Many small children do not receive proper dental care or, indeed, any dental care. Dental care for children should be of great interest to the population at large, as untreated dental caries in preschool can create further, more expensive to repair dental deficiencies, as well as health hazards due to untreated caries. Those adults with a history of poor dental care risk losing teeth at an early age, thereby compromising their nutritional status.

Dental caries can also be a source of infection and place the person at risk for the spread of infection to other organs. A review of the relevant literature allows us to identify through current research the causes of poor dental care among children and what treatments have been studied to enhance dental care for children.

Despite a lack of dental treatment for small children, there is overall widespread concern, as well as many published attempts to identify psychological causes and find solutions which will ensure appropriate dental treatment at an early age. The concern is global. For example, besides the United States, research has been conducted in the Netherlands (Weerheijm et al, 1999), Poland (Ilieva, 1999), Canada (Haas et al, 1996), Finland, Israel (Peretz & Gluck, 1998), Great Britain (Hosey & Blinkhorn, 1995), Japan (Mitome et al, 1997), Turkey (Akyuz et al, 1996), Spain (Boj & Davila, 1995), France (Rousset et al, 1997) and Sweden (Klingberg et al, 1995).

In the United States many books have been written for children in order to promote early dental hygiene through early education by alleviating fears. Interaction between parent and child through these books may alleviate fear passed from parent to child. Newman (1997) states, “adults, particularly parents, should serve as role models for their children.” Several articles imply that good parenting and education can stop dental fear and promote dental compliance.

Price and Vaughn (1999) studied child care centers as a source of good dental care promotion through educational workshops conducted for staff. Their conclusion was the staff could make significant inroads into good dental health through continuous dental health programs and educational workshops.

Other pertinent literature has identified solutions for children’s anxiety and fear of the dentist. Nathan (1995) designates behavior management with strategies to enhance self esteem and foster a positive attitude as the best way to persuade the child to accept care.

Some countries have established special clinics to study the cause of dental fear in children and methods to treat the fear and to promote adequate treatment. In the Netherlands, ten Berge et al, (1999) conducted studies at a special dental care clinic established for children who have very high levels of fear, and also to study their behavior. It was found that children with extremely high dental fears also have other behavioral and emotional problems. Those with developmental delays, as well as behavioral and emotional problems, are among the populations studied with the greatest lack of dental compliance.

In Sweden, those children with severe dental fear and avoidance of treatment are referred to the Dental Fear Clinic in Gothenburg. Besides the high frequency of missed or cancelled appointments, studies there indicate other problem behaviors in many of the children identified with dental fear, as well as a relationship between dental fear in parents and children (Klingberg et al, 1992).

Due to widespread interest in the causes of dental fear, many instruments have been developed to use in research studies. A well known and often used instrument for assessing dental fear with acceptable reliability and validity is the Children’s Fear Survey Schedule (CFSS-DS). The Dutch and Finns have used this instrument and found the single most common fear is related to invasive treatment aspects ten Bergs et al, 1998).

A study by Hosey and Blinkhorn (1995) evaluates four instruments to assess the behavior of anxious child dental patients in order to accurately study dental fear. The scales were used to assess anxious children during dental treatment. They are the Frankl, Houpt, Visual Analogue, and Global Rating scales. An interdisciplinary team, two authorities in the management of anxious children and four dentists, evaluated the scales. While close argument was found on the Visual Analogues and Houpt scales, it was not so with the Frankl scale. The Global rating Scale indicated significant correlation between it and the other three scales. It is obvious from the plethora of instruments to study psychological causes of fear that the conventional wisdom leans in the direction of fear as a major cause of dental anxiety and poor compliance. It is certainly the most studied aspect.

Studies involving drugs such as midazolam for conscious sedation have not clearly given us answers to drug therapy for anxious children (Hass et al, 1996) and its use in promoting good dental hygiene. In Israel, Peretz and Gluck (1998) profess that nitrous oxide benefits are overwhelmed by subsequent visits and fear rendering the drug unhelpful to control fear and increase compliance. Reinemer, Wilson and Webb (1996) conducted studies measuring psychological and behavioral aspects of fearful patients following 4 mg. and 8 mg. ketamine-diazepam administration prior to dental procedures. While the larger dose was more efficacious, it is unclear whether the overall benefit was worth the risk to the patients.

Yasane et al, (1996) studied the effects of home administered oral diazepam prior to dental treatment. The authors concluded the 0.3 mg/kg dosage was safe and an effective treatment for children of approximately three years and eight months. Lu et al (1994) used a retrospective study to evaluate the efficacy of IM injections with ketamine, meperidine/promethazine, and midazolam. The results indicated a good safety and efficacy rating from clinicians and patients for controlling fears.

In 1996, a study by Haas et al, reviewed the use of chloral hydrate, a long used drug, and the newer drug midazolam. Neither was superior for controlling dental fear and the authors called for further studies. Conversely, Duncan et al (1994) touts chloral hydrate as the ideal drug for safety and effectiveness.

Many more efficacy studies in relation to age and level of fear are needed in order to identify those drugs which most successfully control fears. Many are established as safe, but the evidence for efficacy is scattered, unorganized and inconclusive. General anesthesia, while efficacious, is considered as a last resort for treatment due to safety concerns (Seheult et al, 1993).

Very little of the relevant literature on the subject is directed at combination therapy. Lu (1994) promotes the use of hypnotherapy and ketamine. Lu found this combination successful, but it must be noted the population was one with a history of violent reactions to dental treatment and may not be meant for all. Future studies of combination therapies, drugs and psychological treatments, could illuminate useful therapies.

While it is interesting to note that fear is often studied as the major cause of poor dental treatment among children, other important causative factors need further research. Economic status and access to affordable delivery care systems as such factors have not been adequately studied and researched. It is much easier to identify a solution to a child’s fears than it is to solve the economic problems of a whole society or culture. Studying dental fear in children is easily applied to modern psychological theory, while correcting the economic inadequacies of a culture, and the effect of it on dental care in children, is not easily, lightly, or often undertaken.

The identification of other causative factors besides fear could promote comprehensive dental treatment and management. Methods of dental care delivery for those who are economically challenged have uncovered a population, not fearful, but lacking in resources. Transportation, money to pay fees, and distance may be constraints on the poor, which if solved could promote better dental care. Other characteristics of poor, transient populations, such as frequently changing addresses, telephone numbers, and employers, as well as changing insurance and coverage, contribute to poor dental health. Non-psychological causes of non-compliance with dental care regimes have identified all the same problems which plague the poor, i.e. lack of ability to pay, transportation to adequate care sites and the general unstable lifestyle which often accompanies poverty. Those same delivery system problems which make adequate general medical care prohibitive for the poor also have an impact on dental care.

Studies reveal there are two major areas, psychological and economic, which cause poor dental care. Psychological causes of poor dental care among children include the fear and anxiety which lead to noncompliance. The most prevalent fear is of “invasive treatments”. Populations at high risk include those with developmental delays, behavioral and emotional problems (ten Bergs et al, 1999). Klingberg and Berggen (1992) have studied the relationship between dental fears in parents and children. If the parent is frightened and noncompliant, so it follows, the child will be the same.

After reviewing the compilation of material on children and dental care, it is clear the answer to improved pediatric dentistry lies within an interdisciplinary and holistic approach. Individuals must be viewed as such, and appropriate solutions for each individual implemented, be they psychological, economic or social. A thorough assessment by the health care provider will indicate if the source of the problem is psychological, economic, or a combination of both. Treatments by the appropriate discipline will result in enhanced compliance with dental appointments, regimes and treatments. Behavior management, education, “good parenting”, role models, drugs, general anesthesia and hypnotherapy are have all been identified as possible ways to improve dental care for small children by controlling fear.

A combination approach to treatment may be more successful for many as the cause of their dental dilemma may be both psychological and socio-economic. A wise clinician may use behavior modification, drugs and education in order to promote the best outcomes. The relevant literature suggests that family practice settings may well be helpful to initially identify problems and coordinate solutions. Pediatric dentists, who bring special expertise to this area, are not prevalent enough to solve the problem of inadequate dental care among children.

Future studies may best be managed by interdisciplinary teams which cover all the aspects, psychological, economic and sociological. Certainly, there is a need for more studies to evaluate the best approaches to solving the problem. Varpio and Wellfelt (1991) studied children referred to a pedodontic clinic and acceptance outcomes for dentistry over five years. A positive attitude was fostered through the use of a special clinic. The results indicated the high rate of acceptance of dental care by the children over time was due to the early intervention. Hypnotherapy was the only treatment which came close to an alternative medical approach identified in the literature for dental concerns.

On a larger scale, economic solutions may be implemented to aid groups of individuals who are at risk or already lacking in dental services. The focus of these dental solutions will be based on the concept of persons belonging to a group and in need as part of a subculture. Social programs may target children, persons with incomes below a certain level, geographic location, and access to services or special needs populations such as those with developmental delays.

Brown et al (2000) point to a decline in untreated children, which is a positive sign for improved dental health. Improved methods for preventing dental caries such as fluoridated water, dental sealants and early intervention are resulting in generation of children who do not suffer with caries as children have in the past. It is projected that many will enjoy a level of dental health in the future that has not been known in the contemporary world.

As usual, the answer to a large widespread problem is never simple and direct. Pediatric dentists in combination with specialists in psychology can be invaluable in promoting the best therapies for fearful patients. Socially speaking, the legislator may provide the best relief for economic concerns. Social change can be influenced by those who take the time to study the issues and bring it to the attention of those in a position to implement such change.

References

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