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Adolescent dental patients pose a unique challenge to providers, particularly when intravenous sedation is introduced to the treatment plan. Surveys show many adolescents are afraid of the dentist. Five to six per cent overall are fearful of dental injections and may avoid care or have irregular attendance. At the same time, adolescents may assert their independence by refusing to cooperate with providers’ and parents’ requests even while accepting that the goal of better health is reasonable. Successful treatment of – and rapport with – the adolescent dental patient, however, can ensure that adolescents’ oral needs are met. Successful providers recognise that adolescents alternate between childlike and mature coping strategies during the course of dental treatment. Identifying an adolescent’s current coping style can help the dental team select appropriate strategies to help treatment proceed more smoothly for the adolescent and clinical team. Working with adolescents’ individual coping styles, rather than expecting consistently adult behaviour, will ideally help decrease frustration and improve treatment outcome.
Adolescents are a challenging dental patient population, particularly when intravenous sedation is proposed as part of the treatment plan. Prior research has suggested that fear of both dental and medical injections occurs in approximately 15% of adolescents, with 5–6% of adolescents avoiding dental and medical care because of injection fear.1 Because adolescents are no longer children, but not yet adults, dental providers must often modify their interaction styles in order to gain adolescents’ cooperation. Behaviour management strategies used for children typically are not developmentally appropriate, yet dental providers who assume that all of their adolescent patients may be treated as adults may find themselves with non-cooperative patients. In short, adolescents may display a much wider variety of behaviour, compared with that of younger children. This paper presents some considerations for what makes some adolescent patients difficult to treat, followed by some brief case examples, and then concludes with suggestions to improve cooperation in this patient population.
The presence of dental fear in some adolescents has been noted in a number of studies.2–4 A recent summary of population-based studies conducted in a variety of countries around the world estimated that 9% of children and adolescents experience dental fear.5 Common fears include the dental injection, drilling and choking.6 In the UK, fearful patients may comprise the greatest number of child and adolescent patients seen in speciality dental clinics. For example, clinicians in Glasgow reported that behavioural management problems were the most common reason for referral to a child and adolescent speciality clinic, occurring in one-third of the patients referred.7 In a different study, clinicians in Newcastle reported that one-fifth of the referrals were due to behaviour management problems, more than for any other reason.8 While management techniques for fearful children and adults have been described in the literature (e.g. Milgrom, Weinstein & Getz)9, less has been written about working with fearful adolescents. In this paper, we propose that a developmental model of adolescence that focuses on cognitive and emotional development may provide additional insight into the nature of adolescent fear and coping with the dental situation.
One of the hallmarks of adolescence is the gradual shift in cognitive style from one focusing on concrete objects and events to one marked by the increased use of abstract thinking, in a set of cognitive skills and styles Piaget termed ‘formal operational thinking’.10–11 Formal operational thinking permits adolescents to think of possibilities, rather than just ‘what actually is’.12 For example, some adolescents may be able to imagine what it would be like to receive dental treatment with little or no fear, rather than assuming that dental treatment will always be frightening and traumatic. A second hallmark of this advanced set of cognitive abilities is the ability to formulate and test hypotheses using formal logical methods,11 rather than employ the trial-and-error methods of younger children. For example, an adolescent who realises that his/her fear is exacerbated by worry that he/she ‘won’t be able to cope’ can then logically deduce: ‘If I could cope better, then I wouldn’t get so frightened’.
Despite the ability to use formal logic in many instances, sometimes adolescent thinking can be less logical. Adolescents tend to have a ‘sense of invincibility’, believing that they are immune from the logical outcomes of certain events. This is thought to be one of the primary reasons why some adolescents engage in risky or unhealthy behaviours, as they claim that the possible negative outcomes, such as severe dental disease, ‘can’t happen to me’.13–14
Health attitudes and behaviours of adolescents undergo a transformation during this period of growth. The attitudes and behaviours of younger adolescents are largely influenced by current wants and needs, likely related to the sense of ‘invincibility’ in that long-term consequences are less likely to be considered. However, by late adolescence, adolescents have a better sense of time, and therefore may modify their health opinions and behaviours to be more aligned with long-term outcomes they value.15 For example, older adolescents may be more likely than younger adolescents to respond to the rationale: ‘You should have your tooth fixed now so that it doesn’t cause you pain later on’.
One of the primary tasks of adolescence is the development of an individual sense of identity.16 Parents and dentists need to recognise the adolescent’s need to operate independently, while at the same time permitting him/her to depend on parents or other adults for nurturance, guidance and support. Disagreements with parents are common, especially in early adolescence,17 and thus the exercise of adolescent independence is often frustrating to parents and other authority figures.18–19 As a result, adolescent dental patients may respond in various ways to requests from dental providers and parents. In some cases, they may rely solely on parents and providers to make decisions for them regarding care, while in other cases they may behave illogically as they assert their independence by refusing treatment or being non-compliant.
Another developmental change occurring during adolescence involves conceptions and understanding of pain.20–22 Young children tend to define pain concretely (‘it hurts’). Adolescents are better able to define pain in more abstract terms, referring to the physiological and/or psychological nature of pain (with references to nerves, signals, the brain, etc., and/or to anxiety, suffering, and the like). Because children have had fewer painful experiences than adults, they tend to experience and rate less noxious stimuli as more painful than they appear to adults.23 Additionally, adolescents are able to conceive of pain as something that needs to be coped with, whereas young children describe pain as something they passively endure.21 Thus, adolescents are more likely to use a variety of cognitive coping mechanisms, such as distraction, information-seeking, problem-solving and positive self-talk, compared with younger children.20,22–24 In addition, because adolescents have a more complex understanding of pain, they are more likely to consider positive aspects of the otherwise stressful situation (‘I know that the dentist has to put a needle in my arm, so that I won’t feel it when she uses the drill to fix my tooth’), which can also help with coping.20
Despite the ability to successfully use coping skills, adolescents – like younger children – are also likely to engage in strategies that increase anxiety, such as worrying or focusing on fear.25–26 It appears that many adolescents make negative self-statements (e.g. ‘This hurts, I hate shots’) and other anxiety-increasing responses when stressed (e.g. focusing attention on increased heart rate and concluding that the situation is dangerous), while those who cope best utilise more helpful coping skills. As they grow, adolescents also are able to increasingly inhibit or cover up behavioural signs of distress, with boys more likely to suppress these behaviours compared with girls.20 Thus, an adolescent who appears calm outwardly may actually be feeling distressed internally. Finally, adolescents – like adults – may differ as to which situations are stressful, and may utilise different coping strategies in different situations. As a general rule, adolescents are more likely to use less effective strategies when their stress is greater.
During the initial evaluation, straightforward questions such as ‘How do you usually deal with stress at school, at home, or with friends?’ will help the dentist learn the extent to which the adolescent tends to use more mature (e.g. distraction, positive self-talk) vs. more concrete (e.g. attempting to flee the situation) coping strategies, as well as provide ideas for strategies that can be adopted for use in the dental setting. Adolescents who are able to identify and regularly use adequate coping strategies in their daily lives are usually able to translate these skills to the dental setting when coached to use them by the dental team. This will allow for an easy sedation when such treatment is dentally needed. On the other hand, many adolescents have not developed adequate coping skills by the time they arrive in the dental office and have been impossible to treat in a typical surgery. In these cases, sedation will be less stressful for the patient, and less difficult for the clinician, if the dental team is able to teach the adolescent new coping skills. However, as described above, there may be developmental factors that make it more difficult for the adolescent to learn and use more mature skills.
The following three cases describe adolescents who received intravenous sedation as part of their treatment at the Dental Fears Research Clinic at the University of Washington in Seattle. In each case, the adolescent presented with few mature coping skills. In the first two cases, the adolescent needed curative dental treatment quickly and thus we describe the challenges that these adolescents posed to us. In the third case, there was no immediate need for extensive treatment and thus we were able to allow the adolescent time for development. Additional treatment recommendations are summarised in Table 1.
Twelve-year-old Bonnie, an overweight young adolescent, had many carious teeth and needed numerous restorations. Since she expressed no interest in overcoming her fear of dental injections and her dental needs were great, she was scheduled to receive all of her dental treatment in a single clinical session under sedation. When asked what she did in other stressful situations, Bonnie shrugged and could not answer. Her mother said that she liked to look at comic books and magazines. Bonnie appeared calm and not very interested when the dental team explained the procedures to her. Once treatment began, she extended her arm as requested and sat quietly as the Emla cream (2.5% Lidocaine, 2.5% Prilocaine; AstraZeneca Pharmaceuticals LP, Wilmington, Delaware, USA) was applied. Then she sat in the waiting room for the cream to begin working. Back in the dental chair she became visibly anxious as the dentist attempted to cannulate the vein. Bonnie was hypovolemic and the veins were hard to see because of the blanching caused by the cream. When the dentist was unsuccessful in her first attempt, Bonnie turned her head and stared at the needle and the injection site on her arm. Her eyes were wide. The dentist calmly told her to look away, but she continued to stare. However, she continued to extend her arm. On the second try Bonnie stiffened and pulled her arm away. The dentist gently and matter-of-factly explained that it would be easier for her if she looked away, but Bonnie stared fixedly and appeared to become even more anxious, but did not try to escape.
At this time, the dental nurse remembered that Bonnie had been looking at magazine pictures of female movie stars wearing fancy dresses while she was in the waiting room. Upon hearing this, the dentist asked the nurse to get the magazine. At the dentist’s instruction, the nurse brought the magazine into the treatment room and held it in front of Bonnie’s eyes, opened to a page of the stars in dresses. The nurse animatedly described one of the dresses in the photographs and then asked Bonnie to state which dress was her favourite. Bonnie’s stiffness relaxed as she answered. While continuing to describe the dresses, Bonnie calmly allowed the dentist to move her arm back into position and to palpate and successfully cannulate a vein. There was no pain because of the Emla cream.
In retrospect, Bonnie’s initial calm demeanour probably hid some degree of internal distress. When the initial attempt to place the needle did not succeed, Bonnie quickly ran out of reserves and became overcome by distress. The dentist directed her to use distraction (to look away) and included an explanation as to why this would be helpful. However, Bonnie was unable to do this on her own. It was only when the nurse introduced direct distraction by placing the magazine in front of Bonnie’s eyes and asking her questions about what she saw that Bonnie was able to take her eyes and mind away from the needle. Bonnie’s failure to utilise distraction on her own was probably also related to her relatively young age.
This case also illustrates the need to consider the merits of using topical anaesthesia to help adolescents tolerate the discomfort of cannulation, particularly when more than one attempt to place the needle becomes necessary. While the Emla cream blanches the tissue and sometimes makes it hard to see the vein, the additional difficulty for the dental surgeon may be preferable to dealing with the upset caused by additional cannulation attempts without numbness. Because of their youth, adolescents may not have had previous experience with intravenous cannula placements and therefore there may not be information in the medical history to predict whether they may be difficult to cannulate. While Bonnie was not obese, she was overweight, and therefore in retrospect was at higher risk for needing additional attempts before cannulation was successful.
Emily, aged 14, was referred by her dentist and first came with her mother to our clinic because of fear of both medical and intraoral injections. Her mother reported that when the referring dentist attempted to complete the one filling that Emily required, Emily ‘wouldn’t let the procedure happen’, refusing to proceed due to her fear. The possible need for sedation was frustrating to the dental team, because sedation for a single filling is hardly cost-effective in the US system.
During the initial evaluation, Emily refused to speak or make eye contact with members of the dental team, deferring all questions to her mother. She was unable to identify any coping skills she used to deal with stressful events; her mother, however, noted that Emily enjoyed talking with friends on the telephone and computer as well as listening to music. When not in her mother’s presence, Emily was willing to discuss her love of movies, and tolerated the initial dental examination without difficulty. Although Emily appeared to cooperate with all steps designed to help her overcome her fear and have treatment without sedation, she seemed emotionally disengaged as though she were ‘just going through the motions’. She also expressed frustration with her mother’s encouragement (repeating, ‘Mom, stop pushing me to do this!’), yet refused to take part in any of the treatment steps without her mother present.
After several sessions of rehearsing the injection process, Emily ultimately refused to receive an intraoral injection. To avoid having the tooth abscess because of delays, intravenous sedation was recommended. Emily was initially hesitant to proceed with this option due to her fear of medical injections. However, when it was explained that we would provide an oral sedative medication prior to the cannulation, Emily agreed.
Emily’s mother, somewhat frustrated at her daughter’s refusal to accept treatment without sedation, told the dental team (with Emily in a separate room), ‘We only have one chance at this’, as she thought that Emily was not likely to agree to return for more than one appointment. After conversations with both of her parents and the entire dental treatment team (including the anaesthetist), it was decided that deception would be used. Emily would be told that the appointment would be a practice of the placement of the cannula without any poking, and that she would be given a liquid to drink (oral midazolam syrup; Roche Pharmaceuticals, Nutley, New Jersey, USA) that would make her feel sleepy, much like what would happen on the day of treatment. It was planned to use the anterograde amnesia caused by the midazolam to allow the dental team and Emily’s mother to suggest to Emily that she remained calm enough to allow the IV sedation to proceed ahead of schedule.
At the appointment, Emily drank the midazolam (0.5mg/kg) without protest and engaged in a conversation with her mother and the dental nurse about movies while sitting in the dental chair. With her mother in the treatment room, the dental anaesthetist then administered intramuscular ketamine (2mg/kg IM; Bristol-Myers Squibb, Princeton, New Jersey, USA) mixed together with the antisialagogue glycopyrrolate (0.05mg IM; Baxter Healthcare Corporation, Round Lake, Illinois, USA) without any advance warning, which allowed the successful placement of the IV and completion of the dental treatment with a minimal adjunctive use of intravenous midazolam.
After treatment, Emily’s mother reported that her daughter did not recall anything about the appointment after the time when they were discussing movies with the dental nurse. Emily’s mother told her that, because she was coping so well with sitting in the dental chair, it had been decided to move ahead with the sedation ahead of schedule. Emily reportedly was very relieved that the dental treatment was completed, as well as happy that she had coped well with treatment. The retrograde amnesia provided by the medications allowed Emily’s mother to suggest that Emily remained calm and allowed the IV sedation to proceed.
While Emily was superficially cooperative with the initial attempts to help her overcome her fear, she was ambivalent about having her mother present in the surgery. She required that her mother be present, yet would complain that her mother was ‘getting in the way’ with her suggestions and encouragement. It is possible that Emily’s refusal to receive an intraoral injection reflected rebellion against the wishes of authority figures (i.e. her mother and the dental team), or alternatively reflected an overwhelming of her age-limited coping skills. By relying on her mother’s presence during rehearsals, Emily was not required to use or develop any of her own coping skills.
Fifteen-year-old Richard was referred to us because he had a history of severe anxiety about situations involving authority figures, secondary to having experienced physical trauma from an older relative who had been living in the home. While Richard was very quiet with us initially, the dental nurse noticed that he was willing to cooperate with her while waiting for his mother, who was talking privately with the dentist. This cooperation led us to postulate that Richard might not be overtly negative towards dentistry and oral health per se. Nevertheless, he was passive when asked to articulate his dental (and other) goals, often demurring to his mother. However, we did learn that he tended to cope with stressful situations at school by gathering more information about the situation so that he didn’t feel overwhelmed – a sign of mature coping. We hypothesised that Richard’s normal development had become disrupted by the trauma he had experienced as a younger child. Fortunately, Richard had no serious oral problems and therefore we recommended waiting on any curative treatment at this point. Instead, we chose strategies to control disease progression, buy time, and permit his normal development to continue and mature.
In conjunction with frequent short visits for topical fluoride treatments by the dental nurse to control caries, we actively searched for ways to engage him about his areas of interest and accomplishments that would help build a rapport and nurture a positive view of the dental team and dental care. For example, we learned he was planning a science trip at school, and asked him to tell us why he had chosen to go. Later, we asked him to bring photographs of the trip, and then engaged him in further discussion about his choice of subjects to photograph. These conversations – coupled with games – took place over a number of visits, during which the nurse monitored his oral status. During this time he began to take an interest in cleaning his teeth better.
As we had hoped, Richard’s dental anxiety diminished. In addition, his self-assertiveness increased in appropriate ways. For example, shortly after his first appointment in our clinic, Richard had been referred for orthodontic care, which he initially accepted passively (‘I’m here because my mom wants me to’). When orthodontic treatment began a year later, he delighted in making choices of which colour elastics to have placed, selecting colours that referred to sports teams or the current season. While his mother sometimes rolled her eyes at his choices, she recognised that this was really minor and supported his sometimes humorous attempts at achieving autonomy.
Two years after beginning treatment in our clinic, Richard’s increased maturity and cognitive development were evidenced when he was scheduled for orthognathic surgery. He elected to make a separate appointment with the surgeon to view an information video about these procedures, discussed with his mother the benefits of the procedure and also how he would handle his fears, and made some decisions about how to best handle the cannulation. He requested his mother’s presence during the cannula placement (which the anaesthesiologist accepted), and his mother reported that Richard calmly accepted the preparation while thinking about playing soccer. He successfully completed the entire procedure, demonstrating mature coping strategies such as information-seeking, problem-solving, and distraction.
This case presents an example of an adolescent who is fearful but has no urgent dental problems. In such cases, we frequently use topical fluoride treatments intensively to arrest/prevent caries and buy time for adolescent maturity to develop naturally. Whenever possible, we try to defer invasive treatments until such time as the adolescent has developed more mature coping methods.
Dentists using sedation with adolescents should be aware of the complex cognitive and emotional transitions that occur during this time. Adolescents may alternatively be concrete and abstract in their thinking during this transition. To this end, dental providers must be prepared to provide both very structured coping directives (e.g. looking away from the IV site) for patients who are more concrete in their thinking while instructing more abstractly thinking adolescents to use their own coping strategies. Table 1 includes some common challenges with this population and suggested recommendations.
While establishing rapport is important with all patients, it is particularly critical that the dental staff engage with adolescent patients to make the patients ‘part of the team’. Simple steps, such as taking time to learn about the adolescent patient’s interests, hobbies, and even dislikes, will help the adolescent feel more valued and understood. Additionally, the dentist should have conversations with the adolescent directly (rather than relying purely on parental report, if at all possible) about his/her concerns about dental treatment. Most adolescents will respond to simple requests to open their mouths, allow the application of topical fluoride, and the like. These cooperative efforts should be praised, which will help build rapport and lay the groundwork for cooperation with future treatment.
Successful completion of dental treatment with sedation can be presented to the adolescent patient with extensive tooth decay as a chance to ‘wipe the slate clean’ and begin again with an opportunity to begin a sound oral healthcare regimen. Talking with adolescents about what they are and are not willing to do (e.g. using toothpaste, fluoride rinses, chlorhexidine rinses or gel, or to floss at home), rather than giving them an extensive list of instructions from the ‘authority figure’, will increase the likelihood of at-home compliance. As adolescents are continually developing to become more independent and future-oriented, they are likely to take increasing responsibility for their healthcare habits. Adolescence, therefore, can be an ideal time for dental providers to help patients establish long-term preventive oral health practices.
This manuscript was supported by grants DE016952 and T32DE07132 from the National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Maryland, USA as well as support from the Society for the Advancement of Anaesthesia in Dentistry (SAAD), London.
These two papers describe various positive and negative self-statements and other behaviours that fearful and non-fearful adolescents use in the dental situation:
Brown JM, O’Keefe J, Sanders SH, Baker B. Developmental changes in children’s cognition to stressful and painful situations. J Pediatr Psychol 1986;11:343–357.
Prins PJM. Self-speech and self-regulation of high- and low-anxious children in the dental situation: An interview study. Behav Res Ther 1985;23:641–650.
This book describes adolescent development in detail, as well as how to tailor health-promotion interventions to this population according to their level of development:
Breinbauer C, Maddaleno M. Youth: Choices and Change: Promoting Healthy Behaviors in Adolescents. Washington, DC: Pan American Health Organization; 2005.
Trilby Coolidge, Dental Public Health Sciences, Box 357475, University of Washington, Seattle WA 98195.
Lisa J. Heaton, Dental Public Health Sciences, Box 357475, University of Washington, Seattle WA 98195.
Peter Milgrom, Department of Sedation and Special Care, King’s College Dental Institute, London.