Dental anxiety is a very common condition that can severely affect children. It is often described as a cycle where fear and anxiety cause avoidance of dental care, leading to a deterioration in oral health.¹ It is important to manage dental anxiety in children as poor dental health can cause pain and infections. Additionally, decreasing anxiety can significantly improve a child’s well-being.

Parents and guardians are a vital part of managing a child’s dental anxiety as they are trusted people who can provide positivity and reassurance. There are many methods to manage dental anxiety ranging from calming communication to positive reinforcement. Preventative measures, such as pre-appointment preparation, can diffuse this anxiety before it becomes a cycle of dental anxiety and avoidance. Children with mild dental anxiety can benefit from these methods but children with severe dental anxiety might need long-term management methods such as working with paediatric psychologists.

Understanding dental anxiety and using strategies to manage this anxiety can significantly improve the health and well-being of children.

Understanding dental anxiety in children

Research has shown that several interacting factors contribute to the development of dental anxiety. These include personal factors such as personality and environmental factors such as parents’ attitudes.² Psychological factors have been identified as important in the development of dental anxiety, particularly shyness and general fearfulness.³ It has also been found that negative attitudes from parents and guardians surrounding dental care and treatments can be transferred to their children.^4,5

The first step to managing dental anxiety is recognising it. Children with dental anxiety may experience a range of symptoms which can help parents or guardians to identify it. Symptoms of dental anxiety include:

• Sweating
• Fainting
• Dizziness 
• Nausea
• Visible distress, crying, or signs of panic before appointments
• Racing heartbeat or palpitations
• Shortness of breath
• Trouble sleeping or concentrating before dental appointments

These symptoms can differ between children and children may not experience every symptom.

Avoidance of dental appointments is a key aspect of dental anxiety. This can be due to difficulty physically getting the child to appointments or the child hiding dental issues to avoid an appointment being made. As dental hygiene decreases, the amount of treatment needed increases which can in turn increase the level of dental anxiety.¹ It is important to recognise dental anxiety early on to avoid this from occurring. 

Strategies for managing dental anxiety in children

Choosing a child-friendly dental environment 

When in a positive, comfortable environment it can decrease negative emotions such as anxiety. Generally, children visiting a dental office prefer to have walls with painted cartoons and have access to toys. They also enjoy watching cartoons and listening to rhymes during their treatment sessions.⁶ Considering a dental office an environment that accommodates anxious children may create a more positive experience for children and reduce their dental anxiety. Studies have also found that children prefer having their parents present during treatment.⁶

Trust and rapport between parent/ guardian and child

One key method to combat anxiety is through reassurance. If a child has a good rapport with their parent, they are more likely to ask for reassurance. Research has shown that children who had higher rates of emotional alienation (not being emotionally close to their parents) were linked to more emotional problems, including anxiety.⁷ This highlights the importance of building a strong relationship with a child to try to reduce the risk of them developing anxiety. This can be applied to dental anxiety. Additionally, when a child has a strong trust in their parents, they tend to feel less anxious about situations their parents bring them into, such as dental appointments.

Calming communication techniques

When a child experiences dental anxiety it may cause moments of panic. It is important to try to calm the child down or they might associate this panic with dental issues. Speaking in a calm tone and providing reassurance will help the child but there are also calming techniques that have proven effective. One is using all five senses, naming:

• five things you can see
• four things you can hear
• three things you can touch
• two things you can smell and
• one thing you taste

This is often called ‘grounding’ and can make a child feel more present and less focused on their anxiety. 

Relaxation techniques

 Besides using calming communication, various relaxation techniques can also help ease anxiety. Breathing techniques help calm the body's fight-or-flight response, which is triggered by stress. An easy breathing exercise for children is hand breathing which a parent or guardian can do with their child. Holding a hand in front of them, the child traces the outline of their fingers using their other hand. Whilst doing this, they should be breathing in as they go up each finger and breathing out as they come back down the finger. This technique is easy for children to master and can help to relax them in a moment of panic.

Distraction

A common technique used to manage anxiety in children is using distractions. Often toys can provide a good distraction from dental care without disrupting treatment. Fidget spinners and kaleidoscopes have been found to alleviate children’s anxiety during dental procedures.⁸ Fidget spinners are sold in most toy stores and online along with other fidget toys. In addition to toys, watching cartoons or listening to music can provide a distraction. Whilst children are distracted, they are focusing less on their anxiety and the dental care that is causing this anxiety. This, in turn, reduces anxiety for future appointments.

Positive reinforcement

Positive reinforcement can decrease anxiety and avoidance of dental appointments by rewarding children for attending appointments and rewarding them throughout appointments. This can be through verbal praise, physical demonstrations of affection, like a hug, or physical rewards, such as toys or treats. For this technique to be effective the rewards need to be something the child will respond well to, something they particularly like, and be frequently provided.⁹ This technique is often used by dentists and dental nurses, which could be a contributing factor when choosing a child-friendly dental office.

Desensitisation 

Desensitisation is commonly used to conquer fears and it can be applied to dental anxiety. It consists of three steps:

• Firstly, discuss with the child their dental anxiety and construct a hierarchy of feared dental situations. Starting with the least anxiety-inducing to the most
• Then teach the child relaxation techniques, for example, hand breathing
• Finally, expose the child gradually to these situations working through the hierarchy whilst they actively practise the relaxation techniques¹⁰

An example of a hierarchy:

• Thinking about going to the dentist
• Talking about what happens at a dentist appointment
• Booking a dentist appointment
• Going for a check-up at the dentist
• Having a dental procedure

The idea is that once the child can do each situation on the hierarchy without anxiety, due to the relaxation techniques, they continue to the next situation until they no longer experience dental anxiety. This method creates less anxiety than going straight to the most anxiety-inducing situation which in this case is having a dental procedure.

Pre-appointment preparation

Anxiety about dental appointments tends to increase in the lead-up to attending an appointment. Discussing what will happen at the appointment beforehand with the child can reduce this anxiety. Educating children about situations that could happen at their appointments will decrease the risk of panic at appointments when something happens that they weren’t expecting. Ensuring children are prepared for various scenarios can help them to stay calm.

Regular visits

When children attend regular appointments, it removes the ambiguity of what could happen at appointments. The more they are exposed to dental care, with positive experiences created using the strategies discussed, the more relaxed they will be. Ensuring regular visits will lead to improved oral hygiene and could reduce the risk of needing a potentially anxiety-inducing procedure.

Working with paediatric psychologists or therapists

When a child’s dental anxiety is severe, they might need more help than their parent or guardian trying to manage their anxiety. Trained professionals such as paediatric psychologists and therapists can support children to combat their dental fears and anxiety. Cognitive behaviour therapy (CBT) is an effective treatment for children with dental anxiety.¹¹

Pharmacological interventions

Sometimes a child’s dental anxiety is so extreme that these techniques are not enough to manage their anxiety. This does not mean they can’t receive the care they may need. Dentists can intervene and consider sedative techniques if other methods of anxiety management have been exhausted. This is typically nitrous oxide with oxygen as it is relatively safe and easy to administer without increasing patient anxiety.¹²

Summary

A wide range of strategies are available to manage dental anxiety in children, with a lot of techniques requiring a parent or guardian to be proactive in ensuring they’re preventing dental anxiety or reducing existing dental anxiety. This can be preparing the child for appointments through discussions, choosing a dental office with a child-friendly environment, or using calming communication and behavioural techniques. In more severe cases children might need pharmacological interventions or to see a specialist. Early intervention is key to decreasing the amount of anxiety management the child will need. Managing dental anxiety is essential to combat the anxiety-avoidance cycle and protect oral health and children’s well-being.