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DOI:10.1111/ipd.12238

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Citation for published version (APA):Morgan, A. G., Rodd, H. D., Porritt, J. M., Baker, S., Cresswell, C., Newton, T., ... Marshman, Z. (2016).Children’s experiences of dental anxiety. International Journal of Paediatric Dentistry. DOI: 10.1111/ipd.12238

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Children’sexperienceofdentalanxiety

AnnieG.Morgan1,HelenD.Rodd1,JennyM.Porritt2,SarahBaker1,CathyCreswell3,TimNewton4,

ChrisWilliams5andZoeMarshman1

1. SchoolofClinicalDentistry,UniversityofSheffield,Sheffield,UK

2. DepartmentofPsychology,SociologyandPolitics,SheffieldHallamUniversity,Sheffield,UK

3. SchoolofPsychologyandClinicalLanguageSciences,UniversityofReading,Reading,UK

4. PopulationandPatientHealth,DentalInstitute,King’sCollegeLondon,UK

5. InstituteofHealthandWellbeing,UniversityofGlasgow,Glasgow,UK

Correspondingauthor:

AnnieG.Morgan

SchoolofClinicalDentistry,UniversityofSheffield,ClaremontCrescent,Sheffield,SouthYorkshire,

S102TA,UK

Email:Annie.Morgan@sth.nhs.uk

Page2

Summary

Background. Dental anxiety is common among children. Although there is a wealth of research

investigatingchildhooddentalanxiety,littleconsiderationhasbeengiventothechild’sperspective.

Aim.Thisqualitativestudysoughttoexplorewithchildrentheirownexperiencesofdentalanxiety

using a cognitive behavioural therapy assessment model. Design. Face-to-face, semi-structured

interviewswereconductedwithdentallyanxiouschildrenaged11to16years.TheFiveAreasmodel

wasusedto informthetopicguideandanalysis.Datawereanalysedusingaframeworkapproach.

Results. In total, 13 childrenwere interviewed.Participants described their experiences of dental

anxiety across multiple dimensions (situational factors and altered thoughts, feelings, physical

symptoms and behaviours). Participants placed considerable value on communication by dental

professionals, with poor communication having a negative influence on dental anxiety and the

dentist-patientrelationship.Conclusion.ThisstudyconfirmstheFiveAreasmodelasanapplicable

theoreticalmodelfortheassessmentofchildhooddentalanxiety.Childrenprovidedinsightsabout

theirowndentalanxietyexperiencesthathavenotpreviouslybeendescribed.

Page3

Introduction

Dentalanxietyiscommonwithanestimatedprevalenceofbetween6%and20%inchildrenaged4

to18yearsold.1IntheUK,anationalsurveyhasidentifiedhighlevelsofdentalanxietyin14%and

10% of young people aged 12 and 15 years, respectively.2 Childhood dental anxiety is associated

with an increased prevalence of decayed and extracted teeth, more episodes of toothache and

symptomatic attendance, and lower oral health-related quality of life.3-5 As dental anxiety in

adolescence is likely to continue into adulthood, it can consequently have long-term negative

implicationsfororalhealthoutcomes.6;7

Althoughthereisawealthofresearchinvestigatingchildhooddentalanxiety,littleconsiderationhas

beengiventoexploringdentalanxietyfromthechild’sperspective.Previousresearchhasinvolved

children completingmeasures of dental anxiety using self-report questionnaires.8 However, these

measures have a limited focus, as they typically only assess severity of dental anxiety within a

preconceived list of dental situational factors (e.g. local anaesthetic, specific dental treatments).9

Paediatric measures also have questionable relevance as they were developed when children’s

dental experiencesdiffered vastly to currentpaediatric dental practices (e.g. questions relating to

fearofpeopleinwhiteuniforms,orteethbeingcleanedandscraped).Moreover,currentlyavailable

paediatric self-reportmeasureshavebeenbasedonadultmeasures,whereby childrenhave to fit

their thinking into adult ideas.10 Therefore, much of the current research may fail to capture

children’sownexperiencesofdentalanxiety.

Thereareanumberoftheoreticalmodelsofthemaintenanceofdentalanxietyinadults,including:

learning/behaviouraltheories;acognitivevulnerabilitymodel,andapsychosocial/dentalmodel.11-14

TheFiveAreasmodelisacognitivebehaviouraltherapy(CBT)assessmentmodelthatdescribesthe

situational factors and altered thoughts, feelings, physical symptoms and behaviours that act

togethertomaintainanxietyovertime.15TheFiveAreasmodelhasanumberofadvantageswhen

Page4

compared to othermodels of dental anxiety, as it provides a structure to summarise the current

problems and difficulties facing an individual, uses language thatmakes it amenable to use with

children,andhasclearclinicalapplications.16

Therefore,theaimofthisstudywastoexplorewithchildrentheirownexperiencesofdentalanxiety

usingtheFiveAreascognitivebehaviouraltherapyassessmentmodel.

Methods

Participants

For thisqualitativeexploration,childrenaged11 to16yearswithdentalanxietywerepurposively

sampledtoprovidediversityofexperiencesaboutdentalanxiety.17Thekeyparticipantdemographic

characteristics used for samplingwere: gender; age; dental care setting (e.g. primary dental care,

secondarydentalcare); livinginareasofvaryinglevelsofdeprivation;andethnicity.Childrenwere

initially approached by a researcher (AM) based on clinician reporting of dental anxiety.18 The

presenceofdentalanxietywasthenconfirmedverballybyparticipantself-report,althoughseverity

of dental anxiety was not measured. The age range of 11 to 16 years was selected to recruit

participantswhowouldbeabletoreflectontheirexperiencesofdentalanxietywithinacognitive

behaviouraltherapyframework.Participantsneededtohavesufficientcognitivematuritytobeable

to thinkabout anddescribe their thoughts aboutdental anxiety.19A samplingmatrixwasused to

monitortherecruitmentofparticipantsagainstkeybackgroundcharacteristics.Childrenwithsevere

communicationdifficulties,or those forwhom interpreting serviceswere required,wereexcluded

due to the risk that their responsesmight be unintentionally altered during the process of being

translated.

Studydesign

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Data collection comprised face-to-face, semi-structured interviews with children. Qualitative

interviews were used to facilitate a more comprehensive, adaptable and individual approach to

understandingthebreadthofchildren’sexperiencesandperspectivesofdentalanxiety.20Thenature

of the study was explained to both potential participants and their parents/carers, with written

consent obtained following a two week consideration period. Ethical approval for the study was

grantedbytheNRESCommitteeYorkandHumber:LeedsWestREC(13/YH/0163).Participantswere

givena choice for the locationof the interview (e.g. home,university), andwhether theywanted

their parent/carer to be present. Each participant provided a pseudonym for the duration of the

interviewtomaintaintheirconfidentiality.Thefirst interviewwascarriedoutbyaresearcher(ZM)

who had extensive experience in conducting qualitative interviews with children. All subsequent

interviews were conducted by a second dentally-qualified researcher (AM) who had received

additional training inqualitative interviewing techniques.Neither researcherwasdirectly involved

with the provision of dental care to any of the participants at the time of the study. The audio

content of the interviews was digitally recorded (Digital Voice Recorder WS-813, Olympus) and

transcribedverbatim.

Theoreticalmodel

ThetopicguideandanalysisoftheinterviewswereinformedbytheFiveAreasmodel.15Participants

wereaskedabouttheirthoughts,feelings,physicalsymptoms,behavioursandexternalfactors(e.g.

dentalanxietytriggersandpositiveandnegativemodifiers)inrelationtodentalanxiety.Duringthe

interviewsthetopicguidewasonlylooselyappliedandparticipantswereencouragedtosharetheir

ownperspectives.

Dataanalysis

Recruitment of participants, data collection and analysis were conducted concurrently until data

saturation occurred and no new ideas emerged. The data were analysed using a framework

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approach.17Fourresearchers(AM,ZM,JPandHDR)completedtheinitialfamiliarisationstagewith

thefirstfivetranscripts.Eachresearcherindependentlyreadandreviewedthetranscriptstoidentify

importantandrepeatingideasthatemergedfromthedata,underpinnedbytheFiveAreasmodelas

thetheoreticalframework.Anydisagreementsininterpretationwereresolvedthroughdiscussion.A

deductive approach was then conducted to organise the data into themes. Subsequently, each

section of the transcripts was systematically reviewed, labelled and indexed on an electronic

database (Excel 2010, Microsoft Office), according to the theme and subtheme, by a single

researcher (AM). Data with the same index number were then brought together for further

discussions amongst the researchers (AM, ZM, JP and HDR) to modify the subthemes. Finally, a

thematic frameworkwasdevelopedwhere evidence to support the subthemeswas traced to the

originaltextfromeachparticipant.21Followinganalysisofthefirstfivetranscripts,furtherinterviews

were conducted. For each subsequent transcript additional discussions were carried out to fully

elucidateandrefineeachidentifiedthemeandsubtheme,untilastagewasreachedwherenonew

ideas emerged and data saturation was accomplished. All interviews were conducted on a

conversationalbasis,wherebyparents/carers,whenpresent,wereabletomakecontributionstothe

discussions.Theseadditionalcommentswerenotincludedintheframeworkanalysis,butdidactto

providecontextandaidinterpretation.

Results

Data saturation was reached when 13 children had been interviewed. Overall, 17 children were

approached, but four declined to participate following the consideration period. Demographic

detailsfortheparticipantsarepresentedinTable1.AllinterviewswerecompletedbetweenJanuary

andApril2014.Theparticipantswererecruitedfromtwogeneraldentalpractices, thecommunity

dental service and a paediatric dentistry unit within an NHS dental teaching hospital. Eleven

interviewswereconductedintheparticipant’shome.Onlyoneparticipantchosetobeinterviewed

without their parent/carer present. The participants all had experience of restorative dental

Page7

treatment and extractions either with local anaesthetic, inhalation sedation and/or general

anaesthetic.

The fivemain themes from the Five Areasmodel were situational factors; and altered thoughts,

emotions,physicalsymptomsandbehaviour.Theadditionalsubthemesthatemergedfromthedata

arepresentedinFigure1.

1) Situationalfactors

Situationalfactorsaretheexternalelementsthatsurroundachildandinfluencetheirdentalanxiety

(e.g. parents, dental team, specific dental equipment).22Within this theme, twomain subthemes

were identified. These were: communication and information-sharing; and potential threatening

stimuliwithintheclinicalenvironment.

a) Communicationandinformation-sharing

Childrenidentifiedthatboththedentalteamandtheirparents/carershadaroleininfluencingtheir

dentalanxiety.Withrespecttothedentalteam,thepersonprovidingtheirdentalcare(e.g.dentist,

dental therapist)was given principle importance during their accounts. Participants described the

qualities of an idealised dental team member as someone professional, honest, and who

demonstrates warmth and friendliness towards them. They perceived that if their dental

professionalpossessedthosecharacteristicsthentheywouldsufferlessdentalanxietyasaresult.

“Likeeveryone’sreallysmiley,andlikereallyhappy…itmakesyoufeelmorewelcomedandmorelike

lessthreatenedasitwere.”(Lucy,13yearsold).

Participantsdiscussed information-sharingduring theiraccounts.Childrenwantedthedental team

totellthemwhatwasgoingtohappenduringadentalvisit,anddidnotwantanythingkepthidden

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from them. It was important to have this information explained in an age-appropriate manner,

wherebythechilddidnotfeelpatronised.

“Welltellmelikeexactlywhattheywoulddo,causeIdon’tlikesurprises.”(Claire,14yearsold).

“Shewasjustannoyingme...TalkingtomelikeIwasfive.”(Katy,13yearsold).

However, conflicting views were expressed about how much detailed information should be

provided,withsomeparticipantswantingtobefullyinformedandgivenspecifics,andothersfinding

detailedinformationoverwhelming.

Interviewer:“Somepeoplehavesaidtheyliketoseeeverythingbeforehand,andhaveitexplainedto

themhoweverythingworks.”

Danielle:“Ido,butthenIjustgetupsetanddon’twantit.”(Danielle,11yearsold).

Interestingly, providing a childwithdetailed informationdidnot appear tonecessarily reduce the

anxietytheywereexperiencing,orguaranteethattheywouldthenagreetoproceed.

“Iwould ifsomebodysaid, ‘Wouldyou liketoseetheneedle?’ Iwouldasktosee it,but Iprobably

wouldn’tletthemdoit.”(Sophie,12yearsold).

As a possible complication, once a plan had been agreed with the dental team the participants

expressedintolerancetoanyunexpectedchanges,suchaschangeofclinicaloperatororprovisionof

differentdentaltreatment.

“Theydidone (injection)and then Iwas like really relievedandhappy itwasdone,and then they

werelikewhydon’twedo3moreandIwaslike‘errrr’.”(Amelia,14yearsold).

Participants also wanted to be given time to consider what they had been told and not to feel

pressuredorrushedintoproceedingimmediatelywiththedentaltreatment.

Page9

“BecauseeveryothertimeIdidthe injection I’d likeopenmymouth,and I’dclose itagain,cause I

wasn’tready.”(Amelia,14yearsold).

Aswiththedentalteam,childrenfeltstronglythattheirparent/carersshouldbehonestwiththem

andtellthembeforehandaboutadentalappointment.Itwasacknowledgedthatthismightleadto

increasedworry and distress at home, but beingworriedwas considered preferable to not being

providedwith the information in the firstplace.However, childrengenerallyhadconflictingviews

abouttheroleoftheirparent/carers.Someparticipantsfoundthemtobeagreatsourceofcomfort

andreassurance,whilstothersfoundparentalanxietyanadditionalburden.

Louise’sMum:“ForsomechildrentheywanttohavetheirMumtoholdtheirhand,butmyanxiety

diddefinitelyhaveaneffectonLouiseaswell.”

Interviewer:“SowhatmadethedifferencewhenyourMumwasn’tintheroom?”

Louise:“Therewasnotsomuchnegativitysurroundingit.”(Louise,14yearsold).

b) Potentialthreateningstimuliwithintheclinicalenvironment

Thedentalenvironmentwas foundtobeanoverwhelming,anxiety-provokingsensoryexperience.

Participantsdiscussedloudnoisestheyhadheardincludingcriesfromotheryoungpatients,strange

soundsfromdentalequipment,andfrighteningcracksofboneasteethwereremoved.Othersgave

accountsofseeingsharpandthreateninginstrumentsontraysinfrontofthem,observingdistressin

otherchildren,thefeelofequipmentatthebackoftheirmouth,andbeingsubjecttounusualand

strange tastes. Some participants expressed specific anxiety about dental local anaesthetic

injections,perceivingthemasbeingpainfultoendure.

“And it’s like it stings, it doesn’t hurt, it stings. It stings really badly like 10,000 bees stinging you

insideyourmouth.”(Michael,13yearsold).

Page10

Even the anticipated sensationof numbness associatedwith local anaestheticwas seenashaving

negativeimplications.

“HeputinaninjectionandIcouldn’ttalkforawhile.”(Lucy,13yearsold).

WithintheFiveAreasmodeldentalanxietyisnotpotentiatedbythedescribedsituationsperse,but

rather how an anxious individual interprets those situational factors.15 Characteristically, anxious

childrenhaveanincreasedperceptionthatanon-threateningsituationisdangerous,coupledwitha

decreased perception of their own coping ability. Consequently, negative thinking patterns can

develop.Inanxietydisordersnegativethoughtsarepersistentandintrusive23

2) Alteredthoughts

Withinthethemeofalteredthoughts,foursub-themesemergedfromthedata:negativepredictions

(catastrophising);negativesocial judgements(mind-reading);relivingtraumaticdentalexperiences;

anddistractionstrategies.

a) Negativepredictions

Numerous negative expectations were reported. Participants discussed that if they had dental

treatmentitwouldbepainfulandthattheywouldnotbeabletostopthedentist,orthataclinical

errorcouldoccurandcausethemharm.

“Whatiftheydosomethingwrong?Theyslip,andthenIswallowsomethinganditchokesandIdie.”

(Michael,13yearsold).

Violent mental images about suffering physical injury as a result of dental treatment were also

described.

“Shelookedlikeabutcher…It’slikeshemayaswellgotanaxeandstartedchoppingatmyfacebut

shehadtissue.”(Claire,14yearsold).

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b) Negativesocialjudgements

Strongnegativeopinionswereexpressedabout thedental team,andwhatchildrenperceived the

dental team thought of them. Specifically, someparticipants thought that the dental teamwould

thinktheyhad‘bad’teeth.Theywereconvincedthatirrespectiveoftheiractionstolookaftertheir

teeth, the dentist would find something wrong and they would need further treatment.

Consequently,theybelievedthedentisttohavemadenegativejudgementsaboutthem,considering

themtobe ‘unhealthy’or ‘lazy’,and failing tobelieve themwhenthey told the truthaboutsugar

consumption.

“Cause Ihardlyhaveanysweets,andthentheyalwayssay Ihave loadsofsweets.” (Bob,11years

old).

Moreover, they alleged that if a dentist thought badly of them then the dentist would obtain

pleasurefromcausingthemsuffering.

“Ibetshelovesmecomingbecauseshe’sgottodolotsofstuffonme,andshecanexperimentonme

likeadoll.”(Emily,14yearsold).

c) Relivingtraumaticexperiences

Distressingaccountswerealsoprovidedofpreviousnegativedentalexperiences.Thedescriptions

included portrayals of vulnerability and loss of control, with the participants remembering dark

rooms,beingunabletospeakorclosetheirmouths,andattemptstotry tostopthedentistbeing

ignored.Clearly, thesememorieswerepersistentandhadaffectedparticipants for longperiodsof

time.

“Yeah,andthenforaboutayearafterIhaditdoneit’skindof,it’sstillthesamememorieswasgoing

aroundinmyhead,thesamedayeverynight.”(Sophie,12yearsold).

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d) Distractionstrategies

Participantsdiscussed recovering fromnegativedental experiences, andbeingable toutilise their

learning as a positive cognitive coping strategy to challenge their negative thoughts. In addition,

children appeared to employ a range of other cognitive strategies in the dental environment,

includingthoughtsofwhentheyhadbeenhappy,activitieswithfriends,orwishescomingtrue.

“I just shutmy eyes and like, and not to be stupid, just pretend that you’re in a happy place…On

beachwiththeseatricklingalong.”(Joe,12yearsold).

3) Alteredfeelings

According to the Five Areas model, unhelpful thoughts affect emotional state and physical

symptoms. Characteristically, fear and anxiety result in a distressing negative affective state and

activationoftheautonomicnervoussystem.Reciprocally, thesedistressingfeelingsandsymptoms

can lead to further deterioration in the already established unhelpful thinking patterns, with

unhelpfulthoughtsbecomingmorenegativeandextreme.23

Withinthethemeofalteredfeelings,subthemesfortheemotionsexperiencedbeforeandduringa

dentalvisit,andafteradentalvisit,weredescribed.

a) Beforeandduringdentalvisits

Many emotivewordswere used to illustrate feelings and negative affect. Broadly these could be

groups into fear-based feelings (e.g. “petrified”, “terrified”), and anxiety-based feelings (e.g.

“flustered”, “trapped”, “uncomfortable”). Children suffered considerable emotional distress and

spokeofthebehaviouralconsequencesofthis(e.g.having“meltdowns”,beingin“floodsoftears”

and“screamingwithfear”).Somewereembarrassedbytheirdentalanxiety,comparingthemselves

unfavourablytotheirdentallysuccessfulpeers.Othersexpressedstronganger,principallywiththe

dentalprofessionalwhoprovidedtheirtreatment.

Page13

“Angry...Becausetheydidn’tlisten.Theylied.Iwantedtoshoutatthem,"Sowhydidn’tyoulisten."

(Danielle,11yearsold).

b) Afterdentalvisits

After dental appointments children similarly experienced a range of emotional responses.

Participantsdescribed feeling“exhausted”and“drained”bywhat theyhad faced.However, if the

visithadbeensuccessful,participantsdescribedpositiveemotionalexperiences.

“Feelabitproud.I’vedoneit.I’vefacedmyfears.”(Chloe,11yearsold).

Anticipationofareward, includingbeingabletoembarkonorthodontictreatment,addedtotheir

positivity.Interestingly,participantsalsospokeaboutexperiencingpositiveemotionswhentheyhad

managedtosuccessfullyavoidhavingdentaltreatment.

Interviewer:“WhenyourMumsaidyoudidn’thavetogo,shewasgoingtocancelyourappointment,

whatdiditfeellikethen?”

Claire:“Justlikeaweightliftedoffyourshoulder.”(Claire,14yearsold).

4) Alteredphysicalsymptoms

During an episode of dental anxiety, different physiological symptoms were experienced,

characteristicallydepictingfeaturesofautonomicarousal(e.g.sweating,decreasedgastricmotility,

cutaneous vasoconstriction).24 Symptoms described included: “sweating and shaking”; “clammy

palms”; “having butterflies”, “stomach-aches”, “feeling sick” and “becoming pale”. Other somatic

manifestations were sleep disturbances, and symptoms of temporomandibular dysfunction,

includingtoothclenchingandmandibularpain.

Page14

5) Alteredbehaviour

In perceived threatening situations, behavioural responses to prevent harm include:

escape/avoidance; aggression; and immobility and hiding.25 In the survival context, avoiding the

danger may be associated with less risk of harm, whilst becoming aggressive or immobile are

reasonabledefensivestancesshouldallelsefail.25 Inanxietydisordersunhelpful thinkingpatterns,

feelings,andphysicalsymptomscanleadanindividualtomakeunhelpfulbehaviouralchoicesinan

attempt toalleviate thedistress theyareexperiencing.26However, suchbehavioursareultimately

self-defeating.22 Within this theme, subthemes of avoidance, aggression and behavioural coping

strategieswereevidentfromthedata.

a) Avoidance

A number of strategieswere employed by participants to avoid attending an appointment, or to

hinder dental activities once in the dental environment. Children spoke of trying to cajole their

parents/carers into cancelling dental appointments. This included attempts to deceive their

parents/carersbyclaimingtobefeelingunwell,orbydown-playingdentalproblems.

Interviewer:“Haveyouevermadeexcusesnottogotothedentist?”

Samantha:“Triedto.LikeI’mpoorlyandIcan’tgo.Ifeelill.”(Samantha,15yearsold).

Once in the dental chair, participants discussed trying to delay their dental treatment. Examples

were given where participants forced siblings to have their dental visit first, stalled by asking

multiplequestions,orrefusedtoopentheirmouths.

“They can’t force yourmouthopenoranything, so I thought tomyself, ‘Well if I keep it shut they

can’treallydoanything’.”(Sophie,12yearsold).

Asalastresort,negotiationswiththedentalteamwereattempted,wherebychildrenvolunteeredto

carryouttreatmentproceduresbythemselves.

Page15

“IsaidIwasgoingtopullitbuttheywouldn’tletme”(Danielle,11yearsold).

b) Aggressivebehaviour

Participantsdescribedaggressivebehaviourtheyhadshowntowardsthedentalteam.Mostly,this

took the form of making unkind and discourteous statements. It was generally reported by

parents/carers that this was uncharacteristic of them. Although, participants were not physically

aggressive,theydescribedthoughtsofwantingtohurttheirdentist.

“Last time I nearly hit somebody...onpurpose. I got really annoyed likewhenpeoplemessaround

withyoulikethis,pullingyourfaceandlikeopeningyourmouthandstuff,itgetsreallyannoyingsoI

waslikestopit!Youwanttohitthemandstuff.”(Michael,13yearsold).

c) Behaviouralcopingstrategies

Notall thebehavioursreportedbythechildrenwereunhelpful.Behaviouralcopingstrategiesthat

enabledthechildtocompletetreatment includedholdingthedentalnurse’shandand listeningto

music,

Discussion

Theaimof this studywas toexplorechildren’sexperiencesofdentalanxietyusing theFiveAreas

cognitivebehavioural therapyassessmentmodel toprovidea structure for theirexperiences. This

studyisamongthefirsttoaskchildrendirectlyabouttheirdentalanxiety,andtobeunderpinnedby

atheoreticalmodelfortheconstructofdentalanxiety.27Theparticipantswithinthisstudydescribed

theirexperiencesrelatingtoeachofthefactorswithintheFiveAreasmodelvividly.Therefore,the

findings support theuseof this cognitive behavioural therapymodel for understanding childhood

dentalanxiety,withapplicationsfortheassessmentandtreatmentofdentalanxiety.

Page16

Commonrecurringthemesdescribedbythedentallyanxiousparticipantsincluded:makingnegative

predictionsaboutwhatcouldhappen(e.g.expectationofpain,clinicalerror,sufferingharm,being

powerless);relivingtraumaticdentalexperiences(e.g.memories,nightmares);avoidingdentalcare

(e.g.deceptivestrategies,negotiation);andexperiencingnegativeaffectivestates(e.g.fear,anxiety,

anger, shame, embarrassment), and physical symptoms (e.g. autonomic arousal). In this study a

deductive, top-downapproachwasutilised.17However, as further evidence for the helpfulness of

the Five Areas model in describing and making sense of child dental anxiety, the findings are

consistent with previous qualitative studies involving dentally anxious adults that used inductive

analysis(e.g.GroundedTheory),28;29orwherenovelmethodswereused,suchasevaluatingvideos

aboutdentalanxietythatwerepostedonsocialmedia.30Althoughthechildandadultexperienceof

dentalanxietyhavesimilarities,adifferencewasapparentinrelationtoavoidanceofdentalcare.29

Unlike adults, children do not make the decision themselves about dental attendance. The

participants in this study described attempts to deceive or pressure their parents into cancelling

appointment.Correspondingly,parentshavereportedthat theycan feeloverwhelmedandunable

to convince their child they needed to attend.31 Themulti-dimensional nature of the experiences

describedbychildrenalsohighlightspotential limitationsof thecurrentlyavailablepaediatric self-

reportmeasureswhichmayonlycapturepartofchildren’soverallexperienceofdentalanxiety.

Evidenced within the examples given across the themes was the role of the dental professional

within the children’s experiences. Consistent with studies with adults,32 participants in this study

identified empathetic dental professionals as having a positive influence on dental anxiety.

Conversely, criticismbyadental professional, evenwhenwell-intentionedduring theprovisionof

oral health advice, acted to promote dental anxiety in children. In this study, children placed

considerablevalueoncommunicationandinformation-sharing.Thisisconsistentwithfindingsfrom

a study of children aged 10 to 13 years from New Zealand in which children attending dental

appointmentsreportedthattheywantedtobegivenfactualinformation,evenifitwasunpleasant

Page17

to hear.33 However, dental professionals allocate little time to discussing the specifics of a dental

visitwithyoungpatients,andestablished routinesandunequalpower relationshipsmaypreclude

children from being able to ask questions themselves.34 To complicate matters, dentally anxious

children in this studydidnothaveuniform informationneeds.Regardless, if adentalprofessional

failedtomeettheirneeds,theconsequenceswereharmfulforthedentist-patientrelationship,trust

inthedentalprofessionandongoingmaintenanceofdentalanxiety.Therefore,considerationshould

be given to providing training to dental professionals, and to develop communication tools that

promote positive dentist-patient interactions, and that can meet the needs of individual young

patients.

Thereareanumberoflimitationstothisstudy.Firstly,itwaschallengingtorecruitparticipantsfrom

certain population groups; notably,male participants, particularly older adolescents, and children

fromethnicminorities.Possibleexplanationsincludesocialandculturalbarrierstoadmittingdental

anxiety,willingnesstoparticipateininterviews,andlanguagedifficulties35;36Itisnotknownifthese

barriers to study participation could also have had impacts on children’s experiences of dental

anxiety.Itshouldalsobenotedthatduetothecognitivetasksrequiredofparticipantsinthisstudy

only children aged 11 to 16 yearswere included. It is possible that younger childrenwould have

described different experiences of dental anxiety.Additionally, nearly all participants,when given

theoption, chose tobe interviewedwith theirparents/carers. It is alsopossible thatparent/carer

presence had an influence on participants’ response. As the aim of the studywas to explore the

overallexperiencesofdentalanxiety,participantswerenotaskedtocompleteanobjectivedental

anxietymeasure.However, thedatasuggestarangeofseveritiesofdentalanxietywere included.

This studywasalso conductedwith children fromonlyoneUK region.Consequently, someof the

languageusedbyparticipantswasbasedon localcolloquialisms,andmaynotbeapplicabletothe

child population in general. Finally, both interviewers in this study were qualified dentists, with

potentially implications for the way questions were phrased, and the interpretations made. To

Page18

reducetheimpactofthisanon-dentallyqualifiedmemberoftheresearchteamwasinvolvedinthe

developmentofthetopicguideandanalysis.

Bulletpoints

Whatthispaperisimportanttopaediatricdentists

1) This is one of the first studies to explore the multidimensional aspects of childhood dental

anxietyunderpinnedbyatheoreticalmodel.

2) Participantsinthestudywereaskeddirectlyabouttheirownexperiencesofdentalanxiety,and

providedinsightsthathavenotpreviouslybeendescribed.

Acknowledgements

This paper presents independent research funded by the National Institute for Health Research

(NIHR)under itsResearch forPatientBenefit (RfPB)Programme (GrantReferenceNumberPB-PG-

1111-26029).Theviewsexpressedare thoseof theauthorsandnotnecessarily thoseof theNHS,

theNIHRortheDepartmentofHealth.ThetermFiveAreasTMisaregisteredtrademarkofFiveAreas

ResourcesLtd(www.fiveareas.com).

Conflictofinterest

Part of the grant funding paid Five Areas Ltd to develop the course book and linked training

resourcesusedinthisgrant.CWisshareholderanddirectorofthiscompanywhichcommercialises

these resources. His wife is Company Secretary and shareholder in the same company. CW is

President of the British Association for Behavioural and Cognitive Psychotherapies

(www.babcp.com)acharitythatpromotesCBT.

Page19

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Table1.

Demographicdetailsforparticipants

Pseudonym Age(years)

Gender Recruitmentlocation Deprivationquintile*

Dentalanxiety(Clinicianreported)

Ethnicity

Chloe 11 Female DentalHospital 2 High WhiteBritish

Samantha 15 Female GeneralDentalPractice 5 Mild WhiteBritish

Danielle 11 Female DentalHospital 5 Moderate WhiteBritish

Amelia 14 Female DentalHospital 4 HighWhiteBritish

Joe 12 Male DentalHospital 3 HighWhiteBritish

Lucy 13 Female DentalHospital 3 Moderate WhiteBritish

Bob 11 Male DentalHospital 2 Mild WhiteBritish

Emily 14 Female GeneralDentalPractice 4 MildWhiteBritish

Sophie 12 Female DentalHospital 2 HighWhiteBritish

Katy 13 Female SalariedDentalService 2 HighWhiteBritish

Louise 14 Female DentalHospital 5 Veryhigh WhiteBritish

Claire 14 Female SalariedDentalService 5 Moderate WhiteBritish

Michael 13 Male DentalHospital 4 High Mixed

*Deprivationquintilesbasedon IndexofMultipleDeprivation2010 rank 37.Deprivationquintile 5

representsthemostdeprivedlowersuperoutputarearanksacrossEngland.

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Figure1.Thematicframeworkoutline(adaptedfromWilliamsandGarland22)