Application of cognitive behavioral therapy and behavioral modification therapy in pediatric dental anxiety: a systematic review

Background: Pediatric dental anxiety (DA) is a common problem which impacts children’s cooperation during dental procedures and hampers long-term oral health outcomes. Effective DA management is crucial for the positive dental experiences and regular dental care visits among children. Most randomized controlled trials (RCTs) suggest that psychotherapy, particularly the cognitive behavioral therapy (CBT) and behavioral modification therapy (BMT), is conducive in alleviating DA. This systematic review aims to evaluate CBT and BMT in managing pediatric DA via the comprehensive assessment of RCTs. Methods: Multiple electronic databases including Cochrane Oral Health Group’s Trials Register, Web of Science, PubMed, and EMBASE via Ovid were systematically searched from January 2000 to October 2023. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed for the search. Eligible studies were the RCTs assessing CBT or BMT interventions for pediatric DA. The outcomes included validated measures of anxiety and physiological parameters. Two reviewers independently examined the study selection, data extraction, and risk of bias assessment. The discrepancies were resolved with consensus. Results: Fourteen RCTs met the inclusion criteria with 11 focusing on BMT and 3 on CBT interventions. Most studies showed favorable impact of psychotherapy in reducing DA, however, there were methodological limitations such as lack of blinding and small sample sizes. The outcome measures included validated scales for DA assessment and parameters like heart rate and blood pressure. Conclusions: CBT and BMT may alleviate pediatric dental anxiety, however existing studies demand cautious interpretations because of methodological limitations. Future studies should prioritize high-quality RCTs with larger number of samples and effective methodologies to enhance interventions’ efficacy in pediatric dental care. The PROSPERO Registration: The systematic review protocol was registered in PROSPERO (ID: CRD 42024524307).

Cognitive behavioral therapy; Behavior therapy; Dental anxiety; Systematic review; Randomized controlled trial

[1] Klingberg G. Dental fear and behavior management problems in children. A study of measurement, prevalence, concomitant factors, and clinical effects. Swedish Dental Journal. Supplement. 1995; 103: 1–78.

[2] Eijlers R, Utens EMWJ, Staals LM, de Nijs PFA, Berghmans JM, Wijnen RMH, et al. Systematic review and meta-analysis of virtual reality in pediatrics: effects on pain and anxiety. Anesthesia & Analgesia. 2019; 129: 1344–1353.

[3] Felemban OM, Alshamrani RM, Aljeddawi DH, Bagher SM. Effect of virtual reality distraction on pain and anxiety during infiltration anesthesia in pediatric patients: a randomized clinical trial. BMC Oral Health. 2021; 21: 321.

[4] Uziel N, Gilon E, Bar I, Edri N, Eli I. Excessive gag reflex, dental anxiety, and phobia of vomiting in dental care. International Dental Journal. 2024; 74: 801–807.

[5] Xing F, Zhang T, Yang Z, Qu M, Shi X, Li Y, et al. Comparison of dexmedetomidine and a dexmedetomidine-esketamine combination for reducing dental anxiety in preschool children undergoing dental treatment under general anesthesia: a randomized controlled trial. Journal of Affective Disorders. 2024; 347: 569–575.

[6] Locker D, Liddell A, Dempster L, Shapiro D. Age of onset of dental anxiety. Journal of Dental Research. 1999; 78: 790–796.

[7] Margraf-Stiksrud J, Pieper K. Assessment of dental anxiety in children: reliability and validity of the questionnaire to assess dental anxiety in children (QADA-C). Dentistry Journal. 2024; 12: 23.

[8] Leko J, Škrinjarić T, Goršeta K. Reliability and validity of scales for assessing child dental fear and anxiety. Acta Stomatologica Croatica. 2020; 54: 22–31.

[9] Grisolia BM, dos Santos APP, Dhyppolito IM, Buchanan H, Hill K, Oliveira BH. Prevalence of dental anxiety in children and adolescents globally: a systematic review with meta-analyses. International Journal of Paediatric Dentistry. 2021; 31: 168–183.

[10] Gaffar BO, Alagl AS, Al-Ansari AA. The prevalence, causes, and relativity of dental anxiety in adult patients to irregular dental visits. Saudi Medical Journal. 2014; 35: 598–603.

[11] Tellez M, Kinner DG, Heimberg RG, Lim S, Ismail AI. Prevalence and correlates of dental anxiety in patients seeking dental care. Community Dentistry and Oral Epidemiology. 2015; 43: 135–142.

[12] De Jongh A, Adair P, Meijerink-Anderson M. Clinical management of dental anxiety: what works for whom? International Dental Journal. 2005; 55: 73–80.

[13] Folayan MO, Idehen E. Factors influencing the use of behavioral management techniques during child management by dentists. Journal of Clinical Pediatric Dentistry. 2004; 28: 155–161.

[14] Ansari MT, Tsertsvadze A, Moher D. Grading quality of evidence and strength of recommendations: a perspective. PLOS Medicine. 2009; 6: e1000151.

[15] Schulz KF, Altman DG, Moher D. CONSORT 2010 statement: updated guidelines for reporting parallel group randomised trials. The BMJ. 2010; 340: c332.

[16] Jeddy N, Nithya S, Radhika T, Jeddy N. Dental anxiety and influencing factors: a cross-sectional questionnaire-based survey. Indian Journal of Dental Research. 2018; 29: 10–15.

[17] Wolf TG, Schläppi S, Benz CI, Campus G. Efficacy of hypnosis on dental anxiety and phobia: a systematic review and meta-analysis. Brain Sciences. 2022; 12: 521.

[18] Armfield JM, Heaton LJ. Management of fear and anxiety in the dental clinic: a review. Australian Dental Journal. 2013; 58: 390–407; quiz 531.

[19] Appukuttan DP. Strategies to manage patients with dental anxiety and dental phobia: literature review. Clinical, Cosmetic and Investigational Dentistry. 2016; 8: 35–50.

[20] Wide Boman U, Carlsson V, Westin M, Hakeberg M. Psychological treatment of dental anxiety among adults: a systematic review. European Journal of Oral Sciences. 2013; 121: 225–234.

[21] Rachman S. Psychological treatment of anxiety: the evolution of behavior therapy and cognitive behavior therapy. Annual Review of Clinical Psychology. 2009; 5: 97–119.

[22] Rachman S. The evolution of behaviour therapy and cognitive behaviour therapy. Behaviour Research and Therapy. 2015; 64: 1–8.

[23] Matsuoka H, Chiba I, Sakano Y, Toyofuku A, Abiko Y. Cognitive behavioral therapy for psychosomatic problems in dental settings. BioPsychoSocial Medicine. 2017; 11: 18.

[24] Thoma N, Pilecki B, McKay D. Contemporary cognitive behavior therapy: a review of theory, history, and evidence. Psychodynamic Psychiatry. 2015; 43: 423–461.

[25] Kushner R. Diets, drugs, exercise, and behavioral modification: where these work and where they do not. Surgery for Obesity and Related Diseases. 2005; 1: 120–122.

[26] Vishwakarma AP, Bondarde PA, Patil SB, Dodamani AS, Vishwakarma PY, Mujawar SA. Effectiveness of two different behavioral modification techniques among 5–7-year-old children: a randomized controlled trial. Journal of the Indian Society of Pedodontics and Preventive Dentistry. 2017; 35: 143–149.

[27] Schiavenato M, Chu F. PICO: what it is and what it is not. Nurse Education in Practice. 2021; 56: 103194.

[28] Cuschieri S. The CONSORT statement. Saudi Journal of Anaesthesia. 2019; 13: S27–S30.

[29] Moher D, Hopewell S, Schulz KF, Montori V, Gøtzsche PC, Devereaux PJ, et al. CONSORT 2010 explanation and elaboration: updated guidelines for reporting parallel group randomised trials. The BMJ. 2010; 340: c869.

[30] Sridhar S, Suprabha BS, Shenoy R, Shwetha KT, Rao A. Effect of a relaxation training exercise on behaviour, anxiety, and pain during buccal infiltration anaesthesia in children: Randomized clinical trial. International Journal of Paediatric Dentistry. 2019; 29: 596–602.

[31] Kaur R, Jindal R, Dua R, Mahajan S, Sethi K, Garg S. Comparative evaluation of the effectiveness of audio and audiovisual distraction aids in the management of anxious pediatric dental patients. Journal of the Indian Society of Pedodontics and Preventive Dentistry. 2015; 33: 192–203.

[32] Sayed A, Ranna V, Padawe D, Takate V. Effect of the video output of the dental operating microscope on anxiety levels in a pediatric population during restorative procedures. Journal of the Indian Society of Pedodontics and Preventive Dentistry. 2016; 34: 60–64.

[33] Nuvvula S, Alahari S, Kamatham R, Challa RR. Effect of audiovisual distraction with 3D video glasses on dental anxiety of children experiencing administration of local analgesia: a randomised clinical trial. European Archives of Paediatric Dentistry. 2015; 16: 43–50.

[34] Dedeepya P, Nuvvula S, Kamatham R, Nirmala SV. Behavioural and physiological outcomes of biofeedback therapy on dental anxiety of children undergoing restorations: a randomised controlled trial. European Archives of Paediatric Dentistry. 2014; 15: 97–103.

[35] Howard KE, Freeman R. An evaluation of the PALS after treatment modelling intervention to reduce dental anxiety in child dental patients. International Journal of Paediatric Dentistry. 2009; 19: 233–242.

[36] Shahnavaz S, Hedman E, Grindefjord M, Reuterskiöld L, Dahllöf G. Cognitive behavioral therapy for children with dental anxiety: a randomized controlled trial. JDR Clinical and Translational Research. 2016; 1: 234–243.

[37] Kebriaee F, Sarraf Shirazi A, Fani K, Moharreri F, Soltanifar A, Khaksar Y, et al. Comparison of the effects of cognitive behavioural therapy and inhalation sedation on child dental anxiety. European Archives of Paediatric Dentistry. 2015; 16: 173–179.

[38] Maru V, Patil RSB, Kumari S, Tiwari S, Bapat S. Influence of pretreatment exposure to pediatric dental care using the “Tiny dentist” game on 4–7 years old children’s pain and anxiety: a parallel randomised clinical trial. Journal of Clinical Pediatric Dentistry. 2023; 47: 96–102.

[39] Bhusari BN, Hugar SM, Kohli N, Karmarkar S, Gokhale N, Saxena N. Comparative evaluation of anxiety level during restorative treatment using no music, monaural beats, and binaural auditory beats as audio distraction behavior guidance technique in children aged 6–12 years: a randomized clinical trial. Journal of Indian Society of Pedodontics and Preventive Dentistry. 2023; 41: 156–162.

[40] Bagher SM, Felemban OM, Alandijani AA, Tashkandi MM, Bhadila GY, Bagher AM. The effect of virtual reality distraction on anxiety level during dental treatment among anxious pediatric patients: a randomized clinical trial. Journal of Clinical Pediatric Dentistry. 2023; 47: 63–71.

[41] Gozin F, Tabe Bordbar F, Esmaeili M. Audio-visual storytelling for reducing dental anxiety in Iranian children: a randomized controlled trial. European Archives of Paediatric Dentistry. 2022; 23: 953–960.

[42] Du Q, Ma X, Wang S, Zhou S, Luo C, Tian K, et al. A digital intervention using virtual reality helmets to reduce dental anxiety of children under local anesthesia and primary teeth extraction: a randomized clinical trial. Brain and Behavior. 2022; 12: e2600.

[43] Zhu M, Yu H, Xie B, Li H, He Q, Li H, et al. Experiential learning for children’s dental anxiety: a cluster randomized trial. BMC Oral Health. 2020; 20: 216.

[44] Fiorillo L. Conscious sedation in dentistry. Medicina. 2019; 55: 778.

[45] Nayani-Low S, Patel J. Safe intravenous sedation for oral surgery in a primary care setting. Primary Dental Journal. 2022; 11: 46–52.

[46] Ball R, Arya R, Patel J. Record-keeping in intravenous sedation: are we meeting the standards? Primary Dental Journal. 2022; 11: 53–60.

[47] Prado IM, Carcavalli L, Abreu LG, Serra-Negra JM, Paiva SM, Martins CC. Use of distraction techniques for the management of anxiety and fear in paediatric dental practice: a systematic review of randomized controlled trials. International Journal of Paediatric Dentistry. 2019; 29: 650–668.

[48] De Stefano R, Bruno A, Muscatello MR, Cedro C, Cervino G, Fiorillo L. Fear and anxiety managing methods during dental treatments: a systematic review of recent data. Minerva Stomatologica. 2019; 68: 31–331.

[49] Yan X, Yan Y, Cao M, Xie W, O’Connor S, Lee JJ, et al. Effectiveness of virtual reality distraction interventions to reduce dental anxiety in paediatric patients: a systematic review and meta-analysis. Journal of Dentistry. 2023; 132: 104455.

[50] Barros Padilha DX, Veiga NJ, Mello-Moura ACV, Nunes Correia P. Virtual reality and behaviour management in paediatric dentistry: a systematic review. BMC Oral Health. 2023; 23: 995.

[51] Shi Y, Wu W. Multimodal non-invasive non-pharmacological therapies for chronic pain: mechanisms and progress. BMC Medicine. 2023; 21: 372.

[52] Gillies D, Maiocchi L, Bhandari AP, Taylor F, Gray C, O’Brien L. Psychological therapies for children and adolescents exposed to trauma. Cochrane Database of Systematic Reviews. 2016; 10: CD012371.

[53] Sirin Y, Yildirimturk S, Ay N. Do state-trait anxiety and previous unpleasant dental experiences predict the need for sedation in women having third molar surgery? The British Journal of Oral & Maxillofacial Surgery. 2020; 58: 530–534.

[54] Jeppesen P, Wolf RT, Nielsen SM, Christensen R, Plessen KJ, Bilenberg N, et al. Effectiveness of transdiagnostic cognitive-behavioral psychotherapy compared with management as usual for youth with common mental health problems: a randomized clinical trial. JAMA Psychiatry. 2021; 78: 250–260.

[55] Indovina P, Barone D, Gallo L, Chirico A, De Pietro G, Giordano A. Virtual reality as a distraction intervention to relieve pain and distress during medical procedures: a comprehensive literature review. The Clinical Journal of Pain. 2018; 34: 858–877.

[56] Kisely S, Sawyer E, Siskind D, Lalloo R. The oral health of people with anxiety and depressive disorders—a systematic review and meta-analysis. Journal of Affective Disorders. 2016; 200: 119–132.

[57] Kopycka-Kedzierawski DT, Feng C, Billings RJ, Watson GE, Ragusa PG, Flint K, et al. Psychosocial risk exposure limits routine pediatric oral health care. AJPM Focus. 2024; 3: 100191.

[58] Schneider A, Andrade J, Tanja-Dijkstra K, Moles DR. Mental imagery in dentistry: phenomenology and role in dental anxiety. Journal of Anxiety Disorders. 2018; 58: 33–41.

[59] Beaton L, Freeman R, Humphris G. Why are people afraid of the dentist? Observations and explanations. Medical Principles and Practice. 2014; 23: 295–301.