception of dentist competence decreases.1,9,10

In general, dental anxiety can be treated through non-pharmacological, pharmacological, or a combination of the two, depending on the level of anxiety, patient characteristics, and clinical conditions. The non-pharmacological approach is behavioral or cognitive intervention.

Pharmacological approaches are carried out using sedation or general anesthesia. Sedation is a conscious pharmacological approach and general anesthesia as an unconscious pharmacology.

Behavior modification therapy aims to change unacceptable behavior through the learning process and involves muscle relaxation and breathing along with guided imaginary techniques and physiological observation using hypnosis, acupuncture, distraction, positive reinforcement, stop signals, desensitization, "tell-show-do". And modeling. Patients who are unresponsive, uncooperative, and refuse to undergo treatment through a non-pharmacological approach may be considered pharmacologic treatment such as sedation or general anesthesia.5,11,12 According to the American Academy of Pediatric Dentistry (AAPD), a combination of non-pharmacological and pharmacological approaches is used to alleviate anxiety in pediatric patients with the aim of maintaining a positive attitude and obtaining maximum dental treatment results.6,12,13 An unconscious pharmacological approach with general anesthesia in dental procedures is an important part that demands a close working relationship between dentists, anesthetists and other multidisciplinary teams .7,8,14

Methods Search Strategy

A search was..performed on Google Search, Pubmed, dan Cochrane Library. Studies published from 2013 to 2020. Pubmed keywords and terms..used for the search,,included various,combinations of the following "Anxiety", "Child behavior management", and "Dentistry"

or each of the searches abstracts and titles were screened and the text full versions of articles that met criteria were downloaded.

The flowchart in Figure 1 identifies the excluded and included articles at each stage. 86 were assessed, including 86 articles from the databases electronic, 0 from the manual search. 65 records screened, 20 records excluded, 45 full-text articles assessed for eligibility and 17full text articles included.

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Results

In this systematic review there was a choice of studies: the inclusion criteria for this review were: 1) Articles 2013-2020 years, 2) English and Indonesian, 3) Type of publication and all study designs considered, 4) published and unpublished data is being sought. The exclusion criteria were studies that did not discussed the management of anxiety in pediatric patients in dentistry.

Table 1. Article on Anxiety Management Patterns in Pediatric Patients in Dentistry

No. Author Year Title Conclusion

1 S. Bagattoni, L. Lardani, M.R. Gatto, M.R. Giuca, G. Piana14

2020 Effects of audiovisual distraction in children with Down syndrome duringdental restorations:

a randomised clinical trial

Audio-visual distraction using video glasses is of no use in managing the anxiety behavior of a pediatric patient with Down syndrome in the unit chair during dental and oral care.

2 A. Vinita Mary, R. 2020 Dental Anxiety Among An adequate approach Ident

ificat ion

Database searching N=86

Manual search N=0

Records after duplicates removed N=86

Records screened N=65

Records excluded N=20

Full-text articles assessed for eligibility N=45

Full-text articles N=17 Scre

enin g

Inclu ded Eligi bility

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Kesavan, Priya G., Priyanka P, and Ramya R15

Pediatric Patients And Their Parents

regarding children with dental anxiety can help in building a good dental experience and a trusting relationship between pediatric dentists, patients and parents.

3 Madhuri Khandelwal ,RaghavendraMShetty, Sujata Rath16

2019 Effectiveness of Distraction Techniques in Managing Pediatric

Dental Patients

AVD techniques

installed on the ceiling and on seats are new distractions that can be an effective alternative distraction technique for

the behavioral

management of anxious children's patients.

4 Sreeraksha

Radhakrishna, Ila Srinivasan, Jyothsna V Setty, Murali Krishna D R, Anjana Melwani, Kuthpady Manasa Hegde17

2019 Comparison of three behavior modification

techniques for

management of anxious children aged 4-8 years.

Penggunaan teknik permainan Tell-Show- Play-doh dan smartphone efektif untuk mengurangi kecemasan pada pasien anak dalam perawatan dental yang dilakukan.

5 Kuthpady Manasa

Hegde, Neeraja R, Ila Srinivasan, Murali Krishna D R, Anjana Melwani, Sreeraksha Radhakrishna18

2019 Effect of vibration during local

anesthesiaadministration on pain, anxiety, and behavior ofpediatric patients aged 6–11 years:

A crossoversplit-mouth study.

The use of device methods is more

effective than

conventional methods in dealing with pain, anxiety, and behavior of patients aged 6-11 years.

This device is cost- effective, simple, and friendly to children

especially in

administering local anesthetic to pediatric patients.

6 Prema Sivakumar, Deepa Gurunathan19

2019 Behavior of Children toward Various Dental Procedures

The importance of adequate behavioral management techniques and skills from dentists

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to build good relationships with children and parents for more cooperation and better treatment outcomes.

7 Sandaka Raja Rajeswari, Rayala Chandrasekhar, C Vinay, KS Uloopi,

Kakarla Sri

RojaRamnya,

Manumanthu Venkata Ramesh20

2019 Effectiveness of Cognitive Behavioral Play Therapy andAudiovisualDistraction for Management of Preoperative

Anxiety in Children

Anxiety management in child patients with Active distraction techniques with cognitive behavioral play therapy proved more effective in reducing preoperative anxiety in child patients compared to audiovisual distraction and tell-show-do technique.

8 Manal Al Halabi, Iyad Hussein, Anas Salami, Rawan Awad, Najla Alderei, Ahtiq Wahab, Mawlood Kowash21

2019 A study protocol of a single-center

investigatorblinded

randomized parallel group study to

investigate the effect of an acclimatization visit on children’s behavior during inhalational sedation in a United Arab Emirates pediatric dentistry

postgraduate setting as measured by the levels of salivary Alpha Amylase and Cortisol

The use of IHS or general anesthesia (GA) is recommended to facilitate dental care when

nonpharmacological behavioral treatment cannot cope with the anxiety of a child's patient during dental care.

9 Lojain Abdulaziz Melebari, Seba Essam Attas, Abla Arafa22

2019 The motivational effect of multicolored dental restoration on dental behavior of first preliminary school children

The use of colorful restoration can provide benefits that are improving the oral health status of the child and may help in improving cooperative behavior in dental clinics, especially children patients with a

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younger age.

10 Nadica Pop-Jordanova, Olivera Sarakinova, Maja Pop-Stefanova-

Trposka, Efka

Zabokova-Bilbilova ,Emilija Kostadinovska

23

2018 Anxiety, Stress and Coping Patterns in Children in Dental

Settings

Moderate levels of stress and anxiety were present in both groups of orthodontics and dental care in general such as extraction. Several strategies to deal with this problem are discussed both non- pharmacologically and pharmacologically.

11 Idelia Gunawan, Eriska Riyanti, Annisa Isfandiary24

2018 Combined techniques for managing behavior in anxious children: a case report

Dental treatment in general anesthesia is carried out according to indications and if the nonpharmacological approach does not give a good response and results. Dental treatment in general anesthesia is carried out according to indications and if the nonpharmacological approach does not give a good response and results.

12 Nidhi Agarwal, Jayata Dhawan, Dipanshu

Kumar, Ashish

ANAND, Karan

Tangri25

2017 Effectiveness of Two Topical Anaesthetic Agents used along with Audio Visual Aids in Paediatric Dental Patient

In dental care, especially in pediatric patients, the use of Eutectic Mixture of Local Anesthesia with Audio Visual aids is better than Eutectic Mixture of Local Anesthesia without Audio Visual aids followed by benzocaine with Audio Visual aids.

13 A. Ramírez-Carrasco,C.

Butrón-Téllez Girón,O.

Sanchez-Armass,and M.

2017 Effectiveness of Hypnosis in Combination with ConventionalTechniques

The use of hypnosis methods combined with conventional pain

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Pierdant-Pérez26 of Behavior Management

in Anxiety/Pain

Reductionduring Dental Anesthetic Infiltration

management techniques has shown improvements in pain and anxiety control in children receiving dental anesthetic treatment.

14 Vasanthi

Done,Ravichandrasekhar Kotha, Aron Arun Kumar Vasa,

Suzan Sahana,

Raghavendra Kumar Jadadoddi

, Sushma Bezawada27

2016 A Comparison of the Effectiveness of Oral Midazolam –N2O Versus Oral Ketamine – N2O in Pediatric Patients-Anin–

Vivo Study

Both drugs are effective in reducing patient anxiety during tooth extraction. Oral midazolam-N2O showed slightly better results compared to oral ketamine-N2O with respect to psychomotor effects.

15 Denise Espíndola Antunes, Karolline Alves Viana, Paulo Sucasas Costa, Luciane Rezende Costa28

2016 Moderate sedation helps improve

future behavior in pediatric dental

patients – a prospective study

Dental treatment in early childhood caries with moderate sedation was shown to significantly improve children's cooperative behavioral responses during subsequent memory lifting 4 to 29 months after completing treatment. Sedation can reduce the suffering of toddlers and preschoolers during dental work.

However, pediatric dentists should receive special training to provide sedation.

16 Saumya Navit, Nikita Johri, Suleman Abbas Khan, Rahul Kumar Singh,Dheera Chadha , Pragati Navit,Anshul Sharma, Rachana Bahuguna29

2015 Effectiveness and Comparison of Various Audio Distraction Aids in Management of

Anxious Dental Paediatric Patients

Audio distraction techniques are effective in reducing anxiety in pediatric patients and audio-stories are the most effective.

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17 Kaviani N, Ashrafi S, Jabbarifar SE, Ghaffar E30

2015 The Efficacy of Two Intravenous Sedative Drugs in Management of Uncooperative Children for Dental Treatments

There were no significant differences between the intravenous midazolam- ketamine or midazolam- fentanyl groups. Both types of drugs are appropriate in controlling the child's behavior during dental treatment.

Management of pediatric patients with anxiety in dental care consists of a norfarmacological and pharmacological approach. Non-pharmacological approaches that can be applied to children who come with anxiety in dental care are Communication, Modeling, Tell Show Do (TSD), Ask-tell-ask, Distraction, Desensitation, Voice Control, Reinforcement, Hypnosis, Sensory-adapted dental environments (SADE), and Animal-assisted tandherapy (AAT).

A pharmacological approach can be used in children with anxiety when receiving dental treatment when a non-pharmacological approach is unsuccessful. The pharmacological approaches are sedation, general anesthesia, and nitrous oxide / oxygen inhalation.28,29

Disscussion

Anxiety in dental care is often defined as an abnormal fear or fear when visiting the dentist for preventive or therapeutic treatment, unwarranted anxiety over dental procedures, may have psychological, cognitive, and behavioral consequences. In addition, an anxious person tends to overestimate the pain and discomfort caused by dental work and may also delay or miss appointments, with negative consequences for their oral health and often having to undertake more complex interventions, thus entering a vicious cycle that tends to increase anxiety related to treatment. Dental care anxiety can be a major obstacle for children receiving dental care.

Children have limited communication skills and are less able to express their fears and anxieties.

Their behavior is a reflection of their inability to cope with anxiety and behavior management is a guide that can provide appropriate coping strategies for pediatric patients.29,30,31

The strategies for handling anxiety behavior in children in dentistry are divided into two general categories, namely non-pharmacological and pharmacological approaches. Handling anxiety in pediatric patients with a pharmacological approach in the form of sedation techniques, general anesthesia, or use of nitrous oxide / oxygen inhalation. Meanwhile, several behavioral management techniques with a non-pharmacological approach, including communication, modeling, tell show do, ask tell ask, distraction, desensitation, sound control, reinforcement, hypnosis, Sensory-adapted dental environments (SADE), and Animal-assisted therapy (AAT).2,6,24,46

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Tabel 2. Management of Anxiety in Pediatric Patients with a Non Pharmacological Approach in dental care47,48,49,50,51

No Management of Anxiety

in Pediatric Patients Indication Contraindicated

1 Non Verbal

Communication In all pediatric patients Does not exist 2 Modelling Effective in children 3-5 years of

age and best used during the child's first visit to the dentist

In pediatric patients who are unable to see

3 Tell Show Do (TSD) In all pediatric patients either with anxiety, fear, or neither

Does not exist

4 Ask-tell-ask Can be applied to any patient, that is, with anxiety, fear, or without both

Does not exist

5 Distraction Dapat diterapkan dengan pasien manapun, yaitu dengan kecemasan, rasa takut, atau tanpa keduanya

Does not exist

6 Desensitation Can be applied to all pediatric patients, especially those with anxiety

Does not exist

7 Voice Control Can be applied with any pediatric patient including patients with anxiety.

Pediatric patients with hearing loss

8 Reinforcement Can be applied to all pediatric patients including pediatric patients who have anxiety

Does not exist

9 Hypnosis Children over 5 years of age are the best subject to hypnosis, because their life images are an integral part of hypnosis.

Does not exist

10 Sensory-adapted dental environments (SADE)

Patients with autism disorders, difficulty with sensory processing, other disabilities, or patients with anxiety

Does not exist

11 Animal-assisted therapy (AAT)

Additional techniques for reducing anxiety, pain, or emotional distress in pediatric patients.

Pediatric patients who have allergies or other medical conditions that are aggravated by exposure from

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animals; and a lack of interest or fear in therapy animals.

Successful management of anxiety in dental care not only paves the way to satisfactory clinical outcomes and better oral health, but also builds trust in pediatric patients and can help them regulate their emotions when facing other challenges in daily life. After the dentist's visit, the patient and the parents seem happy to continue to undergo dental examinations which is a good thing to find out the status of the patient's oral cavity and it is fun to see the dental environment for pediatric patients. Meanwhile, dentists still feel that pediatric patients are not anxious about undergoing dental examinations as described by dentists regarding the procedure. As for the use of conscious sedation, it is used to relieve anxiety, pain, and discomfort for patients with long dental procedures. 8,9,20,22,52

One of the methods often used in dental care to overcome the anxiety of children patients is the method of distraction. The audio-video distraction (AVD) technique installed on the ceiling and on the seat is a new distraction that can be an effective alternative distraction technique for the management of the behavior of anxious children patients. However in some cases for example in behavioral management anxiety of children patients with Down syndrome the use of the method of distraction of audivisual video-extracted glasses is useless in this case.

The AVD glasses method is not indicated in some situations. Some children who exhibit disruptive behavior and refuse treatment immediately refuse AVD glasses. Furthermore, AVD glasses are not suitable for children who are very alert and insist on controlling the situation or uncooperative, as well as the need for care and the un availability of glasses for children with small faces restricts the use of AVD glasses. In addition, the operator in this case the dentist should pay attention to the position of avd glasses correctly so as not to interfere in the treatment in pediatric patients.8,10,42,53,54

Tell show do and reinforcement methods should be used to complement the modelling procedure, along with desensitation, this is an effective approach to problem-solving in introducing simple care in children who are afraid and excessive anxiety. The Tell-Show-Do technique is based on the principle of learning theory and is carried out by the dentist himself in the treatment room. Play with denture toys and use tools to demonstrate and provide a clearer explanation of dental procedures in pediatric patients so that the child can receive the treatment that will be done by the dentist.11,14,17,45,46

Hypnosis is an effective method of treating anxiety and fear in dental care in children.

This technique makes the patient feel more comfortable, and the patient is instructed to concentrate and focus the mind. The advantage of this hypnosis is that it is comfortable, inexpensive, and can be used anytime and anywhere. This technique makes the patient more calm and focused on one thought. Thereby limiting the incoming sensory to only receiving hypnodontist commands. When the dental procedure is completed with the aim of hypnosis the patient becomes more oriented. The use of hypnosis methods combined with conventional pain

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management techniques has shown improvements in pain and anxiety control in children receiving dental anesthetic treatment.20,27,33,57,58

The use of sedation can be used safely and effectively in patients who are unable to cooperate due to a lack of psychological or emotional maturity and / or mental, physical, or medical conditions. Dental care in early childhood caries with moderate sedation has been shown to significantly increase responses to cooperative behavior. children during the next memory lift 4 to 29 months after completing treatment. Sedation can reduce the suffering of toddlers and preschoolers during dental work. However, pediatric dentists should receive special training to provide sedation. Contraindications to the use of sedation are in cooperative patients with minimal dental requirements; and any medical and / or physical conditions that cause sedation are discouraged. A number of studies regarding the use of sedation drugs in pediatric patients in dental care found that there were no significant differences between the intravenous midazolam- ketamine or midazolam-fentanyl groups. Both types of drugs are appropriate in controlling the child's behavior during dental treatment.22,23,41,50,51

Nitrous oxide / oxygen inhalation is a safe and effective technique for reducing anxiety and promoting effective communication. The onset of action is fast, the effects are easily titrated and reversible, and the recovery is fast and complete. In addition, nitrous oxide / oxygen inhalation mediates variable rates of analgesia, amnesia, and reduction of the gag reflex. This technique is one of the right techniques to overcome anxiety in pediatric patients in dental care with a pharmacological approach, patients whose vomiting reflex interferes with dental care, and patients who cannot be localized to anesthesia, and cooperative children undergoing long dental procedures. Contraindicated against respiratory diseases such as pulmonary obtructive and upper respiratory tract infections. Also in severe emotional disorders and patients with drug dependence, pregnant (first trimester) and patients with vitamin B-12 deficiency.11,21,22,41,59

Treatment of anxiety in children patients in dentistry can also be combined between a non-pharmacological approach and a pharmacological approach. In dental care especially in children patients, the use of Local Anesthetic Eutektic Mixture with Audio Visual aids is better when compared to Local Anesthetic Eutektic Mixture without Audio Visual aids followed by benzocaine with Audio Visual aids. Then, the use of device methods is more effective than conventional methods in dealing with pain, anxiety, and behavior of patients aged 6-11 years.

This device is cost-effective, simple, and child-friendly especially in the administration of local anesthesia in child patients.5, 20, 28,60,61

Conclusion

Recent literature shows that there are various methods of treating anxiety in child patients in dentistry. Anxiety management can be a non-pharmacological approach and a pharmacological approach or a combination of the two. This pattern of treatment can be used to overcome children's anxiety towards dental care so that this systematic review can be used as a reference in the treatment of anxiety in children patients in dentistry.

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