ORIGINAL RESEARCH

Management of Dentally Anxious Adolescents with Retraining

A b s t r ac t
Background: Anxiety toward dental treatment may be the reason for not only young children but also secondary school children to postpone
dental treatment despite having severe pain. Hence this study was undertaken to recognize such anxious secondary school children prior to
the treatment and tried to manage them with the retraining technique.
Materials and methodology: The present interventional study comprised 100 participants with highly anxious about dental treatment and were
selected randomly within the secondary school age group of 11–16 years visiting the dental hospital. These selected participants were randomly
allocated into two groups with 50 members in each group. Group I participants were managed with the retraining behavior management
technique and in group II subjects retraining behavior management technique was not employed. Preinterventional and postinterventional
dental anxiety (DA) scores were assessed using a Modified Dental Anxiety Scale (MDAS). The data obtained was statistically analyzed with
Statistical Package for the Social Sciences (SPSS) version 22 using the Wilcoxon sign ranked test.
Results: There was a significant difference in preinterventional and postinterventional mean DA scores in group I treated with the retraining
technique with no significant difference in group II.
Conclusion: The retraining technique can be used in managing highly anxious secondary school children during dental procedures.
Keywords: Dental Anxiety, Retraining technique, Secondary school children.
International Journal of Clinical Pediatric Dentistry (2023): 10.5005/jp-journals-10005-2655

Introduction 1,3–6
Department of Pedodontics, Kamineni Institute of Dental Sciences,
Odontophobia means “marked and persistent fear that is Nalgonda, Telangana, India
excessive or unreasonable cued by the presence or anticipation 2
Department of Pedodontics and Preventive Dentistry, Kamineni
of a specific object or situation.”1 Dental anxiety (DA) is a known Institute of Dental Sciences, Nalgonda, Telangana, India
factor that plays a significant factor in dental care. 2–5 Despite Corresponding Author: Kiranmayi Merum, Department of Pedodontics,
the advancements in dentistry, that is, techniques and dental Kamineni Institute of Dental Sciences, Nalgonda, Telangana, India,
materials, there is still a considerable section of people who Phone: +91 8919425949, e-mail: kiranmayee30dec@gmail.com
are apprehensive toward dental treatment. The DA prevalence How to cite this article: Saraswati S, Saraswati SD, Mudusu SP, et al.
among people from different developed countries shows that Management of Dentally Anxious Adolescents with Retraining
these patients seek emergency dental care and postpone their Technique: A Double-blind Randomized Controlled Clinical Study. Int J
further appointments, which could lead to poor oral health.6,7 Clin Pediatr Dent 2023;16(S-2):S118–S121.
It has been attributed to factors such as vicarious learning from Source of support: Nil
dentally anxious family members or peers, perception of body Conflict of interest: None
image, blood injury fears, and pain reactivity. 8,9 The anxiety
toward dental care is seen in every age group, that is, children,
adolescents and adults. As age advances adults try to cope
with stress and anxiety during dental procedures, but young
M at e r i a l s and M e t h o d o lo g y
adults tend to postpone them. Many anxious secondary school Ethical Approval
children accept dental treatment if treated by loving and caring The present study was accepted by the Ethical Committee of
staff with the assistance of behavioral therapies like retraining Kamineni Institute of Dental Sciences, Nalgonda, Telangana, India.
techniques apart from pharmacological methods. Prior to the
treatment, the dentist should identify such anxious children Sample Collection
undergoing dental care which makes them execute certain Study participants were recruited from the walk-in patients of the
behavioral therapies which reduce anxiety toward dentistry. Department of Pedodontics over a period of 6 months. To evaluate
In this study, such anxious adolescent patients were identified anxiety in children, the Modified Dental Anxiety Scale (MDAS) was
prior to the treatment and tried to manage them with retraining considered. In the reception area, the patient was requested to answer
management techniques. the questionnaire of the MDAS. In this scale, anxiety scores will range

© The Author(s). 2023 Open Access. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons.
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 Retraining the Dentally Anxious Adolescents

from 5 to 25. An anxiety score in the range of 19 to 25 was considered Avoidance and Substitution
to be highly anxious toward the dental treatment and these children If the patient was afraid of any dental sounds or chemicals which
were opted for the study group. A sample of 100 secondary school provoke anxiety then they were avoided and replaced with
children within the age group of 11–16 years with the following another. If the patient had discomfort with the sound of the suction
inclusion criteria was selected and informed consent was obtained. apparatus, then they were asked to spit in the spittoon avoiding
the suction apparatus. Cotton isolation with intermittent suction
Inclusion Criteria
was done to avoid the sound of a high-volume suction apparatus.
• Adolescents willing to take part in the study. If the patient had discomfort with the usage of zinc oxide eugenol
• Adolescents who are highly anxious about dental treatment. cement, it was replaced with other restorative material. If the
• Adolescent with comprehensive treatment needs such as oral patient had discomfort with airotor, it was substituted with a spoon
prophylaxis, tooth restorations, and procedures requiring local excavator or chemomechanical caries removal agents. If the patient
anesthesia (LA). had discomfort with ultrasonic scalers, they were substituted with
hand scalers. In the case of extraction or pulpal therapy, as many of
Exclusion Criteria the patients were afraid of injection prick, a local anesthetic topical
• Those who are not willing to participate. spray was applied followed by administration of LA using an insulin
• Those who are not anxious about dental procedures. syringe or electronic dental anesthesia.
• Special children who are not able to cooperate. During the treatment procedure, the patient was asked to
raise their hand if there was any history of pain/anxiety if so the
The selected 100 adolescents were randomly allocated into
procedure was immediately stopped and the patient was reassured.
two groups based on the management technique employed.
If the patient had severe anxiety, then a short break was given in
Group I participants were managed with a retraining technique.
between the procedure, and the patient was asked to do breathing
These two groups were further divided into two subgroups with
and muscle relaxation exercises. The operating pediatric dentist had
25 participants in each based on gender.
shown utmost patience throughout the procedure and reassured
Group I (study group)—group IA—boys; group IB—girls.
the adolescent to complete the treatment.
Group II (control group)—group IIA—boys; group IIB—girls.
Intraoral examination and oral prophylaxis procedures in both
Group II
groups were done on the first visit. Cavity preparation followed
by restoration and procedures requiring LA were planned in the In this group the dental procedure was done with general
second visit. instructions. If the patient was apprehensive, then the procedure
was stopped and another appointment was given.
Group I In the last appointment of the treatment plan, each patient was
The retraining technique includes distraction, avoidance, and again given MDAS questionnaire and postintervention DA scores
substitution. were measured. If the patient didn’t turn up, then the anxiety
score was taken as 25 which is the highest score. The respective
Distraction operating pediatric dentist was blind to the postoperative DA
Dental sounds such as airotor and suction apparatus during the scores. One blinded observer calibrated the preintervention and
treatment procedure will provoke anxiety. To avoid these dental postintervention DA scale values. The obtained data was statistically
sounds, patients were asked to wear headphones to listen to analyzed with Statistical Package for the Social Sciences (SPSS)
songs (audio distraction) or watch their favorite show on television version 22 using the Wilcoxon sign ranked test.
(audiovisual distraction). This will distract the patient from unpleasant
dental sounds which in turn reduces their anxiety levels (Fig. 1). R e s u lts
The preinterventional mean DA in group IA is 17.86 ± 1.98. The
preinterventional mean DA in group IIA is 17.72 ± 1.99. The
preinterventional mean DA scores show no statistical significant
differences between group IA and group IIA.
The postinterventional mean DA in group IA is 9.72 ± 1.42.
The postinterventional mean DA in group IIA is 18.04 ± 1.64.
Postinterventional mean DA scores show statistical significant
differences between group IA and group IIA.
The preinterventional mean DA in group IB is 19.32 ± 1.90.
The preinterventional mean DA in group IIB is 18.88 ± 2.04. The
preinterventional mean DA scores show no statistical significant
difference.
The postinterventional mean DA in group IB is 9.84 ± 1.06.
The postinterventional mean DA in group IIB is 19.56 ± 1.58.
Postinterventional mean DA scores show significant differences
between the two groups.
A statistical significant difference (p < 0.05) between
preinterventional mean DA and postinterventional mean DA in
Fig. 1: Management of dentally anxious secondary school child with group IA was seen. Group IB also shows a statistical significant
retraining technique difference (p < 0.05) between preinterventional mean DA and

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 Retraining the Dentally Anxious Adolescents

Table 1: Depicts the preinterventional mean DA score and Table 2: Depicts the preinterventional mean DA score and
postinterventional mean DA of group I participants postinterventional mean DA of group II participants
Preintervention Postintervention Preintervention Postintervention p-value
Group mean DA score mean DA score p-value (<0.05) Group mean DA score mean DA score (<0.05)—significance
Group IA 17.86 ± 1.98 9.72 ± 1.42 0.000 (significant) Group IIA 17.72 ± 1.99 18.04 ± 1.64 0.039
Group IB 19.32 ± 1.90 9.84 ± 1.06 0.000 (significant) (no significance)
Group IIB 18.88 ± 2.04 19.56 ± 1.58 0.011
(no significance)
postinterventional mean DA scores (Table 1). No statistical
significant difference was seen between preinterventional mean
DA and postinterventional mean DA scores in group IIA (p > 0.05). the postponement of appointments and some patients even didn’t
Preinterventional mean DA and postinterventional mean DA turn up to the clinic. Deogade et al. also concluded that adult
scores show no statistical significant difference in group IIB patients who are highly anxious about dental treatment tend to
(p > 0.05) (Table 2). postpone their visit.19 Participants of group II who didn’t turn up to
the clinic were recalled after the study and completed the treatment
procedures using retraining techniques to instill a positive dental
Discussion attitude in them. During the treatment procedure, the clinician
Dental anxiety (DA) is a major issue which is prevalent worldwide. asked the patients to raise their hands if they had any complaint
The quality of dental care and ultimately the quality of life can be of anxiety/pain, which made them feel that treatment, was in their
improved by reducing the anxiety of the patient when a dental hands which in turn reduced anxiety levels.20
issue arises.10 Dentally anxious individuals, because of their avoidant Patients visiting the hospital with tooth pain tend to be highly
behavior, often have poorer dental health.11,12 Those people who anxious compared to the patients visiting for cosmetic reasons.10
delay dental visits for a prolonged time might have extensive Tooth cavity preparation and restoration is the most common
problems that require more complex and complicated treatment.13 procedure preferred in dental clinics for the management of tooth
Bad dental experiences in the past might be a key factor in the pain associated with reversible pulpitis. Retraining management
initiation of anxiety toward dental treatment. Fotedar et al.14 in technique is the most effective technique to reduce anxiety toward
their study concluded that a correlation was seen between negative dental procedures ranging from minimally invasive procedures
dental experience in the past and MDAS score. Identifying these such as cavity preparations, and oral prophylaxis to highly invasive
anxious individuals can enable the dentist to retrain them which procedures such as extraction and pulpectomies.
reduces DA and instill a positive dental attitude. Since the majority of adolescent patients were anxious and
The Modified Dental Anxiety Scale (MDAS) (modified version scared of injection pricks, in this study adolescents were distracted
of Corah Dental Anxiety Scale) is considered to assess anxiety for with audio or audiovisual methods, and an insulin syringe was used
community-based research and is easy to compare responses. This for LA administration. Thinner gauge needles cause less pain during
MDAS comprises five different questions related to a dental situation tissue penetration which results in a decrease in anxiety during
that was given to the study population. They rate the anxiety level LA administration.21 Similarly, Khandelwal et al.22 and Prabhakar
score according to their perception of a particular dental situation. et al.23 in their study concluded that a decrease in anxiety was seen
Considering its advantages, in the present study this scale was in children distracted with audio-visual methods.
considered to know the anxiety levels of the study population.
Anxiety reduces as age advances,15 hence adults try to
cooperate during the procedure, but children and adolescents tend C o n c lu s i o n
to postpone them. This study was planned on secondary school Secondary school children who were highly anxious tend to avoid
children who were highly anxious to dental treatment. In our study dental procedures and it is a barrier to render quality oral health
Female patients have more anxiety than male patients and these services. Identifying these anxious children prior to the treatment
results were similar to studies done earlier.16,17 Social factors such and managing them with the retraining technique was found to
as phobia, panic, depression, stress, and fear are more common in reduce their anxiety and thereby instill a positive dental attitude
females.18 This might be the reason in our study female patients toward dental procedures.
have high DA than male patients.
There are many behavior management techniques in pediatric Orcid
dentistry but the technique that is commonly used for adults
Srikanth Saraswati https://orcid.org/0000-0001-7442-3821
shouldn’t be childish as secondary school children have enough
Kiranmayi Merum https://orcid.org/0000-0003-4266-5847
maturity to understand the situation. The only criterion is to
reduce the DA. Conscious sedation is a pharmacological behavior
management technique that reduces anxiety but this conscious References
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