A clinical guide to needle desensitization for the paediatric patient

Dental anxiety may occur without a triggering stimulus and may be a reaction to an unknown danger, or anticipated due to previous negative experiences. Whilst dental fear is a normal emotional response to objects or situations perceived as genuinely threatening,1 both are problems which dental practitioners may encounter on a daily basis.2 Phobia is a clinical mental disorder in which subjects display persistent and extreme fear of objects or situations with avoidance behaviour and possible interference to daily life. Understanding these terms and associated issues allows effective management of both dentally anxious children, who may have a generalized anxiety associated with the dental setting,3 and dentally fearful children, who have a specific stimulus, for example an injection or needles (trypanophobia), the drill, or the dentist, which precipitate a negative response. These children who present with behavioural challenges and, as stated, a dental phobia diagnosis, exhibit avoidance or extreme fear of dental care when brought to appointments by their parents. Patients should be assessed with an appropriate clinical history. This should include past dental experiences, awareness of dental procedures/problems, previous hospital/medical contact/treatments, and any parental anxieties or contributing social factors.2 If mistrust of dentists is the presenting problem, it can be helpful to reassure the child that you are there to help; there is nothing to be gained by actually giving the injection before they feel comfortable in accepting it. An assessment tool should also be completed at this appointment, such as the Modified Child Dental Anxiety Scale faces version (MCDASf) (Figure 1), which is a reliable and quick measure of how the child feels and is validated for children who are 8–12 years old.3^,4 Alternative assessment tools are also available for use, for example CFSS-DS3 and Venham picture scale.3 These tools, along with a good history and clinical assessment, are all helpful in assessing the extent of the dental management challenge, which then determines the correct pathway to ensure children are seen in the most appropriate setting for their emotional and dental requirements. Some patients may be suitable for a dentist in primary care to address both needs. When children are assessed as having mild or moderate dental fear, and this is supplemented with a MCDAS(f) score of 24/40 or less, and a specific aetiology of needle phobia, then relaxation exercises with needle desensitization can be very effective for the facilitation of dental injections. While other patients, who are assessed with both their history and clinically as having severe fear or dental phobia or with a MCDAS(f) score of greater than 24, (dental phobia is consistent with a MCDAS(f) score of 27 or greater) may be better served by being referred to a specialist or consultant in paediatric dentistry or may require referral for psychological assessment by the appropriate local child psychology team prior to, or in conjunction with, dental treatment.