fear and its management

1. GOOD MORNING

2. FEAR AND ITS
MANAGEMENTPresented by
Dr.sinu jayaprakash
PG student
Dept of Pedodontics

3. • CONTENTS
• Introduction
• Definition
• Types
• Features
• Signs and symptoms
• Response to fear
• Anxiety

4. • Anxiety assessment
• Phobia
• Fear assessment
• Management
• Conclusion
• References

5. • INTRODUCTION
• Children's dental anxiety is a natural developing
emotion expected due to meeting unfamiliar
adults, strange sounds, and tastes and even pain.
• Several personal, familial and environmental
elements affect the severity of child's dental
fears.

6. • After the age 6, children acquire abilities in
adjustments, independence and self-control.
• However, some children have severe dental
anxiety resulting in interruption of the dental
treatment process.
• This anxiety possibly continues to adulthood

7. Definition
• Fear is a primary emotion for survival against
danger, which is acquired soon after birth.
(Sydney Finn)
Prevalence
• 3-21%, depending on the age of the child
• Girls have more fear than boys
• Inherent timidity in girls
• Girls are encouraged to display, while boys are
encouraged to hide it.

8. Innate fear: without stimuli or previous
experience
Objective fear: acquired objectively or produced
by direct physical stimulation of the sense organs
but not of parental origin which are disagreeable
and unpleasant in nature.
• Result of previous improper dental handling
• They fear white uniforms and smell of certain
drugs and chemicals in hospital.

9. Subjective fear: based on the feelings and
attitudes suggested to the child by others without
the child personally experiencing them.
Due to family experience, peer, information
media (TV, papers, comics)
• 3 types
Suggestive fear: acquired by observing fear in
others and then the child develops a fear for the
same object as real and genuine

10. Imitative fear :
• A mother who fears going to the dentist may
transmit this unconsciously to her child who is
observing her.
• They are deep seated and difficult to eradicate.
• Imaginative fear:
• As child’s imaginative capabilities develop, they
become more intense with age and mental
development with certain age.

11. Change in fear perception with age
• The expression and intensity of child’s fear varies
with emotions, illness and age.
• Sleepy child shows more fear and irritation than
widely awake child.
• Physically healthy child respond more actively
than child who is weak.
• Mentally alert child respond more intelligently
and rapidly than mentally retarded individual.

12. 2-3 years
• Right time to introduce child to dentistry
• Less afraid of new people and surroundings
• Appropriate time to begin any preventive
procedures.

13. 3-4 years
• Fear of separation and abandonment prevails in
this age group.
• They think and feel that dentistry is a mode of
punishment.
• It is advised to allow parents in the operatory
during dental treatment

14. • At 4 years of age, the peak of definite fears is
reached and from 4-6 years there is gradual
decline in the earliest fears, due to
• Realization that there is nothing to fear
• Social pressure to conceal fear
• Social limitation
• Adult guidance
• Fantasy plays a role, and gains comfort and
courage to meet the real situation
• Intelligent child display more fear

15. • 7 years
• Child tries to resolve real fears.
• Family support is important in understanding and
overcoming his fears
• 8-14 years
• Learns to tolerate unpleasant situation and has
marked desire to be obedient.

16. • Teenage
• Become concerned about their appearance
• Dentist as motivation for seeking dental attention
can use this interest in cosmetic effect.

17. • Nature of fear
• The emotional status is release by way of ANS
through hypothalamus, modified by cortical
interference, so that man can control his
emotions.
• In young children who can’t rationalize, behavior
is produced which is difficult to control.
• As a child’s mental age increases these responses
can be controlled more by cortex through higher
psychic functions

18. • Value of fear
• Fear lowers the threshold of pain so that every
pain produced during dental treatment becomes
magnified
• Is of great value when given in the right direction
• Helps people to be prepared against danger
• It should be channeled in the direction of real
danger, and acts as a protective mechanism.

19. • Child should be taught that dental office is not a
place to fear.
• Dentistry should not be employed as a threat or
punishment.
• If the child has become attached to the dentist,
fear of loss of his approval have value in
motivating child for dental treatment.

20. Fear evoking dental stimuli
• Anesthesia administration locally by injection
• Extraction
• Sound of a drill

21. Factors causing dental fear
• Fear of pain or its anticipation
• A lack of trust or fear of betrayal
• Fear of loss of control
• Fear of unknown
• Fear of intrusion

22. Features of fear
• Tendency to freeze
• Startle, scream, run away from scene of danger,
i.e. flight
• Turns a shift from freeze reaction to flight

23. Symptoms of fear
• Unpleasant feeling of terror
• An urge to cry or hide
• Pounding of heart
• Tense muscles
• Liability to startle
• Dryness of throat and mouth

24. • Sinking feeling
• Nauseous feeling
• Urge to urinate
• Irritability
• Anger
• Weakness
• Sense of unreality

25. • Physiological signs
• Pale sweaty skin
• Hair standing on end
• Dilation of pupils
• Rapid breathing
• Increased heart rate
• Rising BP
• Increased blood flow through muscles
• Contraction of bladder and rectum

26. Biochemical changes in few minutes
• Secretion of adrenaline
• Secretion of nor adrenaline
• Increase in free fatty acids and corticosteroids in
plasma

27. Chronic fear leads to
• Tiredness
• Difficulty in sleeping and bad dreams
• Restlessness
• Loss of appetite
• Aggression
• Avoidance of tension producing stimulation

28. Response to fear
• Described at 3 levels
• Intellectual level: where the child is ready to
accept the situation and face the difficulties to
achieve results and benefits (usually seen at
adolescent age)

29. • Emotional level: fight or flight response which
acts as an instantaneous response (seen in school
age)
• Hedonic level: self-centeredness, thereby
accepting what is comfortable and rejecting what
is not without too much concern for the outcome
or nature of Rx. (very young children).

30. iety (fear of unknown)
Types
Trait anxiety
• Life-long pattern of anxiety as a temperament feature.
State anxiety
• Acute situational-bound episodes of anxiety that don’t persist
beyond provoking situation
Free floating anxiety
• Condition of persistently anxious mood in which the cause of
emotion is unknown and many other thoughts or events trigger
the anxiety.

31. Situational anxiety
• Only seen in specific situations or objects
General anxiety
• Where the individual experiences a chronic
pervasive feeling of anxiousness, whatever the
circumstances.

32. • Anxiety Rating Scales
• Pictorial and response card
• Evaluates the child’s fear
• Appointment with the dentist
• Waiting for his turn in the dentist’s office
• Dental procedures

34. • 0-relaxed
• 1-uneasy
• 2-feeling scared but cooperative
• 3-feeling scared and uncooperative
• 4-feeling very scared, uncooperative, requires
physical restraint

35. • Verbal questions
• Child is asked questions or given sentence
completion tasks to verbalize his fear.
• Negative or reluctant answers imply fear while
positive opinions imply non-fearful child.

36. • Questionnaire
• Evaluated by answers to the questionnaire given
to the child patient and parent.
• Helps to determine attitude and experiences of
both patient and parent.

37. • Venham 6-point Index to obtain anxiety level
• 0=Relaxed: smiling, willing, able to converse,
displays behaviour desired by the dentist
• 1=Uneasy: concerned, may protest briefly to indicate
discomfort, hands remain down or partially raised.
Tense facial expression , 'high chest'. Capable of
cooperating

38. • 2=Tense: tone of voice, questions and answers reflect
anxiety. During stressful procedure, verbal protest,
crying, hands tense and raised, but not interfering
very much. Protest more distracting and troublesome.
Child still complies with request to cooperate.
• 3=Reluctant: pronounced verbal protest, crying.
Using hands to try to stop procedure. Treatment
proceeds with difficulty.

39. • 4=Interference: general crying, body movements
sometimes needing physical restraint. Protest
disrupts procedure
• 5=Out of contact: hard loud swearing, screaming
unable to listen, trying to escape. Physical
restraint required

40. Phobia
Irrational fear resulting in the conscious avoidance
of a specific feared object, activity or situation.
• Not age appropriate
• Can’t be reasoned with
• Being out of voluntary control
• Persistent and inadaptable

41. Types
• Shelhan (1982)
• Exogenous (non-endogenous)
• Endogenous

42. Non-endogenous
• Anxiety or phobia due to a factor to be produced from outside
• Individual can readily identify the etiological agent.
• Moist palms
• Fluttery stomach
• Fine hand tremors
• Shaky inside
• Rapid heart beat

43. • Endogenous
• Cause is to be produced from within
• More severe cluster of symptoms
• Light headedness or dizziness
• Difficulty in breathing

44. • Paraesthesia
• Hyper-ventilation
• Chest pain
• Losing control

45. Based on causative factor 3 major categories
Simple phobia
Isolated fear of a single object or situation leading
to avoidance of it
Acrophobia
Agoraphobia
Arachnophobia
Anthropophobia
Aquaphobia

46. • Aichmophobia
• Trypanophobia
• Belonephobia
• Enetophobia

47. Situational phobia
• Fear of open or crowded places, public transport,
bridges, tunnels etc.
• Characteristics
• Dizziness, loss of bladder control or bowel
control, cardiac distress

48. Social phobia
• Fear of being looked at and the concern about
appearing shameful or stupid in presence of
others.
• Public speaking

49. Phobia in childhood
• Fear of animals- 2-4 years
• Fear of darkness- 4-6 years
• School phobia-11-12 years
• Previous aversive dental experiences-12 years
• Adolescent –fear of blushing and being looked at

50. • Fear assessments
• The children’s dental fear picture test (Klingberg,
1994)
• CDFP consist of 3 different subtests
• The dental setting pictures (CDFP-DS)
• The pointing pictures (CDFP-PP)
• A sentence completion task (CDFP-SC)

51. MANAGEMENT
Behavior management
• Means by which dental health team effectively
and efficiently performs dental treatment and
there by instills a positive dental attitude.
(Wright, 1975)
• Non-pharmacological
• Pharmacological

52. Non-pharmacologial
• Pre appointment behavior modification
• Communication
• Behavior shaping
desensitization
modelling
contingency management

53. • Behavior management
Audio analgesia
Biofeedback
Voice control
Hypnosis
Humor
Coping
Relaxation
Implosion therapy
Aversive conditioning

54. • Pharmacological methods
• Premedication
sedatives and hypnotics
antianxiety drugs
antihistamines
• Conscious sedation
• General anesthesia

55. • Pre appointment behavior modification
• Includes audiovisual aids, letters, films and
videotapes
• With other patient as models such as siblings,
other children or parent.
• Mails can be send addressed to the child that
provides brief information regarding procedure-
pre appointment mailing

56. • Communicative management
• Types
• Verbal
• Nonverbal
body language
smiling
eye contact
expression of feelings without speaking
• Using both

57. • Use of euphemisms
• Substitute words which can be used in presence
of children
• Mosquito bite-needle prick
• Pudding-alginate
• Wind gun-air syringe

58. • Desensitization-reciprocal inhibition
Tell-show-do technique
• Introduced by Addleslon
• Indications
• First visit
• Subsequent visits when introducing new dental
procedure
• Fearful child
• Apprehensive child

59. • Modelling
• Introduced by Bandura, developed from social-
learning principle.
• Models can be
• Live models- siblings, parents of child
• Filmed model
• Posters
• Audiovisual aid

60. • Contingency management
• Method of modifying the behavior of children by
presentation or withdrawal of reinforcers
• Positive reinforcer
• Negative reinforcer. Eg: withdrawal of mother

61. • Types of reinforcements can be
• Social-positive facial expression-most effective
• Material-toys
• Activity –involving the child in some activity like
watching a TV show.

62. • Audio analgesia
• White noise
• Providing a sound stimulus of such intensity that
patient finds it difficult to attend to anything else.
• Biofeedback
• Use of certain instruments to detect physiological
process associated with fear.

63. • Humor
• Elevate the mood of child, which helps the child to
relax.
• Functions
• Social
• Informative
• Motivation
• Cognitive

64. • Coping
• Cognitive and behavioral efforts made by an
individual to master, tolerate or reduce stressful
conditions.
• Behavioral: physical and verbal activities in which
child engages to overcome a stressful situation
• Cognitive: child may be silent and thinking in his
mind to keep calm.

65. • Signal system: when it hurts, we ask the child to raise
his hand as suggested by Musslemann(1991).
• Voice control
• Modification of intensity and pitch of one’s own
voice in an attempt to dominate the interaction
between dentist and child.
• Used in conjunction with physical restraints and
HOME.

66. • Relaxation
• Based on the principle of elimination of anxiety.
• Series of basic exercises, which may take several months
to learn.
• Hypnosis
• Altered state of consciousness characterized by a
heightened suggestibility to produce desirable behavioral
and physiological changes.

67. • Implosion therapy
• Sudden flooding with a barrage of stimuli which
have affected him adversely and the child have
no other choice but to face the stimuli until
negative response disappears.
• Mainly comprises HOME, voice control and
physical restraints

68. • Aversive conditioning
• Safe and effective method of managing
extremely negative behavior.
• HOME and physical restraints

69. • HOME (Hand over mouth exercise)
• Introduced by Evangeline Jordan, 1920
• Purpose is to gain attention of a child
• Indications
• A healthy child who can understand but exhibit defiance
and hysterical behavior during treatment
• 3-6 years old
• Child who can understand simple verbal commands

70. • Contraindications
• Child under 3 years of age
• Handicapped/immature child, frightened child
• Physical, mental and emotional handicap
• Variants
• Hand over mouth with airway restricted
• Hand over mouth and nose and airway restricted
• Towel held over mouth only
• Dry towel held over nose and mouth
• Wet towel held over nose and mouth

71. • Physical restraints
• Last resort of handling un co-operative patients.
• Restraints are needed for children who are hyper
motive, stubborn or defiant.
• Active : performed by dentist, staff or parent
without aid of restraining device
• Passive: with the aid of restraining device

73. Types
For body: pedi wrap
papoose board
sheets
beanbag with straps
towel and tapes
For extremities
velcro straps
towel and tape

74. • For the head
head positioner
forearm body support
• Mouth
mouth blocks
banded tongue blades
mouth props
others
straps are attached to dental unit

76. Conscious sedation
• Minimally depressed level of consciousness, that retains
the patient’s ability to maintain an airway independently
and respond appropriately to physical stimulation and
verbal commands
Indications
• Patients who can’t cooperate or understand for definitive
treatment
• Patients lacking cooperation due to lack of psychological
and emotional maturity

77. • Patients with dental care requirements, but are
fearful and anxious
Contraindications
• COPD, pregnancy, myasthenia, epilepsy, bleeding
disorders
• Un cooperative patients, unwilling, unaccompanied
• Dental difficulties, prolonged surgery, inadequate
personnel

78. Routes of administration of drug
• Inhalation Eg: nitrous oxide
• Oral
• Rectal
• Parental
intravenous
intramuscular
sub mucosal

79. Agents used
• Gases : nitrous oxide and oxygen combination
• Antihistamines : hydroxyzine, promethazine
• benzodiazepines : diazepam, midazolam
• Barbiturates : pentobarbitol
• Chloral hydrate
• Narcotics : meperidine, fentanyl

80. General anesthesia
• Indications
• patients with certain physical, mental or
medically compromising condition
• LA is not effective or the patient is allergic to it
• Fearful, uncooperative anxious patient with no
expectation that behavior will improve

81. Agents used for general anesthesia
• Halothane
• Enflurane
• Isoflurane
• Sevoflurane
• Desflurane

82. • Conclusion
• Anxiety and fear of dental treatment in child patients
have been recognized as potentially problematic
entities in patient management.
• A variety of behavioural techniques have been
exercised to counteract such negativity in behaviour
pattern.
• Early recognition and management of this dental
fear is the key to an effective treatment delivery to
the child patient.

83. • References
• Text book of Pedodontics - Shobha Tandon-2nd
edition
• Principles and practice of Pedodontics – Arathi Rao-
2nd edition
• The Effect of Parental Presence on the 5 year-Old
Children's Anxiety and Cooperative Behavior in the
First and Second Dental Visit:Hossein Afshar, Yahya
Baradaran Nakhjavani, Sommaye Zadhoosh

84. • Reliability and factor analysis of children's fear
survey schedule-dental subscale in Indian
subjects: Journal of Indian Society of
Pedodontics and preventive Dentistry,
2010 ,Volume :28, Issue 3: 151-155

85. THANK YOU!