Summary : Pediatric patients are a difficult case for many dentists in their clinics. Some doctors do not undertake the treatment of young patients because they are associated with potential difficulties in communication, lack of treatment effects, or simply low profitability.

On the other hand, parents do not realize that their own negative experiences related to dental treatment are transferred to their own offspring. Therefore, especially children of anxious parents need so-called adaptation visits that will most skillfully introduce them to the atmosphere of a dental clinic and will model their behavior during the visit. The child is our most important patient because by shaping his attitude from the first contact, we have a chance to build a proper patient-dentist relationship. Denying your child’s fear and not noticing it can lead to dentophobia in adulthood.

Dental fear

Etiology

In a review by M. Themessi-Huber et al. forty-three studies from six continents were analyzed ^[1]. The studies varied in their design, methods, age of subjects, and the relation between parents and children’s dental fear. The etiology of dental anxiety is certainly multifactorial and multidimensional, but the presented meta-analysis confirmed the relation between parents and children’s anxiety before treatment. It is most noticeable in the group of 8 years old and under. Then, along with mental development, this relation diminishes. In the etiology of fear in older children, the acquisition of fear follows three different paths. Dental anxiety can be the result of:

• Direct conditioning
• Acquired through model learning,
• The consequence of negative information

The influence of anxiety on the perception of pain

It is worth bearing in mind that anxiety plays a very important role in the perception of pain. Anxiety thoughts and assumptions (such as “it will hurt”) modulate the perception of pain and its intensity. Even thinking about visiting a dentist may be threatening to such a patient. He/she expects the worst and processes information in a distorted and one-sided way and pain seems stronger than it really is. Researchers suggest that anxiety lowers the pain threshold, making normally painless stimuli painful. A possible mechanism for increasing pain in anxious patients may be that the anxiety increases sympathetic activity and epinephrine is released at sympathetic tips. It may sensitize or directly activate nociceptors and unpleasant emotions to prevent and better control the pain.

Prophylaxis and psychoeducation

If a dental office has the ambition of being a family clinic, dental prophylaxis for children should primarily include psychoeducation of parents. It is a dentist’s responsibility to make patients aware of the need to include dental preventive measures in the care of children, at the earliest possible stage of their life. Parents educated in this way, even despite their own prejudice, will adapt their children to regular visits before any medical intervention in dental clinics becomes necessary. A good relationship with a young patient can be one of the most difficult and at the same time most rewarding work experiences for dental professionals.  Such a process requires action on two levels: psychological knowledge and appropriate environmental conditions (e.g., instruments, presence of a supportive parent), that will create an atmosphere of trust and security.

In the early stages of mental development, the quality of the relationship with the mother is of utmost importance. That is why many authors have been investigating this issue. For example, Freeman points to the importance of the maternal ability to bear and deal with her child’s anxiety. Whether this ability is viewed in terms of personality strength or affects inhibition, it is important how a mother’s behavior enables her baby to cope with internal fears caused by situations such as dental treatment ^[2]. Pregnancy is the best time to initiate maternal dental psychoeducation. Perhaps many people will find it over-dimensional, but this type of awareness reaches women too late, mostly in challenging situations with a child (trauma, pain, complicated treatment, or need for immediate extraction). Therefore it would be ideal to include this aspect in programs of childbirth classes.

For example, it’s important to know that there are three models of mother-child relationship functionality:

• The competent mother-child model is characterized by supporting the child in his/her mental development.
• The aggressive mother-child model, characterized by inconsistency and emotional distance,
• Anxious mother-child, characterized by ambivalence and intrusiveness. ^[3,4]

Aggressive behavior (shouting, forceful actions) acts as fear shielding. A child with dental anxiety, embroiled in a restless and/or aggressive model of the mother-child relationship, will be left alone to control his/her dental anxiety, even bigger because of the mother’s inconsistent and ambivalent behavior. Making children afraid of dentists and threatening them with complications is an inappropriate and certainly wrong way to build a positive attitude towards dentists and the procedures they perform. If the mother tells the child in a broken voice to keep quiet because nothing is happening – it is likely to cause anxiety in the child. It is also worth defining a list of forbidden words and messages like “do not be afraid”, and “it will not hurt”. Let us also ask the parents not to lean over the chair during the procedure and ask many questions, mostly  “Are you okay?”. It also creates a nervous atmosphere. Be careful not to laugh at your child’s fear and not embarrass him. This will certainly increase the child’s level of stress and anxiety. Freeman argues that shaping positive, consistent, and caring interactions with children (the competent mother-child model) is crucial for children’s ability to adequately cope with anxiety during dental treatment. [2]

Schema of Adaptation Visits

Ramos-Jorge et al. tested a six-visit scheme of adaptation visits that took place at weekly intervals. The level of anxiety in children was assessed between visits.

The following scheme assumed the following doctor’s treatment at individual 6 visits:

• General and dental interview
• Application of the “tell-show-do” technique, extraoral and intraoral clinical examination, treatment planning, and talking to parents.
• Simple and short prophylactic procedures and oral hygiene instruction.
• Oral hygiene instruction and watching videos for children (modeling behavior by watching other children during treatment in the office)
• Treatment with the ART technique (atraumatic restorative treatment), i.e., treatment of the cavity with an excavator and use of a glass ionomer.
• Possible continuation of the treatment

Children from 8 to 11 years old without prior dental treatment and with two or more carious teeth were enrolled in the study. The level of anxiety in the dental clinic was assessed in children without toothache (G1) and with toothache (G2 – then the necessary treatment was performed on the first visit), using a modified VPT scale ^[5]. There was a significant decrease in anxiety levels between the first and fifth visit in both children with and without toothaches. It is worth noting, however, that those children who felt pain experienced a higher level of anxiety. It should also be remembered that patients’ increased level of anxiety sensitizes them to nociceptive stimulation, causing a greater feeling of pain stimuli (requires a need for local anesthesia) and lower tolerance to chronic pain ^[6]. Parents of the youngest patients, when making an appointment at the dentist’s clinic, should consider the fact that visits should take place during the child’s active hours, taking into account everyday habits, and should not affect bedtime or meals.

Behavioral Techniques

One of the recommended strategies for reducing discomfort and anxiety during anesthesia in children is behavioral techniques (BMT). ^[10] A comparison of the Tell-Show-Do (TSD-T) technique to the dental needle concealment technique (HDN-T) in terms of assessing the level of anxiety, pain, and behavior of children during the first mandibular block anesthesia was made in a randomized clinical trial by Vidigal et al. Both techniques were performed by a dentist experienced in working with preschool children. In the TSD-T technique, the operator explained to each patient with a child-friendly voice that “he would use a small device with a small bottle that contains magic water and put the tooth to sleep.” Then he showed the patient a syringe with an ampule inserted and a needle without a protective cap. In the HDN-T group, the patient did not see any instruments. The operator said in a friendly voice that “the aching tooth would fall asleep under the influence of the magic water, and it would be better later”. The dentist then picked up the carpule in his right hand. The dentist’s left hand held the patient’s cheek with his/her thumb and forefinger, and the child’s field of vision was carefully covered with the remaining fingers. No significant differences were found in the statistical evaluation of the results obtained. However, as the authors emphasize in the conclusion, practitioners should pay attention to the fact that hiding the view of the needle had a positive effect on reducing the level of anxiety.

Medical solutions

Pharmacosedation

If there is a need for immediate medical intervention due to, for example, pain, the dentist can use pharmacosedation or inhalation sedation. In pharmacological sedation, a primary drug used in dental clinics is midazolam (a benzodiazepine derivative). It has a sedative, myorelaxant, and hypnotic effect and causes anterograde amnesia. Midazolam is most often administered orally. After the application of the drug, a paradoxical reaction in the form of psychomotor agitation can occur. In the event of such reactions, the patient should never be repeatedly administered midazolam. The feeling of relaxation can also be obtained by inhalation sedation with a mixture of oxygen and nitrous oxide. In addition to its sedative and anxiolytic effect, it also provides a low degree of analgesia. The inhalation sedation method is the safest method that can be used by a dentist and… what is worth adding is attractive to use. We are often dealing here with an effect of “positive surprise with the novelty”. And those children who are afraid of equipment can be familiarized with it by borrowing a mask to take home. Returning to the dental office, they willingly cooperate. Ultimately, however, one should strive to build a relationship with a child that does not require pharmacological support, because this may shape their relationship and attitude for the whole life. Children who have experienced a toothache present a higher level of anxiety before treatment than those who have never had any dental problems.

Atraumatic Restorative Treatment

In the discussed algorithm of the adaptation procedure, it is worth considering the possibility of replacing the traditional glass ionomer material with a new generation of bioactive types of cement. These include Biodentine (Septodont), a tri-calcium silicate cement. It releases Ca (OH) 2, induces the formation of reparative dentin, and has antibacterial properties ^[7]. During the minimally invasive cavity preparation in the ART technique, it is possible to intentionally leave soft dentin on the pulpal wall, in the cavity (where the bactericidal effect of the material is particularly desirable) and the remaining surface is prepared for the hard dentin tissue.

Current reports clearly show that new generations of biomaterials such as Biodentine allow more teeth to be kept alive after direct dental capping. Undoubtedly, such a procedure is also a significant reduction of stress in a child, which is always associated with the decision to extract a tooth. In clinical practice with young patients, we encounter various pulp exposure. It happens before the procedure there is no evidence of a deep carious lesion, while the exposure of the pulp occurred due to a tooth trauma or an iatrogenic trauma (class I). Treatment of an asymptomatic tooth with Biodentine seems to be relatively simple, with a one or two-visit procedure. Class II exposure, on the other hand, includes a deep or very deep carious lesion. Exposure of the pulp tissue is considered clinically to be in the zone of bacterial infection provided that this is pulpitis without symptoms. In these situations, ESE (EuropeanSociety of Endodontics) recommends an extended treatment protocol (aseptic procedure with magnification, disinfection, and the use of calcium silicate cement). Biodentine has a stimulating effect on the pulp-dentin complex. In practice, it can extend the vitality of the pulp even in the case of very deep defects, reversible and even irreversible pulpitis, eliminating pain.

Painless Injection

When working with a child, it is necessary to perform local anesthesia to prevent and minimize discomfort. It is worth remembering the need to use topical anesthesia, preferably in the form of a gel. Regardless of the type of active substance (benzocaine or lidocaine), it is necessary to provide the preparation with at least 2 minutes of action. A painless injection is a prerequisite for gaining the trust of the young patient. Currently, we have at our disposal instrumentation that allows this procedure to be performed in an almost completely atraumatic, painless, and stress-free manner. For example, at the very beginning of the injection, the design of the Evolution (Septodont) needle requires less force to be applied. The rapidly growing feeling of tissue dislocation may also be interpreted by an anxious child as a strong stressor. Therefore, very slow administration of the anesthetic is of fundamental importance for the comfort and safety of a patient (the risk of overdosing increases with rapid deposition of the drug). The sight of the metal, and at the same time an unpleasant touch of cold carpula, makes the classic dental syringe an object that arouses negative emotions for all patients. Therefore, especially when working with anxiety patients, modern, safe Ultra Safety Plus Twist (Septodont) syringes are an excellent solution. Their main advantage is the guarantee of protection against accidental injuries. They are disposable, so from the perspective of patients, they perfectly match the stringent requirements of the pandemic period. Introducing Ultra Safety Plus Twist with a hidden needle into a dental office would be very beneficial. It would reduce anxiety in pediatric patients who have had a traumatizing experience directly related to the use of metal capsules. A needle is often a powerful stimulus to change a patient’s behavior. This reaction is considered to be the fear of stab wounds, deeply rooted in the human psyche. The construction of the Ultra Safety Plus Twist makes it easier to hide a needle, which is not possible even in the case of computer anesthesia.

Inferior Alveolar Nerve Block

Performing inferior alveolar nerve block is a very stressful procedure, especially when it is done for the first time. In the case of extraction of a lower deciduous molar, this technique can practically be replaced by infiltration anesthesia from the buccal side with Septanest 1:200,000 (Septodont) ^[8]. In the case of deciduous dentition, an effective technique is also the incisal nerve block

Nevertheless, in older children, this procedure is quite difficult, especially in patients with anxiety. High dental anxiety, toothaches, and children’s uncooperative behavior in prior medical experience have been proven to be predictive factors for children’s behavior prior to their first visit to the dentist ^[9]. Therefore, it is worth making every effort to ensure that the first mandible block is not a traumatizing experience for pediatric patients.

Conclusions

Pediatric dentistry is a specialization where children and parents expect from dentists the following: specific knowledge, skills, proper instrumentation, and also a large dose of empathy. Therefore, the awareness of the importance of psychological aspects is a significant factor in facilitating the treatment of young patients and modeling attitudes,

And since the visits are long …?

Antoine De Saint-Exupery also included another famous sentence in The Little Prince:

“You lost so much time for me that I felt important”