From Volume 44, Issue 1, January 2017 | Pages 45-51
Dental fear in the paediatric population can be a significant barrier to providing optimal dental care. Pharmacological management techniques utilized to manage anxiety, such as conscious sedation and general anaesthesia, are expensive and require specialized equipment with additional staff training. With recent advances in technology, video glasses are an economic and novel distraction technique that may aid in improving behaviour management and facilitate dental treatment.
The dental team play a pivotal role in making a child's visit to the dentist a positive experience. It is often necessary to adapt communication and behaviour management techniques in order to ensure patient comfort and compliance. Apprehension towards dental treatment, however, can impede the provision of care and affect a child's long-term outlook on dentistry.1
In the Child Dental Health Survey of 2013, the prevalence of anxiety in the UK was assessed. Overall, 14% of 12-year-olds and 10% of 15-year-olds were found to suffer from extreme dental anxiety. Higher anxiety levels of 21% and 17% were reported in 5- and 8-year-old children, respectively. In regards to gender differences, boys seem to report less dental anxiety compared to girls, which may be due to a reluctance in describing their dental fear. Unsurprisingly, the administration of local anaesthetic elicited the highest anxiety scores in both the 12- and 15-year-old age groups.2
It is essential that dental phobia is appropriately managed owing to its impact on a child's oral health. Anxiety is common in children who irregularly attend the dentist and miss several appointments.3 This cohort of children exhibit increased caries morbidity or DMFT (Decayed Missing or Filled teeth) scores.4 Additionally, children with higher anxiety levels tend to suffer more dental pain compared to co-operative children.5
It is not only patients that suffer as a consequence of their dental phobia. Levels of stress can be elevated in the operating practitioner whilst undertaking dental treatment in a nervous child. This may affect rational thought and can be associated with significant health risks in the long term.6
Currently in the UK general anaesthesia is a commonly used pharmacological technique to manage insufficient co-operation in children. In 2013–2014, 46,500 children and young people in England under 19 years of age were admitted to hospital as a result of dental caries. The numbers are highest in the 5–9 year-old age category in which there has been a 14% rise in admissions since 2010–2011.7 These children placed on exodontia lists are a considerable financial burden costing taxpayers £30 million in 2012/13,8 with an average cost of £673 per child.9
In addition, dental treatment under general anaesthetic can be a distressing experience and, unfortunately, is accompanied in a healthy individual by approximately a 1:100,000 risk of suffering a life-threatening complication.10
Conscious sedation techniques aim to tackle dental anxiety by depressing the central nervous system with the administration of drugs. However, this differs from a general anaesthetic as verbal contact is maintained during treatment and a significant margin of safety exists to prevent the loss of consciousness.11
Oral pre-medication can involve a small dose of oral sedative to help relieve anxiety prior to a dental visit. This is not routinely prescribed in children as its effects are unpredictable and cannot be titrated. Side-effects, such as nausea, vomiting, behavioural disinhibition and, in severe cases, respiratory depression and arrest may occur.12 However, a pre-operative sedative is sometimes warranted to facilitate the induction process by allowing cannulation and reducing the need for physical intervention.13
Nitrous oxide is frequently employed in paediatric dentistry to alleviate anxiety. A titrated mix of nitrous oxide in oxygen delivered via a nasal hood has been reported to aid in undertaking dental treatment successfully by its ability to depress a patient's gag reflex and facilitate prolonged treatment.14 Nitrous oxide may be favoured over general anaesthesia in medically compromised children as it is not metabolized and therefore has a fast onset, quick recovery and, most importantly, is generally safe to use in this cohort.15 On the other hand, it is not generally available in primary dental care. Expensive equipment, maintenance costs and additional staff training,16 without the incentive to be financially compensated under the current NHS contract, deter general dental practitioners from its use.
In complex cases where inhalation sedation is not suitable, intravenous sedation is a viable alternative method of facilitating behaviour management. It can also be utilized in situations where a general anaesthetic cannot be justified, such as the elective extractions of healthy teeth for orthodontic reasons.17 This technique is only indicated in young people over 12 years old. In a primary care setting, the use of a single drug administered intravenously is advised.18 However, it is not routinely available outside a hospital setting due to specific training requirements of teams, risks of administering midazolam or propofol, and the perceived difficulty of cannulation in children.19 These requirements call for the need of a specialist/consultant in paediatric dentistry and a consultant in anaesthesia competent in sedation for dentistry for assessment and treatment in a facility equivalent to an NHS Acute Trust in England.18
Children acquire strategies to aid in coping with new situations and experiences when growing up. Attending the dentist can be a daunting and difficult experience in which these coping strategies are not sufficient.20 A non-pharmacological approach employed by the dental team can acclimatize the patient and tailor the dentist–patient interaction to gain compliance and relieve anxiety. A wide range of practices are available in managing poor behaviour. The use of multiple approaches personalized to an individual child is recommended in order to reinforce good behaviour and build rapport.21
This technique aims to influence a patient's co-operation by the alteration of voice volume and rate of speech. It has proved useful in poorly attentive children as authority can be established simply, therefore resulting in improved co-operation. It is also successful in reducing disruptive behaviour without producing long-term negative effects.22
This simple method is routinely utilized by the dental team to familiarize children with dental procedures quickly.23 It involves: Tell – an explanation which is age appropriate to the patient;
Show – demonstrating the procedure or equipment; and
Do – carrying out what the patient was shown.24
It has been demonstrated to reduce anxiety significantly in paediatric patients and speed up the acclimatization process.25
This approach consists of improving compliance by rewarding the child to reinforce desired behaviours and treatment outcomes. Pleasing items such as stickers, toys and badges can be utilized to reinforce good habits in a dental setting.26 However, praise through non-verbal communication and tone of voice can have a substantial impact on the behaviour-shaping process.27
The influence of a family member, friend or peer should not be underestimated in order to improve the co-operation of a child. An older family member exhibiting appropriate behaviour in the dental chair can be beneficial in reducing dental fear and promote appropriate conduct.28 Studies have demonstrated that live model filming and videos can also encourage good conduct. To be effective, it must display a similar age of the child to be targeted with praise of the required behaviour (Figure 1).29
This process aims to aid a child in overcoming a specific fear via repeated contacts and a gradual increase in stimulus. Relaxation techniques are integrated into the desensitization sessions in children that can identify their fear and communicate it verbally.30
This technique aims to shift children's attention away from unpleasant stimuli, thereby reducing disruptive behaviour. Examples of these include stretching the lip when administering local anaesthetic and asking patients to ‘wiggle’ their feet when taking impressions or radiographs. Verbal distraction throughout the appointment can permit treatment to be carried out without children reacting to the known stimulus.31 Audio distraction has also been proposed and, although proven successful in adults, it has had inconsistent results in managing a child's dental anxiety.32
The medical field was the first to introduce audio-visual distraction to undertake treatment on children suffering from burn injuries.33 These patients are a difficult group to manage owing to their need for multiple dressing changes that are painful and can cause behavioural distress.34 Potent pharmacological analgesic intervention is insufficient due to physiological tolerance of, and dependence on, opioid medication.35 In this cohort of children, studies have shown that audio-visual distraction consisting of video games36 and virtual reality37 can supplement pharmacological behaviour management techniques successfully. In regards to dentistry, this behaviour management technique has increased in popularity in recent years. As a result of its simplicity, further research has been undertaken into its application for dental patients. It has been stated that there can be a significant improvement in behaviour during dental treatment. However, pain and physiological measurements are unaffected by this treatment modality.38 When assessing the success of different non-pharmacological behaviour management techniques, audio-visual distraction is more effective in alleviating paediatric dental anxiety compared to audio distraction alone.39
Several technological methods have been introduced in the dental setting to improve a child's behaviour. Audio-visual distraction in the form of television, video games and virtual reality have been utilized. These devices have several disadvantages when applied to dentistry which include:
Video glasses are a simple and immersive audio-visual distraction tool that seems to overcome the limitations that exist with alternative technological devices. They consist of glasses with incorporated twin high resolution LCD displays which cover the full field of vision and in which sound is provided through headphones. The video glasses can be easily connected to an output device in order to allow for patient choice of a wide range of videos (Figure 2). However, there are limitations to video glasses. Some models may not provide sufficient eye protection and it is contra-indicated in children that suffer from epilepsy elicited by flashing images.
There is limited evidence available to support the use of video glasses, however, small studies have suggested that they may be effective in supporting the administration of local anaesthesia41 and undertaking restorative treatment in children.42
In comparison to pharmacological behaviour techniques, the use of video glasses has shown early promise. No paediatric studies have been undertaken however, in an adult randomized control trial, there was no significant difference between inhalation sedation and video glasses in its effect on perceived pain in patients diagnosed with chronic periodontitis undergoing periodontal therapy.43 It has been proposed that video glasses can be used as an adjunct to relative analgesia.44 Nonetheless, caution is advised owing to the loss of eye and verbal contact during treatment under conscious sedation.
In the experience of the authors, there are several clinical scenarios in which video glasses are invaluable in the management of phobic children and allow treatment to be completed without impacting negatively on their compliance.
Introducing conventional behaviour management techniques in this group of children can be complicated owing to their lack of understanding, communication difficulties and apprehension in accepting an invasion of their personal space.45 Distraction techniques can overwhelm these children due to sensory issues regarding tactile and auditory stimulus. Although this is true, autistic spectrum disorder children spend significantly more time watching television and playing video games compared to siblings.46 Taking advantage of their compulsive behaviour can be the breakthrough needed to initiate dental treatment (Figure 3).
This age group may struggle to receive high quality dental care owing to their short attention spans and inability to tolerate lengthy treatment appointments. Furthermore, parents may be reluctant to consent to treatment under general anaesthesia because of the risks of this procedure and the frequent need to extract all carious primary teeth in order to prevent a repeat general anaesthetic (Figure 4).
A traumatic injury to the incisal teeth can be a harrowing experience for both child and parent. It also may be his/her first experience of receiving invasive dental treatment. Providing timely, appropriate dental care and ensuring that it is a positive experience is paramount to safeguarding the prognosis of injured teeth. Further appointments are always necessary which may also include orthodontic, restorative and surgical treatment. Video glasses have the potential to distract the child sufficiently in order to complete complex therapy (Figure 5).
Video glasses have the potential to be an effective substitute for inhalation sedation in children where it is unavailable, compliance is insufficient or where it is medically contra-indicated. Inhalation sedation is not advisable in children that are mouth breathers, have blocked noses, suffer from chronic respiratory disease and have had a medical procedure involving utilization of intracranial gases.47 Inhalation sedation can impair access to the anterior maxillary region due to the nasal hood that delivers the gas. Video glasses do not impede access to the anterior region in children who require behavioural support to improve compliance (Figure 6).
In the last decade, video glasses technology has evolved to deliver a more immersive entertainment experience by improving the user interface and quality of the audio-visual reproduction. Video glasses are a novel and possibly cost-effective tool in dentistry that can aid in overcoming barriers to help nervous patients accept dental treatment. There is a paucity of data for this treatment modality in the literature. Despite the plethora of non-pharmacological behaviour management techniques available, video glasses stand out as a potential way of effectively supporting paediatric patients and allowing the successful delivery of their care.
The authors declare no conflict of interest or any support from the manufacturers of the video glasses.
