The CALM trial protocol: a randomised controlled trial of a guided self-help cognitive behavioural therapy intervention to reduce dental anxiety in children.

BACKGROUND: Globally, around 13% of children experience dental anxiety (DA). This group of patients frequently miss dental appointments, have greater reliance on treatment under general anaesthesia (GA) and have poorer oral health-related quality of life (OHRQoL) than their non-dentally anxious peers. Recently, a low-intensity cognitive behavioural therapy (CBT)-based, self-help approach has been recommended for management of childhood anxiety disorders. A feasibility study conducted in secondary care found this guided self-help CBT resource reduced DA and a randomised controlled trial was recommended. The present study aims to establish the clinical and cost-effectiveness of a guided self-help CBT intervention to reduce DA in children attending primary dental care sites compared to usual care. METHODS: This 4-year randomised controlled trial will involve 600 children (aged 9-16 years) and their parent/carers in 30 UK primary dental care sites. At least two dental professionals will participate in each site. They will be assigned, using random allocation, to receive the CBT training and deliver the intervention or to deliver usual care. Children with DA attending these sites, in need of treatment, will be randomly allocated to be treated either by the intervention (CBT) or control (usual care) dental professional. Children will complete questionnaires relating to DA, OHRQoL and HRQoL before treatment, immediately after treatment completion and 12 months post-randomisation. Attendance, need for sedation/GA and costs of the two different approaches will be compared. The primary outcome, DA, will be measured using the Modified Child Dental Anxiety Scale. Scores will be compared between groups using a linear mixed model. DISCUSSION: Treating dentally anxious patients can be challenging and costly. Consequently, these children are frequently referred to specialist services for pharmacological interventions. Longer waiting times and greater travel distances may then compound existing healthcare inequalities. This research will investigate whether the intervention has the potential to reduce DA and improve oral health outcomes in children over their life-course, as well as upskilling primary dental healthcare professionals to better manage this patient group. TRIAL REGISTRATION: This clinical trial has been registered with an international registry and has been allocated an International Standard Randomised Controlled Trial Number (ISRCTN27579420).

A Short Form of the Children's Experiences of Dental Anxiety Measure (CEDAM): Validation and Evaluation of the CEDAM-8.

BACKGROUND: The Children's Experiences of Dental Anxiety Measure (CEDAM-14) is a child-centred measure of dental anxiety which assesses a range of behaviours, thoughts and feelings/physical symptoms related to dental anxiety. A short form of the CEDAM-14, which places less time burden on patients and clinicians, could promote the feasibility and applicability of the CEDAM in clinical settings. The aim of the study was to develop a short version of the CEDAM that can be used to assess children's dental anxiety in clinical practice. METHODS: A short version of the CEDAM was developed using a combination of item impact and regression methods. Measurement properties including floor/ceiling effects, variance, criterion validity, construct validity and internal consistency was calculated for the short form. RESULTS: An eight-item CEDAM short form was developed (CEDAM-8) that had good psychometric properties, was significantly correlated with the CEDAM measure (r = 0.90; p < 0.01), had minimal floor and ceiling effects (3.5% and 1.2%, respectively) and was sensitive to change. CONCLUSION: The CEDAM-8 is a useful assessment tool for clinicians that is easy and quick to administer and could help to understand children's experiences of dental anxiety and changes in anxiety over time and following intervention.

Investigating the Temporal Relationships between Symptoms and Nebuliser Adherence in People with Cystic Fibrosis: A Series of N-of-1 Observations.

Treatment adherence in adults with cystic fibrosis (CF) is poor. One of the reasons identified for lack of adherence to nebulised treatments is that patients may not experience any immediate relief in their symptoms or notice changes as a result of taking their treatment, thus many report that they do not perceive there to be consequences of non adherence. The aim of the study was to investigate the temporal relationships between symptoms and adherence to nebulised treatments in adults with CF using an N-of-1 observational design. Six participants were recruited for a six-week period during which time they completed a daily online respiratory symptom questionnaire. Adherence to treatment was measured throughout the duration of the study using an eTrack® nebuliser that logged date and time of treatments taken. Data generated from each participant was analysed separately. There were significant relationships between pain and adherence for three participants, tiredness and adherence for one participant and cough and adherence for one participant. For all of these findings, the symptom and adherence were experienced on the same day. Extending the monitoring period beyond six weeks may provide increased insight into the complex relationship between symptoms and adherence in CF.

'Message to Dentist': Facilitating Communication with Dentally Anxious Children.

Dental anxiety affects children worldwide and can have negative consequences on oral health. This study aimed to evaluate a novel communication aid 'message to dentist' (MTD), as part of a wider cognitive behavioural therapy approach to reduce dental anxiety in young patients. Dentally anxious children, aged 9-16 years, were invited to complete the MTD proforma, before and following their course of treatment. They scored how worried they were and their anticipated pain levels on a scale of 1-10 (10 being the worst outcome). They also wrote down their coping plans and post-treatment reflections. One hundred and five children, from a UK general dental practice and a hospital clinic, were included. They had a mean age of 11.6 years, and 65% were female. There was a significant reduction in self-report worry (from 4.9 to 2.1) and anticipated pain (from 5.1 to 2.0) scores (p < 0.05, paired t-test). Many children (30%) used listening to music/audiobook as a coping strategy. Thematic analysis revealed concerns around pain, uncertainty, errors and specific procedures. The MTD proforma proved an effective means of facilitating communication between anxious children and the dental team, allowing them to identify their worries and make personalised coping plans.

Evaluation of Self-Help Cognitive Behavioural Therapy for Children's Dental Anxiety in General Dental Practice.

Dental anxiety is very common; however, there is a lack of studies focusing on reducing children's dental anxiety. One such initiative, the guided self-help cognitive behavioural therapy (CBT) resources 'Your teeth, you are in control', reduces dental anxiety in children attending paediatric dentistry clinics. This service evaluation aims to investigate whether such CBT resources reduce children's dental anxiety when implemented in general dental practice. A convenience sample of children was given the resources by their dental practitioner. There was no control group. Children completed the Children's Experiences of Dental Anxiety Measure (CEDAM) prior to using the resources and on completion of a course of dental treatment. Overall, 84 children were involved, with a mean age of 10.9 years; 48 were female and 59 were living in the most deprived area of England. At baseline the mean CEDAM score was 20.3, and on receiving the resource and completing treatment the mean CEDAM score was 16.4, showing a significant reduction in dental anxiety (t = 14.6, (df = 83), p < 0.001, 95% CI: 3.4⁻4.4). The items that improved the most were worry over having dental treatment and dental treatment being painful. The service evaluation indicates a reduction in child dental anxiety following the use of CBT resources in general practice. Further evaluation, preferably a randomised controlled trial, is needed.

Development and evaluation of the children's experiences of dental anxiety measure.

BACKGROUND: Existing measures of children's dental anxiety have not been developed with children or based on a theoretical framework of dental anxiety. AIM: To develop the children's experiences of dental anxiety measure (CEDAM) and evaluate the measure's properties. DESIGN: The measure was developed from interviews with dentally anxious children. Children recruited from a dental hospital and secondary school completed the CEDAM and Modified Child Dental Anxiety Scale (MCDAS). A subgroup of children completed the CEDAM before and after receiving an intervention to reduce dental anxiety to examine the measure's responsiveness. Rasch and Classical test analyses were undertaken. RESULTS: Children were aged between 9 and 16 years (N = 88 recruited from a dental hospital and N = 159 recruited from a school). Rasch analysis confirmed the measure's unidimensionality. The CEDAM correlated well with the MCDAS (rho = 0.67, P < 0.01) and had excellent internal consistency (Cronbach's alpha = 0.88) and test-retest reliability (ICC = 0.98). The CEDAM was also able to detect changes in dental anxiety following the intervention (baseline mean = 22.36, SD = 2.57 and follow-up mean = 18.88, SD = 2.42, t(df = 37) = 9.54, P < 0.01, Cohen's d = 1.39). CONCLUSIONS: The results support the reliability, validity and responsiveness of the CEDAM. Initial findings indicate it has potential for use in future intervention trials or in clinical practice to monitor children's dental anxiety.

Children's experiences of dental anxiety.

BACKGROUND: Dental anxiety is common among children. Although there is a wealth of research investigating childhood dental anxiety, little consideration has been given to the child's perspective. AIM: This qualitative study sought to explore with children their own experiences of dental anxiety using a cognitive behavioural therapy assessment model. DESIGN: Face-to-face, semi-structured interviews were conducted with dentally anxious children aged 11-16 years. The Five Areas model was used to inform the topic guide and analysis. Data were analysed using a framework approach. RESULTS: In total, 13 children were 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-patient relationship. CONCLUSIONS: This study confirms the Five Areas model as an applicable theoretical model for the assessment of childhood dental anxiety. Children provided insights about their own dental anxiety experiences that have not previously been described.

Protocol for a feasibility study of a self-help cognitive behavioural therapy resource for the reduction of dental anxiety in young people.

BACKGROUND: Childhood dental anxiety is very common, with 10-20 % of children and young people reporting high levels of dental anxiety. It is distressing and has a negative impact on the quality of life of young people and their parents as well as being associated with poor oral health. Affected individuals may develop a lifelong reliance on general anaesthetic or sedation for necessary dental treatment thus requiring the support of specialist dental services. Children and young people with dental anxiety therefore require additional clinical time and can be costly to treat in the long term. The reduction of dental anxiety through the use of effective psychological techniques is, therefore, of high importance. However, there is a lack of high-quality research investigating the impact of cognitive behavioural therapy (CBT) approaches when applied to young people's dental anxiety. METHODS/DESIGN: The first part of the study will develop a profile of dentally anxious young people using a prospective questionnaire sent to a consecutive sample of 100 young people referred to the Paediatric Dentistry Department, Charles Clifford Dental Hospital, in Sheffield. The second part will involve interviewing a purposive sample of 15-20 dental team members on their perceptions of a CBT self-help resource for dental anxiety, their opinions on whether they might use such a resource with patients, and their willingness to recruit participants to a future randomised controlled trial (RCT) to evaluate the resource. The third part of the study will investigate the most appropriate outcome measures to include in a trial, the acceptability of the resource, and retention and completion rates of treatment with a sample of 60 dentally anxious young people using the CBT resource. DISCUSSION: This study will provide information on the profile of dentally anxious young people who could potentially be helped by a guided self-help CBT resource. It will gain the perceptions of dental care team members of guided self-help CBT for dental anxiety in young people and their willingness to recruit participants to a trial. Acceptability of the resource to participants and retention and completion rates will also be investigated to inform a future RCT.

Utilising daily diaries to examine oral health experiences associated with dentine hypersensitivity.

BACKGROUND: The current investigation examined the determinants of oral health experiences associated with dentine hypersensitivity using prospective diary methodology. METHODS: Staff and students from a large UK university who had self-diagnosed dentine hypersensitivity completed an online daily diary and text survey for 2 weeks recording their mood, oral health-related coping behaviours, coping and pain appraisals, pain experiences and functional limitations. Cross sectional and lagged path analyses were employed to examine relationships. RESULTS: One hundred one participants took part in the diary study. Participants had a mean age of 26.3 years (range = 18-63) and most were female (N = 69). Individuals who used more oral health-related coping behaviours predicted and experienced greater levels of pain on subsequent days. Negative mood also predicted worse pain outcomes. The daily diary method provided a useful avenue for investigating variations in oral health experiences and relationships between variables that can fluctuate daily. CONCLUSIONS: Psychological variables such as coping and mood play an important role in the pain experiences of people with dentine hypersensitivity. The study highlights the benefits of using prospective methods to elucidate the experiences of people with oral conditions.

Childhood dental injuries: a resiliency model of adaptation.

BACKGROUND: There is a paucity of research examining how children and their families adapt to traumatic dental injuries. AIM: This study examined how clinical and psychosocial factors influence adaptation to this oral stressor using a theoretical framework of resiliency and adaptation. DESIGN: Children with traumatised permanent teeth, who were attending a UK dental hospital, completed questionnaires at baseline and at a 6 month follow-up. Child questionnaires assessed coping styles, social support, and quality of life outcomes. Parents were also asked to complete questionnaires, which assessed previous stressors/strains on the family, social support, healthcare satisfaction, and family impacts. Data related to the child's dental injury were collected from clinical notes. Structural equation modelling and regression analyses were employed to analyse data. RESULTS: One hundred and eight children and 113 parents participated at baseline. Children's gender, coping style, social support, and family functioning significantly predicted children's oral health-related quality of life. Parents' satisfaction with their children's dental care significantly predicted parental quality of life outcomes. Children's close friend support and healthcare satisfaction remained significant predictors of positive outcomes at follow-up. CONCLUSIONS: The findings revealed important psychosocial factors that influence child and family adaptation to childhood dental trauma.

The INCENTIVE protocol: an evaluation of the organisation and delivery of NHS dental healthcare to patients-innovation in the commissioning of primary dental care service delivery and organisation in the UK.

INTRODUCTION: In England, in 2006, new dental contracts devolved commissioning of dental services locally to Primary Care Trusts to meet the needs of their local population. The new national General Dental Services contracts (nGDS) were based on payment for Units of Dental Activity (UDAs) awarded in three treatment bands based on complexity of care. Recently, contract currency in UK dentistry is evolving from UDAs based on volume and case complexity towards 'blended contracts' that include incentives linked with key performance indicators such as quality and improved health outcome. Overall, evidence of the effectiveness of incentive-driven contracting of health providers is still emerging. The INCENTIVE Study aims to evaluate a blended contract model (incentive-driven) compared to traditional nGDS contracts on dental service delivery in practices in West Yorkshire, England. METHODS AND ANALYSIS: The INCENTIVE model uses a mixed methods approach to comprehensively evaluate a new incentive-driven model of NHS dental service delivery. The study includes 6 dental surgeries located across three newly commissioned dental practices (blended contract) and three existing traditional practices (nGDS contracts). The newly commissioned practices have been matched to traditional practices by deprivation index, age profile, ethnicity, size of practice and taking on new patients. The study consists of three interlinked work packages: a qualitative study to explore stakeholder perspectives of the new service delivery model; an effectiveness study to assess the INCENTIVE model in reducing the risk of and amount of dental disease and enhance oral health-related quality of life in patients; and an economic study to assess cost-effectiveness of the INCENTIVE model in relation to clinical status and oral health-related quality of life. ETHICS AND DISSEMINATION: The study has been approved by NRES Committee London, Bromley. The results of this study will be disseminated at national and international conferences and in international journals.

The role of illness beliefs and coping in the adjustment to dentine hypersensitivity.

AIM: Dentine hypersensitivity is a common oral health problem, however, there has been little research on how people cope with this condition. This study aimed to quantify the effects of illness beliefs and coping strategies on the health outcomes of individuals with dentine hypersensitivity. MATERIALS AND METHODS: Participants were purposively sampled from students and staff in one large UK University and 101 self-diagnosed dentine hypersensitivity sufferers participated in the longitudinal study. Participants were required to complete questionnaires which assessed health anxiety, specific illness beliefs (control, consequences, illness coherence, timeline perspectives and emotional representations), coping strategies (passive and active coping) and oral health-related and health-related quality of life (OHRQoL and HRQoL) at baseline and 1 month follow-up. RESULTS: Over half of the participants (N = 56) experienced sensations in their teeth on a daily basis and the majority had experienced dentine hypersensitivity for at least 1 year (N = 87). Structural equation modelling indicated that predictors of OHRQoL and HRQoL impacts at follow-up were frequency of sensations, low levels of illness coherence, negative emotional representations, greater health anxiety and use of passive coping strategies at baseline. CONCLUSIONS: Illness beliefs and coping strategies predict oral and health-related quality of life outcomes in people with dentine hypersensitivity.

Assessing children's dental anxiety: a systematic review of current measures.

The reliable assessment of children's dental anxiety can have many benefits for the dental team, service providers and dental public health practitioners. This study aimed to identify and evaluate self-report measures, which are available to assess children's dental anxiety. Systematic searches of the literature between 1998 and 2011 were conducted to identify relevant studies. The properties of each measure (reliability and validity) were assessed, and measures were evaluated against a theoretical framework of dental anxiety. Executing the search strategy generated 498 articles and of these 60 studies met all of the inclusion criteria. Seven 'trait' and two 'state' measures of dental anxiety had been employed to assess children's dental anxiety over the past decade. Reliability and validity estimates for the most widely used measures were good; however, many questionnaires had a limited focus in the aspects of anxiety they assessed. The paper summarizes the measures of children's dental anxiety which may be most useful for a number of different purposes and populations.

Parental quality-of-life impacts following children's dento-alveolar trauma.

BACKGROUND/AIM: The aim of this longitudinal study was to investigate the impacts of children's dental injuries on parents and explore how demographic, clinical and psychosocial characteristics influence parental adaptation to dental injuries over time. MATERIALS AND METHODS: A total of 244 families attending a UK-based Dental Hospital, for management of their child's traumatized permanent teeth, were invited to participate. Clinical information relating to the child's injury was collected from patient notes. Self-report questionnaires collected baseline information on children's oral health-related quality-of-life (OHRQoL), parental satisfaction with dental treatment and parental health-related quality-of-life (HRQoL) and worry. Parental outcomes were assessed again at a six-month follow up. RESULTS: 108 children and 113 parents participated in the baseline study (44% and 46% response rates), and of this group, a total of 73 parents completed follow-up questionnaires (65% response rate). Parents reported improved HRQoL at follow up; however, parental worry did not decrease over time. Parental satisfaction with treatment and children's OHRQoL were the only significant predictors of parental HRQoL at the six-month follow up. CONCLUSIONS: The findings highlight the inter-relationship between child and parental outcomes following their children's dental injuries and the importance of the dental team delivering a family-centred approach for the management of their children's dental injuries.

What influences the use of dental services by adults in the UK?

OBJECTIVES: Optimizing access to and utilization of dental services remains a major public health challenge. The aim of this study was to use Andersen's behavioural model to investigate the factors that influence utilization of dental services and predict oral health outcomes, and to identify how access could be improved. METHODS: Secondary analysis was conducted of data from a regional postal survey (n = 10 864) of adults in the UK. Items were chosen to reflect variables of Andersen's behavioural model including predisposing characteristics (deprivation), enabling resources (perceived difficulty accessing a dentist), need (perceived treatment need), health behaviours (reason for attendance and time since the last visit to the dentist) and oral health outcomes (oral health impacts (symptoms, functional limitation and social) and global oral health). Structural equation modelling was used to estimate the direct and indirect pathways between the variables within the model. RESULTS: When a combination of indirect and direct effects were taken into account, perceived difficulty accessing the dentist was associated with higher perceived treatment need (ß = 0.25, P < 0.01), increased oral health impacts (ß = -0.23, P < 0.01) and worse global oral health (ß = -0.21, P < 0.01). Overall, the variables included within this model explained 17.4% of the variance for dental attendance, 55.4% of the variance for the length of time since people had last visited the dentist, 21.7% of the variance for oral health impacts and 42.9% of the variance for people's global oral health. CONCLUSIONS: Perceived treatment need and difficulty accessing dental services were found to be key predictors of oral health outcomes. Further research is needed to develop and evaluate effective interventions to improve access to dental services.

Understanding children's dental anxiety and psychological approaches to its reduction.

BACKGROUND: Dental anxiety is a common problem, which can affect people of all ages, but appears to develop mostly in childhood and adolescence. Childhood dental anxiety is not only distressing for the child and their family but is also associated with poor oral health outcomes and an increased reliance on costly specialist dental services. AIM: This article will consider the prevalence, development, and implications of children's dental anxiety. It will also discuss the opportunities for and challenges of psychological approaches such as cognitive behavioural therapy aimed at the reduction of dental anxiety in children.

Quality of life impacts following childhood dento-alveolar trauma.

BACKGROUND: Dental injuries occur commonly in childhood and may necessitate demanding courses of treatment. The aim of this study was to investigate a variety of clinical and demographic factors that may influence the quality of life impacts experienced by children after a dental injury. METHOD: A total of 244 children who attended a UK dental hospital, for management of traumatised permanent incisors, were invited to participate in the study. Clinical, demographic and psychosocial variables were collected at baseline, and outcome variables were assessed again at a 6-month follow up. Clinical variables included number of teeth injured; severity of the dental injury; visibility of the injury; time since injury; and number of dental appointments attended within the hospital. Psychosocial outcomes assessed included children's oral health-related quality of life (OHRQoL) and health-related quality of life (HRQoL). RESULTS: One hundred and eight children participated in the baseline study (44% response rate), and of this group of children, a total of 70 children completed follow-up questionnaires (65% response rate). The results indicated that the most affected areas of children's OHRQoL and HRQoL were functional limitations and school-related activities, respectively. Of all the demographic and clinical variables, which were investigated within the current study, the only variable that significantly predicted OHRQoL and HRQoL for children was gender. Boys were found to report fewer impacts on their OHRQoL and HRQoL than girls. Interestingly, over two-thirds of children reported fewer impacts at the 6-month follow up. CONCLUSIONS: The results revealed that girls were more likely to report higher level of impacts on their OHRQoL and HRQoL than boys following traumatic injury to their permanent incisors. Clinical variables were not significant predictors of child quality of life outcomes following dento-alveolar trauma at baseline or at the 6-month follow up.