Anxiety in children visiting the dental clinic is one of the most common challenges faced by paediatric dentists. Dental anxiety, which can manifest as mild apprehension or severe fear, often interferes with a child’s ability to cooperate during treatment. Understanding and managing this anxiety is crucial not only for the success of dental procedures but also for fostering lifelong positive dental attitudes and habits.
Managing an anxious child requires a combination of empathy, communication skills, behavioural techniques, and, in some cases, pharmacological interventions. The primary goal is to help the child cope with the unfamiliar environment of the dental clinic, build trust with the dental team, and encourage cooperative behaviour while minimizing distress and trauma.
Understanding the Nature of Dental Anxiety in Children
Dental anxiety in children may arise from various factors such as previous unpleasant experiences, fear of pain, the sound or sight of dental instruments, or even vicarious learning through parents and peers. Some children are naturally more fearful due to temperament or developmental stage, while others develop fear through conditioning or lack of exposure to healthcare environments.
Children between the ages of three and six are particularly prone to fear and anxiety, as they are still developing their understanding of unfamiliar experiences. Therefore, early positive exposure to dental care, ideally before any invasive procedure is required, is essential in preventing dental phobia later in life.
Anxiety can manifest as crying, clinging to parents, physical resistance, or even psychosomatic symptoms such as nausea or sweating. Recognizing these signs allows the dentist to adapt their approach accordingly.
General Principles for Behaviour Management
Several general principles guide the behaviour management of anxious children in dental practice:
1. Show Interest in the Child as a Person
Establishing rapport is the first and most crucial step. When the dentist shows genuine interest in the child as an individual, it builds trust and reduces fear. A friendly greeting, using the child’s name, and engaging in short conversations about their interests can help to humanize the clinical interaction.
2. Use Non-Verbal Communication Effectively
Non-verbal cues often speak louder than words. A gentle touch, a warm facial expression, or an encouraging tone can convey reassurance. Research indicates that a dentist’s facial expression and tone of voice may have a greater impact on the child’s comfort level than the actual words used.
3. Never Ignore a Child’s Fears
It is essential to validate and acknowledge a child’s fears rather than dismissing them. Statements such as “I understand that this looks a bit scary, but I’ll show you how it works” can make a huge difference in how the child perceives the situation.
4. Explain Procedures Clearly and Honestly
Fear of the unknown is one of the biggest contributors to anxiety. Using the Tell–Show–Do approach helps to demystify procedures. The dentist should explain what will happen, demonstrate it in a non-threatening way (e.g., on a model or finger), and then perform it gently.
5. Reinforce Positive Behaviour
Reinforcement—whether through verbal praise, stickers, or small rewards—encourages cooperative behaviour. Positive reinforcement strengthens the association between dental visits and pleasant experiences.
6. Encourage a Sense of Control
Giving children small choices, such as selecting the flavour of fluoride or choosing which chair they prefer to sit in, can provide a sense of autonomy. Allowing them to raise their hand if they need a break helps them feel in control, reducing anxiety significantly.
7. Gradual Exposure to Dental Experiences
Acclimatizing the child to the dental environment through gradual exposure—beginning with non-invasive procedures and slowly progressing to more complex ones—helps build confidence and reduces fear over time.
Behaviour Management Techniques
Tell–Show–Do Technique
This foundational method involves three steps:
- Tell: The dentist explains the procedure in language appropriate to the child’s age and understanding.
- Show: The dentist demonstrates the procedure using the actual instruments in a non-threatening manner.
- Do: Finally, the dentist performs the procedure as described.
This technique reduces fear of the unknown, builds trust, and allows the child to anticipate what will happen next. It is particularly effective in children aged 3–10 years.
Behaviour Shaping
Behaviour shaping is a process of guiding a child toward the desired behaviour through successive approximations. Instead of expecting perfect cooperation from the start, the dentist reinforces small, positive steps toward that goal.
For instance, if a child allows the mirror to be placed in their mouth without resistance, that behaviour should be praised immediately. Over time, these small reinforcements help build full cooperation. Negative behaviours, on the other hand, are best ignored to avoid reinforcing them.
Reinforcement Techniques
Reinforcement strengthens desired patterns of behaviour.
- Positive reinforcement involves rewards—praise, smiles, or tangible rewards like stickers.
- Negative reinforcement involves removing an unpleasant stimulus when desired behaviour occurs (for example, stopping a noisy suction when the child opens their mouth calmly).
However, reinforcement should be applied carefully and consistently. Overuse or inappropriate rewards can lead to manipulation by the child. If the child becomes uncooperative, it is important not to immediately abandon treatment but to revert to a calming activity or conversation before gently resuming.
Cognitive Behaviour Therapy (CBT)
Cognitive behaviour therapy is a structured, goal-oriented approach designed to help patients recognize and modify negative thoughts and behaviours. In dentistry, CBT can teach children coping mechanisms for anxiety, such as breathing techniques or positive visualization. It is particularly helpful for children with persistent dental phobia or generalized anxiety disorder, often in collaboration with a psychologist.
For example, the child may be taught to replace thoughts like “The dentist will hurt me” with “The dentist is helping me make my teeth healthy.” Chairside self-help strategies can also be incorporated, such as focusing on deep breathing during treatment.
Modelling
Modelling allows the child to learn by observing others. Seeing another child of similar age undergo dental treatment calmly can demystify the process. Video modelling is also highly effective—children can watch educational videos showing cooperative peers having simple procedures done painlessly.
The key is for the model to appear relatable and relaxed, which helps instil confidence and reduce anticipatory anxiety.
Desensitization
Desensitization is particularly effective for children with specific fears, such as needle phobia. It involves gradual, stepwise exposure to the feared object or procedure. The process typically begins with relaxation exercises, followed by exposure to less threatening elements (e.g., showing a picture of a syringe, then the real syringe, then touching it, and finally experiencing the injection).
This approach works best when combined with positive reinforcement and relaxation techniques, as it retrains the child’s emotional response to fear stimuli.
The Role of Parents in Managing Anxiety
Parents play a pivotal role in shaping a child’s perception of dental care. Their behaviour, language, and attitude can either calm or exacerbate the child’s anxiety.
Should Parents Accompany the Child?
On the first dental visit, parental presence is usually essential to provide reassurance and comfort. However, whether parents remain in the operatory during subsequent visits depends on several factors—age, the child’s independence, and the dentist’s professional judgment.
If a parent exhibits dental anxiety, it can be transmitted to the child through modelling and emotional contagion. In such cases, it might be beneficial for the parent to wait in the reception area. Conversely, when parents remain calm, supportive, and encouraging, their presence can help the child feel secure.
Dentists should educate parents on using positive language, avoiding words such as “pain,” “needle,” or “hurt.” Instead, parents should focus on the benefits of treatment and act as role models of composure.
Pharmacological Management
Sedation
Sedation is sometimes necessary for genuinely anxious children who are unable to cooperate despite behavioural techniques. It is also useful for children with an exaggerated gag reflex or those undergoing lengthy procedures.
1. Inhalation Sedation (Relative Analgesia)
This technique uses a mixture of nitrous oxide and oxygen delivered through a nasal mask. It produces mild relaxation and analgesia without loss of consciousness.
Advantages include rapid onset, easy control of depth, and quick recovery. Children often report feeling “happy” or “floaty,” which helps them tolerate treatment better.
Inhalation sedation is safe, effective, and the most commonly used form in paediatric dentistry.
2. Intravenous (IV) Sedation
IV sedation is typically reserved for older children (usually over 12 years) and administered only by trained professionals in an appropriate clinical environment. It provides deeper sedation but requires more intensive monitoring. In the UK, IV sedation in children under 12 is considered an advanced technique and must only be performed by clinicians with specialized training.
3. Other Sedative Agents
Historically, agents such as midazolam or chloral hydrate have been used, though their use has declined due to safety concerns. Intramuscular and rectal routes are rarely used today, except in certain countries or specialized clinical settings.
4. Hypnosis
Hypnosis, when performed by trained professionals, can induce a state of deep relaxation and altered consciousness. It cannot make subjects act against their will but can help them achieve a calm, trance-like state conducive to cooperation. For some children, describing hypnosis as “special relaxation” or “imagination time” helps normalize the experience.
General Anaesthesia (GA)
General anaesthesia allows complete dental treatment to be carried out in one visit for children who cannot cooperate under conscious sedation or local anaesthesia. GA is particularly indicated for:
- Very young children with extensive decay
- Children with severe anxiety or phobia
- Those with special healthcare needs
- When multiple extractions or restorations are required
However, GA carries inherent risks. Although modern anaesthesia is extremely safe, the estimated risk of unexpected death under GA is approximately 3–4 in a million, and about 1 in 2 million under sedation. These figures, though low, underscore the importance of informed consent and careful case selection.
Before proceeding with GA, all alternative strategies should be discussed with the parents. The decision should balance the child’s welfare, treatment needs, and long-term psychological effects.
Other Behavioural Problems and Their Management
Excessive Questioning
Some anxious children attempt to delay treatment by asking endless questions about the procedure. While curiosity should be respected, this behaviour can also be a form of avoidance. The dentist should respond firmly but kindly—acknowledging the child’s need for reassurance while maintaining control of the situation. A statement such as, “That’s a great question! I’ll explain as we go along,” keeps communication open but focused.
Temper Tantrums
Temper tantrums may occur when the child feels overwhelmed, frightened, or frustrated. The key is not to engage in confrontation but to de-escalate the situation. Dentists should remain calm, avoid raising their voice, and try to re-establish communication.
Positive reinforcement again plays a role here—praising even small acts of cooperation can gradually transform behaviour. Setting achievable goals, such as “Let’s open your mouth for five seconds,” and celebrating success helps the child feel accomplished.
The focus should always be on commenting on positive outcomes, rather than criticizing failures. Children thrive on encouragement, not reprimand.
Long-Term Goals in Managing Dental Anxiety
The ultimate objective of managing dental anxiety in children extends beyond the immediate procedure. The aim is to cultivate:
- A positive attitude toward oral health care
- Trust in dental professionals
- The ability to undergo treatment without fear or resistance
- Good lifelong dental habits
Follow-up appointments should reinforce progress and continue to build familiarity with the environment. Each successful visit strengthens the child’s resilience and confidence.
Conclusion
Managing the anxious child in paediatric dentistry is both an art and a science. It requires understanding child psychology, effective communication, and, when necessary, the integration of pharmacological support. The dentist’s empathy, patience, and adaptability are crucial in turning potentially distressing encounters into positive, confidence-building experiences.
By combining behavioural techniques—such as Tell–Show–Do, reinforcement, cognitive therapy, modelling, and desensitization—with thoughtful use of sedation and, when indicated, general anaesthesia, clinicians can provide high-quality, compassionate care for all children, regardless of their level of anxiety.
Ultimately, every successful interaction lays the foundation for a lifetime of positive oral health behaviour and trust in the dental profession.
References
- Marshman, Z. (2017). Behaviour management in paediatric dentistry. BDJ Team, 4, 17010.
→ (Original source cited in your textbook as: Z Marshman 2017 BDJ Team 4 17010.) - Scottish Dental Clinical Effectiveness Programme (SDCEP). (2018). Conscious Sedation in Dentistry: Dental Clinical Guidance. Dundee: SDCEP.
→ (Referenced in your text regarding sedation and inhalation techniques.) - Hartland, J. (2004). Medical and Dental Hypnosis. Edinburgh: Churchill Livingstone.
→ (Cited for hypnosis in dental settings.) - Dental.leif.com (n.d.). Parent information guide for managing dental anxiety in children.
→ (Cited in the text for promoting positive parental involvement.) - American Academy of Pediatric Dentistry (AAPD). (2022). Guideline on Behaviour Guidance for the Pediatric Dental Patient. Chicago: AAPD.
→ (A current and highly authoritative reference expanding on the same techniques mentioned — e.g., Tell-Show-Do, modelling, desensitization.) - Cameron, A.C., and Widmer, R.P. (2013). Handbook of Paediatric Dentistry (4th ed.). Edinburgh: Mosby Elsevier.
→ (A standard reference that aligns with the general behavioural management and sedation principles discussed.) - Wright, G.Z., Kupietzky, A. (2014). Behaviour Management in Dentistry for Children (2nd ed.). Wiley-Blackwell.
→ (Provides expanded explanations on cognitive behaviour therapy, desensitization, and shaping.) - Klingberg, G., and Broberg, A.G. (2007). Dental fear and behaviour management problems in children and adolescents: A review of prevalence and concomitant psychological factors. International Journal of Paediatric Dentistry, 17(6), 391–406.
→ (Evidence-based context for understanding the prevalence of dental anxiety in children.) - McDonald, R.E., Avery, D.R., and Dean, J.A. (2016). McDonald and Avery’s Dentistry for the Child and Adolescent (10th ed.). Elsevier.
→ (Discusses sedation, GA, and general behaviour management strategies consistent with your text.) - British Society of Paediatric Dentistry (BSPD). (2021). Policy Document on the Management of Dental Anxiety in Children.
→ (Modern reference supporting the ethical and procedural framework for sedation and parental involvement.)