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    Behavioural techniques are employed as a matter of routine by many dentists, and are perhaps most evident when children are being treated. Positive reinforcement is frequently used as shown by the delivery of praise to an appropriately behaved patient. The age and emotional development of a child must always be taken into account when deciding upon which techniques to use. Anxious patients should always be given a stop signal as this transfers an element of control to the patient. A commonly used signal is simply raising a hand and it can be helpful for the patient to rehearse this briefly before treatment. The dental team must always respond appropriately to such signals. The trust of a patient can take a long time to build up but can be very quickly undermined or destroyed.A review of Advanced dental nursing, 2nd edition can be found on page 8.

    Behavioural management can be time consuming and expertise is required. Dentists who have access to a clinical psychologist are very much at an advantage. Patients with needle phobias can often be cured of their phobia by employing a systematic desensitisation programme. Desensitisation is a graded introduction to the feared experience/treatment – starting with the least frightening. The patient learns to cope with this before progressing onto the next stage. Finally, the patient is exposed to the most threatening situation. A long-term aim in the management of anxious/phobic patients is to modify their behaviour in order that some or all future dental treatment may be accepted without the assistance of sedation.

    Some clinicians find it useful to categorise anxious patients into four types (Table 3); this is because the patient category influences the choice of behavioural management strategy. It should be appreciated that whilst this classification can be helpful, patients may have features of anxiety that belong to more than one category and several management strategies are sometimes required for one patient.Table 3 Management strategies for anxious patients according to anxiety type.

    A pioneering study led by the University of Sheffield and Sheffield Teaching Hospitals will investigate whether Cognitive Behavioral Therapy (CBT) could help reduce the worryingly high number of children who are afraid of the dentist.

    Around one in three children are scared of going to the dentist, leading to dental avoidance, and end up with poor oral health, more toothache, dental infections and tooth decay as a result.

    Now, a team of dentists and researchers led by the University of Sheffield’s School of Clinical Dentistry have been awarded more than £1.6 million from the National Institute for Health Research (NIHR) to investigate a new way of reducing dental anxiety based on CBT.

    The study, which will involve 600 children from 30 dental practices and clinics across England and Wales will examine whether specially developed, child friendly resources for children, parents and dental professionals will help children complete their dental treatment at their family practice rather than being sent to hospital for specialist services for sedation or general anesthetic.

    Principal Investigator, Professor Zoe Marshman from the University of Sheffield’s School of Clinical Dentistry and Honorary Consultant in Dental Public Health at Sheffield Teaching Hospitals Foundation Trust, said:

    “Dental anxiety is very common in children, and can lead to poor oral health, more tooth decay and extractions.

    “Traditionally, children with dental anxiety have been referred by high street dentists to specialist services for sedation or general anesthetic. This approach does nothing to stop their fear, and they may go on to spend a lifetime avoiding the dentist. A simple and cost-effective way of helping dentally anxious children is desperately needed.”

    Professor Marshman and the team will be investigating a new approach, based on the principles of CBT which involves dental professionals, children and parents working together, using specially designed resources, to help understand why the child is anxious, give them information and choices about the procedures they may need, provide activities the children will find useful to help them cope, and make talking to the dentist easier.

    There is strong evidence to support the use of CBT, a talking therapy, for other forms of anxiety and mental health conditions, however there is currently very limited research into CBT delivered specifically by dental professionals, rather than by psychologists for children with dental anxiety.

    The self-help CBT resources were developed online and hard copy for children aged nine to 16 years and aim to help children provide dental information, suggest strategies for reducing anxiety, encourage reflection and support better communication.

    If our study finds CBT resources delivered by dental professionals are effective, then children can be helped directly in high street dental practices without the need to travel for dental treatment in hospitals.”

    Zoe Marshman, Principal Investigator and Professor, School of Clinical Dentistry and Honorary Consultant, University of Sheffield

    “This has the potential to help children who may otherwise spend a lifetime avoiding the dentist and ignoring potentially serious oral problems. It may also result in cost savings for the NHS.”

    The four-year CALM trial: the clinical and cost-effectiveness of a guided self-help cognitive behavioral therapy intervention to reduce dental anxiety in children, is funded by the National Institute for Health Research and will be overseen by Sheffield Teaching Hospitals NHS Foundation Trust.

    The collaborative team of researchers from the universities of Sheffield, Sheffield Hallam, Cardiff, King’s College London, Leeds, Newcastle and York, working closely with patient representatives, are looking to recruit 60 dentists to take part in the study which will start in September 2021.

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