One of the most challenging situations for all dentists is the arrival of an anxious child into the waiting room. The key aims for the dentist are to recognise and acknowledge the anxiety. We then need to gain the trust and confidence of our young patients in order to achieve the cooperation we require to provide high quality dentistry while instilling a positive attitude to oral health. This is an overview of the techniques available, but each child is different, so part of our skill is to tailor individual management strategies for each patient.

Pre-visit communication
The management of an anxious child begins the minute an appointment for a new patient is made. The more prepared parents and children are the more we can expect from a first consultation. A friendly, reassuring voice on the phone, and pre-visit information letters/website section have been shown to reduce parental anxiety, which is key. Also, encouraging the reading of child-friendly books about going to the dentist is beneficial (Figure 1).

FIGURE 1: Encouraging the reading of child-friendly books about going to the dentist is beneficial.

FIGURE 1: Encouraging the reading of child-friendly books about going to the dentist is beneficial.

Dental environment
The dental surgery is full of strange sights, smells and sounds. Gradual supervised exposure can decrease fearful responses. Child-friendly staff and a pleasant, colourful waiting area with suitable distractions are important (Figure 2). Children respond best to professional, smartly dressed medical personnel.

FIGURE 2: To help relieve a child's anxiety, a pleasant, colourful waiting area with suitable distractions is important.

FIGURE 2: To help relieve a child’s anxiety, a pleasant, colourful waiting area with suitable distractions is important.

Initial meeting
The initial meeting is a key aspect in the development of a relationship with both parent and child. It is best to have the initial meeting away from the surgery (no matter how busy your day is). Going out to the waiting room to say hi and have a chat is very reassuring for patients. It is a useful opportunity to gauge the anxiety level of both child and parent, and also to explain what will happen in the visit ahead – including a time frame and what is expected of patient and parents (Figure 3).

FIGURE 3: It is a good idea to have the first meeting take place outside the treatment room.

FIGURE 3: It is a good idea to have the first meeting take place outside the treatment room.

Recognising an anxious child
Children display anxiety differently – they can seem more irrational and less restrained than adults. Signs of anxiety in a child can include:

  • hiding behind parent/furniture;
  • thumb sucking;
  • nail biting;
  • nose picking;
  • no eye contact;
  • silence;
  • baby language;
  • claiming to have a ‘sore tummy’;
  • crying;
  • using delay tactics, e.g., repeated visits to the bathroom; and,
  • disruptive behaviour.

Entering the surgery
The initial consultation and clinical examination does not have to be in the dental chair. If a child is happier on mum’s or dad’s knee then that’s fine while they relax and get used to the surroundings. Always have another place to sit in the surgery for parents. The child can be distracted brushing model teeth or playing while the medical history and presenting complaint are discussed (Figure 4). Often a child who entered the surgery clinging to their parent for dear life is sufficiently bored and curious after a while to try the chair.

FIGURE 4: The initial consultation and clinical examination does not have to be in the dental chair.

FIGURE 4: The initial consultation and clinical examination does not have to be in the dental chair.

Communication with an anxious child:
Use age-appropriate language at all times. Listen actively to children when they tell you things – if they look worried acknowledge this: ask what they are worried about. Strong feelings do not disappear if ignored (Figure 5).

FIGURE 5: Listen actively to children if they look worried, ask what they are worried about.

FIGURE 5: Listen actively to children if they look worried, ask what they are worried about.

Try and find a common ground for discussion and establish a rapport before getting down to the tooth chat. Lay out the framework for a visit clearly so everyone knows what is next and how long is left. If you promised not to do treatment that day try to stick to your word.

Communication during examination/treatment:
Descriptive praise

  • This should be immediate and specific to a desired behaviour, e.g., “you are opening so wide – that’s brilliant”, as opposed to blanket statements such as “you’re doing great”.

 

Stop signals

  • Feeling out of control is a big worry, so establish a method of communication allowing perceived control, e.g., “raise your hand if you need me to stop” (Figure 6).

 

FIGURE 6: Establish a ‘stop’ signal, such as a raised hand, to reassure the child.

FIGURE 6: Establish a ‘stop’ signal, such as a raised hand, to reassure the child.

Choices

  • These enhance the feeling of being involved and important, e.g., “which side of the chair are you getting up on?”, or “Which tooth will I polish first – top or bottom?”

Tell-show-do

  • This is a tried and tested technique. Talk about the stimulus, show the child and then introduce it gradually (Figures 7 and 8).

 

FIGURE 7: Tell-show-do: first show the child the stimulus.

FIGURE 7: Tell-show-do: first show the child the
stimulus.

FIGURE 8: Tell-show-do: then, if the child is willing, introduce the stimulus gradually.

FIGURE 8: Tell-show-do: then, if the child is willing, introduce the stimulus gradually.

Voice control

  • The tone of what we say is more meaningful than the words, especially accompanied by body language and facial expression.
  • A firm tone can get attention and establish authority, but as soon as behaviour is corrected, your tone should go back to normal.

Positive reinforcement

  •  If a behaviour is rewarded it is likely to be repeated.
  • Rewards can be verbal praise or a sticker or toy.
  • If a behaviour is not rewarded it is less likely to be repeated: ignore bad behaviour where possible.

Distraction

  • Shift attention away from anxiety-producing stimulus – play games, wiggle toes/fingers.
  • Allowing children to role play ‘at the dentist’ can be a great way to help them relax (Figure 9).

 

FIGURE 9: Allowing children to role play ‘at the dentist’ can be a great way to relax and explore the surgery.

FIGURE 9: Allowing children to role play ‘at the dentist’ can be a great way to relax and explore the surgery.

Modelling

  • Use a child of the same gender and similar age.
  • Show the child entering and leaving the surgery.
  • Show treatment completion.
  • Show rewards received for good behaviour.
  • Show that the model is anxious initially but copes.

 

Parental role
There is a strong correlation between parents who have dental anxiety and their children. It is very important that parents are put at ease and well informed from the very first contact with your surgery. It is a good idea for parents to be present in the dental surgery during treatment, but only as a comforting presence not as a participant! Encouraging parents to read a magazine quietly in the corner provides reassurance for the child while allowing the dentist to take the lead.

At end of treatment
When treatment is completed, give a final reward and use encouraging descriptive words. Explain what will happen at the next visit and what is expected of the child. Try to give a time frame for the number of treatments left and the work left to do.

Concluding remarks
As clinicians, if we can recognise an anxious child and guide them through their dental visit with kindness and empathy we are more likely to be successful. Once children feel trust and confidence in their dentist, even the most anxious child can become a positive and committed dental patient.

AbigailMooreBground

Dr Abigail Moore BDentSc DChDent MFD (RCSI)
Abigail’s practice is limited to paediatrics and is based in both the Burlington Dental Clinic, Dublin 4 and the Hermitage Medical Clinic, Dublin 20. She can be contacted at moorea@burlingtondentalclinic.com.