Clinical Psychology Review 55 (2017) 25–40

Contents lists available at ScienceDirect

Clinical Psychology Review

journal homepage: www.elsevier.com/locate/clinpsychrev

Review

Dental anxiety: An understudied problem in youth MARK

a,⁎ a a b
Laura D. Seligman , Joseph D. Hovey , Karina Chacon , Thomas H. Ollendick
a
Department of Psychological Science, The University of Texas Rio Grande Valley, Edinburg, TX 78539, USA
b
Child Study Center, Department of Psychology, Virginia Tech, Blacksburg, VA 24060, USA

A R T I C L E I N F O A B S T R A C T

Keywords: Dental anxiety and dental phobia typically emerge during childhood; the associated avoidance of dental care can
Dental anxiety result in oral health problems and is associated with lower quality of life. In this review, we discuss the definition
Dental phobia of dental phobia and dental anxiety and issues related to their differentiation. We then review the literature on
Specific phobias dental anxiety and dental phobia, including its prevalence, assessment, and sequalae. Moreover, we provide a
synthesis of findings on the etiology and maintenance of dental phobia and propose a comprehensive cognitive
behavioral model to guide further study. We also present a systematic qualitative and a quantitative review of
the treatment literature, concluding that although we have made strides in learning how to prevent dental
anxiety in youth, the methods effective in preventing anxiety may not be equally effective in treating youth with
dental phobia. We propose a multidisciplinary approach, including those with expertise in pediatric anxiety as
well as pediatric dentistry, is likely required to move forward.

1. Introduction dental phobia is classified as a specific-phobia and, more precisely,

under the blood-injection-injury (BII) phobia type (American
Dental fear in youth is often considered to be developmentally Psychiatric Association, 2013). The appropriateness of the BII specifier,
normative. However, when developmentally appropriate fear gives way however, has been called into question because of several distinctions
to significant dental anxiety or dental phobia, the resulting avoidance between those with dental phobias and other BII phobias. For example,
has the potential to impact a child's health status. In this review we first anxiety sensitivity seems to be a significant part of the clinical picture
define and describe dental anxiety and dental phobia and discuss the for those with BII phobias, but this is not reported to be the case for
classification of dental phobia in DSM 5 (American Psychiatric those with dental phobia (Kılıç, Ak, & Ak, 2014), although it should be
Association, 2013). We then review the evidence of the prevalence, noted that the data here are mixed (Liddell & Gosse, 1998; Locker,
assessment, and impact of dental anxiety and dental phobia as well as Shapiro, & Liddell, 1997). In addition, patients with dental phobia often
the literature on its etiology and maintenance – presenting an inte- report more anxiety pertaining to other dental stimuli (e.g., the sound
grated cognitive behavioral model to guide future research. Finally, we of a drill, having a tooth extracted) than to blood and injections per se;
provide a systematic qualitative and quantitative review of attempts to in fact, anxiety regarding blood seems to be relatively uncommon or
treat dental anxiety and phobia, with the aim of elucidating what we minor in individuals with dental anxiety (de Jongh et al., 1998; van
know about addressing this important problem and where we need to Houtem et al., 2014). Moreover, the onset of dental phobia appears to
go to improve the options we can offer youth affected by this condition. occur somewhat later than other BII phobias (Öst, 1987) and there is
some emerging evidence of different physiological reaction patterns
2. Definition and clinical picture between those with dental phobia and those with other BII phobias
(Leutgeb, Schäfer, & Schienle, 2011). Similarly, while there is comor-
Dental phobia is a persistent and excessive fear of dental stimuli and bidity of dental phobia and other BII phobias, it is not as high as would
procedures that results in avoidance or significant distress. Children be expected if these were one in the same and, when there is overlap, it
and adolescents with dental phobia may evidence disruptive behaviors seems to be explained by a diagnosis of dental phobia resulting from a
when undergoing examinations and treatment – ranging from fidgeti- fear of injections, but not other dental stimuli, during dental treatment
ness to full-blown tantrums; in the most extreme cases, youth with or as part of a more general clinical picture that includes multiple
dental phobia may refuse treatment even when experiencing significant phobias and anxiety disorders (Locker et al., 1997; Öst, 1992). In fact,
pain that could be alleviated with appropriate care. In the DSM 5, at least one study suggests that dental phobia is more strongly related to

⁎
Corresponding author.
E-mail address: [email protected] (L.D. Seligman).

http://dx.doi.org/10.1016/j.cpr.2017.04.004
Received 23 June 2016; Received in revised form 10 April 2017; Accepted 14 April 2017
Available online 19 April 2017
0272-7358/ © 2017 Elsevier Ltd. All rights reserved.
L.D. Seligman et al. Clinical Psychology Review 55 (2017) 25–40

fears that center on loss of control rather than medical fears per se portion of the population experiences significant distress related to
(Armfield, 2008). dentistry and importantly, both dental anxiety and dental phobia
Often, studies that investigate fear and anxiety related to dental appear to be related to negative consequences in both the short and
stimuli report on dental anxiety rather than dental phobia. Dental long term (Eitner, Wichmann, Paulsen, & Holst, 2006; Klingberg,
anxiety is a heightened fear of dental procedures that may or may not Berggren, Carlsson, & Noren, 1995).
reach full criteria for diagnosis as a phobia; however, since self-report
measures alone are often used to identify dental anxiety, all data 4. Clinical significance
required for the determination of a diagnosis are typically not available.
Given that much of the literature investigates dental anxiety rather than The clinical significance of dental anxiety should not be under-
dental phobia, we use the term dental anxiety throughout, except when estimated. Dental anxiety is first and foremost an oral-health problem
we wish to make explicit comparisons between heightened anxiety and as it is associated with a lower frequency of dental visits and a higher
a full-blown diagnosis of dental phobia. prevalence of dental caries (Klingberg et al., 1995). Furthermore, as
indicated in the diagnostic criteria for any anxiety disorder or phobia by
3. Prevalence APA (2013), the avoidance or distress associated with the phobic
stimulus interferes significantly with the individual's normal routine,
It is difficult to accurately describe the prevalence of dental anxiety occupational or school functioning, and social relationships.
as many epidemiological studies do not provide such data; data in Luoto, Lahti, Nevanperä, Tolvanen, and Locker (2009) found that
youth samples are particularly scarce. However, looking at adult studies children who were afraid of dental treatment reported lower social
may provide some insight as evidence suggests that most adults with well-being and emotional well-being in comparison to children without
dental anxiety developed their fear in childhood or adolescence fear of dental treatment. Thus, the sequelae of dental anxiety were
(Locker, Liddell, Dempster, & Shapiro, 1999). Again, however, data shown to extend well beyond the actual dental situation itself to life
are problematic in that studies report more often on dental anxiety outside the dental setting and to life in general. These findings are not
with few studies reporting on dental phobia. surprising given that quality of life has been shown to be compromised
in children with other phobias (Ollendick & Davis, 2001; Ollendick
3.1. Prevalence of dental anxiety in adult samples et al., 2009). Additionally, compromised oral health in children, which
is related to dental anxiety, has been linked with a host of quality of life
Given this caveat, it seems that around 15% of the adult population issues in youth including pain, social avoidance, and trouble eating
suffers from significant dental anxiety. For example, Locker et al. (Foster Page, Thomson, Jokovic, & Locker, 2005).
(1999) estimated the prevalence of dental anxiety to be 16.4% and Importantly, emerging research in both children and adults suggests
Locker, Poulton, and Thomson (2001) found that 12.5% of their sample that dental health and, by extension, dental anxiety may also have
of 18 year olds drawn from the Dunedin (New Zealand) Multidisciplin- much broader health implications. For example, Frisbee, Chambers,
ary Health and Development Study (DMHDS) reported moderate to Frisbee, Goodwill, and Crout (2010) found that parent reported dental
severe dental anxiety on a self-report instrument. Similarly, a study in health problems was related to markers of systemic inflammation in
Australia that included both children and adults found high levels of children, possibly putting children at risk for later cardiovascular
dental anxiety in 16.1% of the sample (Armfield, Spencer, & Stewart, disease. Additionally, a recent meta-analysis has shown a link between
2006). Dental phobia in adults, on the other hand, is much less common childhood dental caries and obesity (Hayden et al., 2013). Although the
with about only 1% of the DMHDS sample reporting symptoms link between dental health, inflammation, and conditions such as
consistent with a diagnosis of dental phobia at age 18 years (Locker cardiovascular disease has been suggested as an etiological pathway,
et al., 2001). it must be noted that much of the research in this area is cross-sectional
and correlational. Thus, whether hypotheses about a casual pathway
3.2. Prevalence of dental anxiety in youth samples will be borne out is yet to be seen. However, at this time we do know
that dental anxiety is correlated with poorer dental health, poorer
Prevalence estimates of dental anxiety in youth are somewhat more quality of life, and may even put children at risk for serious disease in
variable, with estimates ranging from approximately 5% to 20%. Baier, adulthood.
Milgrom, Russell, Mancl, and Yoshida (2004) found that 20% of their
sample of youth visiting private pediatric dentists evidenced high 5. Etiology and maintenance
dental anxiety; however, this would seem likely to be an underestimate
in the general population in that children and adolescents with the most Extant research suggests a complex set of factors that lead to the
severe dental anxiety might be expected to avoid dental treatment development and maintenance of significant dental anxiety or dental
altogether or to present at specialty clinics (Bedi, Sutcliffe, Donnan, phobia. Here we review these findings and present an integrated
Barrett, & McConnachie, 1992). However, a study of unselected adoles- cognitive-behavioral model of the development and maintenance of
cents in the United States arrived at a lower figure as approximately dental anxiety (see Fig. 1).
10% of the junior high and high school students in the sample reported
high levels of dental anxiety (Gatchel, 1989). Investigations of un- 5.1. The role of learning in the etiology of dental anxiety
selected youth in Scotland and the Netherlands found somewhat
similar results with about 7% of early adolescents in Scotland and There is growing evidence to suggest that classical conditioning
6% of Dutch youth reporting high dental anxiety (Bedi, Sutcliffe, plays a major role in the development of dental anxiety in a number of
Donnan, & McConnachie, 1992; ten Berge, Veerkamp, sufferers (Fig. 1, panel a) with fewer, but a still significant number of
Hoogstraten, & Prins, 2002a). On the other hand, epidemiological those with dental anxiety, reporting vicarious conditioning experiences.
studies in youth have found estimates of the prevalence of all simple/ Although much of this work has been done with adults, findings have
specific phobias to range from 0.3% to approximately 5% (Costello been supported in the few studies conducted with children and
et al., 1996; Fergusson, Horwood, & Lynskey, 1993). Of course, only a adolescents as well.
subset of these youth would be expected to have dental phobia; thus,
the prevalence of full-blown dental phobia in youth would be expected 5.1.1. Evidence from adult studies
to be much lower than the estimates of dental anxiety. Nevertheless, Berggren, Carlsson, Hägglin, Hakeberg, and Samsonowitz (1997)
estimates from both youth and adult samples suggest a significant found that 47% of their adult sample high in dental anxiety reported

26
L.D. Seligman et al. Clinical Psychology Review 55 (2017) 25–40

a – Onset of dental anxiety b – Maintenance of dental anxiety

Familial and Cultural

Beliefs Remittance

Non-painful events
Repeated
Pain painful
Sensitivity events
Prior Anxiety
Learning and
Disgust
Sensitivity?
Potential
Conditioning
Poor oral
Event health Familial and
cultural beliefs?
Avoidance

Negative
cognitions around
dental stimuli
Fig. 1. The onset of dental anxiety begins with a conditioning event but whether a dental experience serves as a conditioning event is dependent on the context in which it occurs (panel
a). The maintenance of dental anxiety is hypothesized to be influenced by a complex interplay of cognitive behavioral factors influenced by the child's family and cultural beliefs (panel
b).

direct conditioning experiences leading to their anxiety and another with significant dental anxiety seem to have had fewer non-fearful
26% reported a mixture of both direct and vicarious learning experi- learning opportunities before their negative dental experience (Davey,
ences. Similarly, Davey (1989) found that 93% of adults with either 1989; de Jongh et al., 1995). In effect, this means that early learning
current dental anxiety or a history of dental anxiety reported at least experiences will play a particularly important role in determining
one painful dental experience; this proportion was significantly higher dental anxiety. If an individual has several positive experiences with
than that found in individuals with no dental anxiety. Moreover, there dental treatment before having a painful or even traumatic treatment,
was some evidence from this study to suggest that individuals with high the chances of developing significant dental anxiety decrease compared
dental anxiety were also more likely to report at least one very painful to someone who is naïve or relatively naïve to dental treatment when s/
dental experience. de Jongh, Muris, ter Horst, and Duyx (1995) also he first has a negative experience. Given that many individuals first
found that adults with current dental anxiety were more likely to report visit the dentist during childhood or adolescence, these learning
painful or traumatic dental experiences than those who had never experiences will likely take place during youth, which may explain
experienced dental anxiety. In fact, they found very few individuals why many with significant dental anxiety report an age of onset in
with current dental anxiety who had not experienced a painful or childhood or adolescence. This also means that early and regular dental
traumatic dental event. Importantly, although these studies were care should serve to inhibit the development of dental anxiety, barring
conducted with adults, multiple investigations have found that the any very early dental injury or severe disease.
conditioning events leading to dental anxiety have typically occurred in
childhood or early adolescence (Davey, 1989; de Jongh et al., 1995;
Liddell & Locker, 2000), suggesting this period may be critical in the 5.1.2. Evidence from child studies
development of dental anxiety. Specific developmental influences may These conclusions with adults are largely supported by studies in
play a role in this phenomenon, although there is little research or youth in that studies with children and adolescents similarly find that
theory to suggest how or why this might be the case. On the other hand, learning experiences, particularly direct conditioning, are key to the
increasingly fine-grained analyses of the learning histories of those who development of dental anxiety. For example, in a large sample of
develop dental anxiety suggest an alternative hypothesis for why onset elementary school-aged children in Taiwan, Lin et al. (2014) found
typically occurs in childhood or adolescence. Such investigations direct conditioning experiences to be the most commonly reported
suggest that latent inhibition – a history of non-fearful learning prior etiological factor for dental anxiety. Modeling was also found to play a
to a fear conditioning event – may play a key role. role, however, with direct conditioning serving as the best predictor of
More specifically, although it is true that those who develop dental dental anxiety in high socioeconomic status (SES) youth and modeling
anxiety are more likely to have a dental history that includes dental experiences serving as the best predictor of dental anxiety in low SES
trauma and pain than those who do not have dental anxiety, a youth. Similarly, Milgrom, Mancl, King, and Weinstein (1995) found
considerable number of those without dental anxiety also have had that direct conditioning experiences and modeling predicted dental
similar experiences with dental pain or traumatic events at the dentist's anxiety in low income youth in the United States. However, direct
office. In fact, studies suggest that as many as 60–80% of people with no conditioning experiences in this study were inferred from the child's
history of dental anxiety have had at least one painful dental treatment dental health; that is, children with poor dental health (e.g., caries)
(Davey, 1989; de Jongh et al., 1995). However, what seems to were presumed to have had more negative conditioning experiences.
differentiate those who go on to develop significant dental anxiety However, this may not have been the case if the children did not
from those who do not is that those who do not develop dental anxiety actually experience dental treatment that was perceived as painful or
have more non-painful or non-traumatic dental experiences (i.e., a traumatic. Importantly, as we discuss below, what the individual brings
greater number of conditioned stimulus presentations without the with them in terms of their thoughts and beliefs to the dental exam
presence of the unconditioned stimulus) prior to their negative dental room can significantly affect whether or not a particular dental
experience(s) (Davey, 1989; de Jongh et al., 1995). Conversely, those encounter serves as a conditioning event.
Subsequent research in youth, however, did address this short-

27
L.D. Seligman et al. Clinical Psychology Review 55 (2017) 25–40

coming by looking at dental health and perceptions of treatment as anxiety, to date there is not enough evidence to conclude this is the case
indictors of the direct conditioning pathway to dental anxiety in youth despite its link to other anxiety disorders in youth (e.g., Paulus, Backes,
(Townend, Dimigen, & Fung, 2000). Results revealed that youth with Sander, Weber, & Gontard, 2015).
dental anxiety did indeed have more dental decay and missing teeth Anxiety sensitivity and disgust sensitivity, often implicated in the
than their non-anxious counterparts and that anxious youth had more etiology of some specific phobias, would likely function to predispose
visits to the dentist that were perceived as traumatic. Importantly, the one for dental phobia in much the same way as pain sensitivity - by
latent inhibition hypothesis suggested in the adult literature was also focusing the individual on particular stimuli and amplifying their
examined, revealing that children with dental anxiety first experienced aversive properties. In fact, pain sensitivity and anxiety sensitivity
dental trauma at an earlier age than children without dental anxiety. seem as if they should be highly linked and thus it would be expected
While these data, like those in adult studies, were obtained by retro- that anxiety sensitivity would likely play a role in the development of
spective reports, in this case the period of recall was briefer, adding dental phobia. Anxiety sensitivity has been shown to be related to BII
additional credibility to the latent inhibition hypothesis. Interestingly phobias more generally (Kılıç et al., 2014); however, as previously
although modeling was also examined, little evidence was found for noted, the evidence for the link between dental phobia and anxiety
this type of learning as a pathway to dental fear. So while learning sensitivity is mixed (Kılıç et al., 2014; Locker et al., 1997). Interest-
seems to play an important role in the development of dental anxiety, ingly, Liddell and Gosse (1998) found that anxiety sensitivity was
the preponderance of evidence suggests a direct conditioning pathway related only to specific perceptions of early dental encounters – those
in most cases with less evidence supporting the role of modeling as a involving dental injury. Thus, it may be that anxiety sensitivity plays a
direct pathway to dental anxiety in youth. However, as we allude to role in the development of dental phobia only in cases of a particular
above, a dental experience that may serve as a conditioning event for type of early learning event; however, it may also be that pain
one child may be perceived as relatively benign to another. We have sensitivity is a more precise and relevant construct in relation to dental
already discussed how prior learning influences the likelihood that a phobia as opposed to other types of BII phobias. This makes some
painful or traumatic event serves to condition the child to associate intuitive sense as other BII phobias often involve fear of more general
dental stimuli with anxiety; however, so too does the cognitions and bodily sensations (e.g., the physiological cues that precede fainting)
characteristics the child brings with him or her to the dental exam. whereas the physiological sensations that seem to predominate in
dental phobia revolve more around the specific sensation of pain;
however, very little research has been done in this area, particularly
5.2. The role of cognitive and constitutional factors in the etiology of dental
with children, so conclusions at this point are tentative.
anxiety
Similarly, recognition of the role of disgust sensitivity in the
development of specific phobias has been growing and this is true in
One's perception of oneself in relation to dental stimuli seems to also
the case of dental phobia as well. However, the evidence regarding the
play an important role, again functioning to moderate the probability
role of disgust sensitivity in dental phobia is not consistent. For
that one will experience the early learning events that lead to the initial
example, de Jongh et al. (1998) found a non-significant correlation
development of dental anxiety (Fig. 1, panel a). Those with dental
between self-reported dental anxiety and disgust sensitivity whereas
anxiety have been found to be more fearful of pain, particularly minor
other studies found mixed results (Merckelbach, Muris, de Jong, and de
pain, than those low in dental anxiety (Vowles et al., 2005) and to view
Jongh, 1999). Findings may be clouded however because the relation-
themselves as having a lower pain tolerance threshold (Davey, 1989).
ship between disgust sensitivity and dental anxiety may not be a
These beliefs may serve to focus the individual on physical sensations
straightforward one. For example, Armfield (2008) found that disgust
during dental treatment; this biased processing of physical stimuli may
sensitivity and dental fear did covary; however, those with high dental
actually serve to amplify the potentially painful stimuli
anxiety reported disgust sensitivity similar to those with the lowest
(Chapman & Kirby-Turner, 2005).1 Thus, while it is true that the
levels of dental anxiety whereas those with moderate dental anxiety
occurrence and pattern of early learning experiences seems to play a
reported the highest levels of disgust sensitivity. Additionally, Leutgeb
critical role in the development of dental anxiety, whether or not one is
et al. (2011) found fear to be more central to dental phobia than
exposed to these anxiety engendering experiences may not be indepen-
disgust; nonetheless, their data showed that individuals with dental
dent of the individual's perception of those experiences. Pain is a
phobia rated relevant photos as more disgust inducing compared to
complex phenomenon and it is most certainly not a purely physiologi-
controls. This response, however, seemed to be driven primarily by
cal-based response; those individuals who view pain as particularly
items related to oral disgust. Moreover, this investigation also found
aversive and who have relatively low self-efficacy for coping with pain
that those with dental phobia experienced heart rate acceleration when
may be more likely to experience dental pain as a result of these beliefs.
exposed to relevant stimuli in contrast to the heart rate deceleration
Additional constitutional factors such as behavioral inhibition,
that is thought to accompany feelings of disgust. Thus, there is not
disgust sensitivity, and anxiety sensitivity have often been found to
strong support for the role of disgust sensitivity as a primary driver of
put youth at disproportionate risk for specific phobias. In the case of
perceptions of dental experiences. Nonetheless, these mixed results
dental phobia the role of these risk factors is somewhat unclear given
should not be ignored as they lead to several interesting hypotheses
the lack of research. However, what data we do have are mixed.
requiring further exploration. It might be that a specific type of disgust
For example, to our knowledge only one study has investigated the
sensitivity (related to oral intrusions) plays a role in the development of
role of behavioral inhibition in youth dental anxiety. Of note, this study
dental phobia and that this relationship gets obscured when more
investigated dental anxiety in a relatively small sample of young
general measures of disgust are used. Alternatively, there may be a
children and relied almost entirely on measures with unknown
particular subset of those with dental phobia who experience high
psychometric properties developed by the author (Hammock, 1999).
levels of disgust sensitivity and the representation of this group in a
These caveats notwithstanding, child self-reports of dental anxiety were
study drives the modest correlations sometimes found. These indivi-
not significantly related to parent and teacher reports of behavioral
duals might be more similar to those with other BII phobias than to
inhibition; however, in general, observations of anxiety and distress
those with classic dental anxiety. A final possibility is that the
during dental prophylaxis were related to these indices. Thus, although
comorbidity of dental phobias with other phobias, particularly other
behavioral inhibition may be a risk factor for the development of dental
BII phobias, drives the association of dental phobia and disgust
sensitivity. However, few studies in this area have been conducted
1
Chapman and Kirby-Turner (2005) note that this is similar to the process proposed in and those that have been have used small sample sizes and have not
the etiology and maintenance of panic disorder. fully addressed these possibilities. Thus whether disgust sensitivity

28
L.D. Seligman et al. Clinical Psychology Review 55 (2017) 25–40

plays a role in the development of dental phobia and, if so, the specific beliefs about oral health and economic factors related to race and
role it does play, needs to be investigated further before we can ethnicity are likely to affect a child's pattern of attendance at dental
conclude that disgust sensitivity contributes to clinically significant appointments. Latino and African American youth may be less likely to
dental anxiety. visit the dentist regularly and they may be particularly less likely to
visit the dentist for preventative care visits – the types of visits that are
5.3. The role of family and cultural factors in the etiology of dental anxiety more likely to provide an early positive learning history. Such a pattern
would be expected to ultimately impact child dental anxiety by
When family members have negative attitudes toward dental increasing the probability of painful and traumatic dental visits when
stimuli, studies show a link with youth dental anxiety with most of the child does eventually seek care, along with the likelihood that the
these studies examining this phenomenon in the child and parent dyad. child will not have positive early learning history to inhibit the anxious
In fact, in a meta-analysis of the relationship between parent and child learning. On the other hand, there is some evidence that some Asian
dental fear, Themessl-Huber, Freeman, Humphris, MacGillivray, and families are comparatively more concerned about both the social and
Terzi (2010) found evidence for a significant, albeit moderate, correla- physical consequences (i.e., pain) of dental health compared to
tion between parent dental anxiety and child dental anxiety. Although Caucasians (Kiyak, 1981). Such a set of beliefs results in increased
it is tempting to speculate that this is due to modeling of dental anxiety preventative behaviors (Kiyak, 1981), which in turn should decrease
by parents, as discussed previously, the evidence for vicarious learning the possibility of early aversive learning. However, a cultural focus on
as a major direct contributor to dental anxiety is relatively weak. We pain or other constitutional factors that increases hypervigilance during
suggest then that parental anxiety regarding dental procedures may dental treatment could result in aversive learning in response to even a
affect child dental anxiety through a more complex, indirect pathway relatively innocuous dental history; thus increasing the probability of
(see Fig. 1, panel a). First, modeling of dental anxiety and verbal dental anxiety. Moreover, these cultural factors are also likely to play a
learning transmitted from parent to child may cause decreased self- role later in the anxiety cycle, helping to determine whether or not
efficacy for pain and affect perceptions of dental stimuli, in turn initial dental anxiety remits or results in stable anxiety and phobic
increasing hypervigilance in early dental encounters and, as discussed behavior.
previously, this may alter perceptions of potential conditioning events
to make direct conditioning more probable. Additionally, parental 5.4. The role of learning, cognition, and culture in the maintenance of
anxiety may also impact a child's learning history if it results in dental anxiety
avoidance of dental stimuli to the extent that the parent delays taking
his/her child to the dentist for early and regular preventative care. Such While early learning history seems to play a role in the initial
a pattern increases the likelihood that painful treatment or traumatic development of dental anxiety, several other factors including repeated
interactions occur early in the child's dental history without the type of aversive learning, avoidance, the cognitive construal of dental stimuli,
learning events that would result in latent inhibition of anxious and family and cultural values likely contribute to the maintenance of
learning. However, we must note that although these are plausible dental anxiety. Moreover, these factors seem to be intertwined in a very
hypotheses given the present data, we know of no studies that directly complex relationship (see Fig. 1, panel b). For example, when compar-
evaluated these pathways. ing adults who reported stable, persistent dental anxiety to those who
We suggest that, at a broader level, cultural beliefs about oral health reported remitted dental anxiety, Davey (1989) found the experience of
and dental treatment may play out in a similar fashion to affect a child's multiple painful dental events distinguished the two groups – both
early dental experiences and ultimately the child's level of dental groups experienced early negative learning experiences leading to
anxiety. Although extant research has not yet examined how culture dental anxiety, but those who did not have repeated pain paired with
influences the development of dental phobia in youth, studies have in dental stimuli were more likely to remit over time. It seems that
fact shown that culture is indeed related to child dental anxiety multiple painful experiences may function to culminate in stable dental
(Folayan, Idehen, & Ojo, 2004). For example, it has been demonstrated anxiety in several ways. First, multiple UCS/CS pairings make the
that within a small sample in the United States, Puerto Ricans showed learning more probable, although it should be noted that some evidence
higher rates of dental anxiety than either Caucasians or African suggests this is not necessary if the UCS is particularly potent (Davey,
Americans (Weisenberg, Kreindler, Schachat, & Werboff, 1975). Again, 1989; de Jongh et al., 1995). Second, importantly, individuals who
it is not clear why this was the case, but cultural beliefs and the have multiple painful dental experiences are more likely to avoid dental
relationship between race, ethnicity, and economic factors may affect treatment (Skaret, Raadal, Berg, & Kvale, 1999). This avoidance in turn
children's early learning about dentistry. For example, compared to affects dental anxiety through a direct path - not allowing for non-
Caucasian adults living in the same community, Latino and African fearful learning, as well as indirectly- through the impact of avoidance
American adults have been found to have less positive beliefs about a on cognitions regarding dental stimuli (Carrillo-Diaz, Crego,
preventative stance toward dental healthcare (Nakazono, Armfield, & Romero-Maroto, 2012).
Davidson, & Andersen, 1997). The implications of such a perspective More specifically, avoidance circumvents the opportunity for com-
within a culture are underscored by the results of a study exploring peting learning experiences (CS presentations in the absence of the
dental healthcare use among African American, high and low accultu- UCS). Moreover, in a particularly perverse turn, avoidance makes it
rated Latinos, and White families (Valencia et al., 2012). In this study, more likely that phobic individuals will experience compromised oral
less acculturated Latino children were the least likely to have visited a health which (1) increases the likelihood of uncomfortable or painful
dentist in the previous year; in fact, compared to White children, the treatment when the person does eventually seek treatment, thus
odds that a Latino youth from a less acculturated family had been to the increasing the probability of additional aversive learning (Armfield,
dentist in the previous year was 75% lower. The picture for the other 2013) and (2) is related to the development of cognitive vulnerability
minority families was also bleak as the odds for African American and schema in which dental stimuli are viewed as uncontrollable, disgust-
more acculturated Latino youth were 45% and 40% lower respectively. ing, and dangerous or harmful (Armfield, 2008; Carrillo-Díaz, Crego,
Interestingly, in multivariate models predicting dental attendance, Armfield, & Romero, 2012), which creates a vicious cycle.
ethnicity/race appeared to exert its influence on dental visits largely However, family and, on a larger scale, cultural beliefs about oral
through economic factors such as having dental insurance and a regular health seem to also be important in determining the course of dental
source of dental care. Of note, this investigation did not include an in anxiety. For example, when Davey (1989) compared adults with stable
depth assessment of health beliefs so the impact of these beliefs could dental anxiety to those with remitted dental anxiety, they were similar
not be determined. Taken together, however, these studies suggest that on many of the variables discussed here (e.g., pain tolerance); however,

29
L.D. Seligman et al. Clinical Psychology Review 55 (2017) 25–40

those in the remitted group were more likely to have close family from dentists, of the degree of disruption caused, so that the behaviors
members who regularly sought dental care. Davey (1989) postulated that interfere most with dental treatment are weighted most heavily.
that this may lead one to have a positive evaluation of dental stimuli Raters count the frequency of occurrence of each behavior during
that can serve to compete with the negative evaluation formed from consecutive three minute intervals. A total score is obtained by multi-
conditioning events. Such a conflict with family or cultural values may plying the frequency of each behavior by its weight, summing across all
mitigate the likelihood of the aversive learning leading to avoidance, behaviors, and dividing by the number of three minute intervals in the
putting these individuals on a different development course that observation (Melamed et al., 1975a).
ultimately leads to remission rather than maintenance of the fear. The second category of behavior rating scales is more subjective and
rates behavior on a more macro level. This category includes the Frankl
5.5. Summary and implications of key findings Behavior Rating Scale (Frankl, Shiere, & Fogels, 1962) and the Venham
Rating Scales (Venham, Bengston, & Cipes, 1978). In this type of rating
There is good evidence that in many cases dental phobia starts with system, an ordinal rating is made by the dentist or observer with
a direct conditioning event. We hypothesize, however, that whether guidance from descriptors. For example, the Venham Rating Scales
any given dental event results in aversive learning is highly dependent consist of a scale to measure anxiety and a scale to measure coopera-
upon multiple factors including characteristics of the event itself as well tiveness; in both instances, ratings are made on a 5-point scale with 0
as learning history, child factors (pain sensitivity and perhaps anxiety indicating no anxiety (“relaxed, smiling, willing and able to converse”)
and disgust sensitivity), and family/cultural factors. Moreover, family or total cooperation (“total cooperation, best possible working condi-
and cultural factors may also serve to help determine the pattern of tions, no crying, or physical protest”) and 5 indicating extreme anxiety
learning; with parental dental anxiety, cultural beliefs, and economic (“Child out of contact with the reality of the threat. General loud
factors affecting the likelihood that early dental visits will be for crying…”) or lack of compliance (“General protest, no compliance or
preventive care – encounters that are less likely to result in a potential cooperation. Physical restraint required.”).
conditioning event – or for treatment – encounters that are more likely These rating scales have been widely used to measure dental
to result in a conditioning event. Cultural factors may also play a role in anxiety, particularly in treatment studies, and research has shown that
determining a child's perceptions of pain, also influencing the like- raters can be trained to use the scales to make reliable ratings (e.g.,
lihood that a dental event will serve to condition the child. Later in the Sullivan, Schneider, Musselman, Dummett, & Gardiner, 2000). Beha-
cycle, we hypothesize that learning and behavioral patterns (repeated vioral ratings have also been shown to correlate with parent reports of
aversive events, avoidance) again interact with factors including oral children's dental anxiety (Baier et al., 2004). However, very little
health, cognitions regarding dental stimuli, and family/cultural beliefs research has been done to explore the validity of these measures.
to ultimately determine whether dental anxiety remits or begins to Moreover, in the case of the BPRS and the Venham cooperativeness
result in a true phobia. Thus, we hypothesize that a complex interaction scale, dental anxiety is inferred from the level of disruptive behavior
exists between the child and the environment to determine both displayed by the child, despite the fact that disruptive behavior may
whether a potential conditioning event takes place and ultimately the indicate fear and anxiety of the dental situation, fear and anxiety of
effects of such an event. It should be noted, however, that although some other stimuli (e.g., social fears, separation anxiety), or it may be
there is good evidence for some parts of our model, other components reflective of oppositionality that is largely independent of fear. On the
of the model are based on a very small number of studies. Clearly more other hand, a child could be very anxious but cooperative and, in most
research is needed – particularly into how family and culture affects the cases, these rating scales would miss the child's internal distress
onset and maintenance of dental phobia. Nevertheless, we suggest that (Aartman, van Everdingen, Hoogstraten, & Schuurs, 1996). Thus,
this research will prove more fruitful if guided by a comprehensive although behavior rating scales are certainly an important component
model, such as the one we propose here, given that the extant literature of a thorough assessment of dental anxiety in youth, given the nature of
does seem to point to a complex interplay of cognitive, behavioral, and anxiety and fear, we recommend a multimethod approach that includes
contextual factors in both the development of dental phobia and self-report data as well.
determination of its course. This research, as well as effective inter-
vention efforts, relies on our ability to properly identify clinically 6.2. Self-reports
significant levels of dental anxiety; thus, we now turn to the assessment
of dental anxiety and dental phobia. The Children's Fear Survey Schedule – Dental subscale (CFSS-DS;
Cuthbert & Melamed, 1982) is perhaps one of the most widely used self-
6. Assessment reports of dental anxiety in youth. The CFSS-DS is based on the original
Children's Fear Survey Schedule (Scherer & Nakamura, 1968) with
Two methods have been commonly used to assess dental anxiety in items added to create a dental fears subscale. The result is a list of
youth. These include behavior ratings scales used by trained coders or 15-items (e.g., “the dentist drilling”) that children react to by rating
by dental professionals providing treatment, and self-reports. Below we their fear on a 5-point fear thermometer. Although the CFSS-DS is
discuss some of the most widely used measures employing each of these described as a subscale of the Children's Fear Survey Schedule, it has
methods. typically been administered in isolation from the rest of the original
measure. Cuthbert and Melamed (1982) provide some normative data
6.1. Behavior ratings scales but no evidence of reliability or validity of the measure. However, other
investigators have found evidence supporting the reliability of various
Behavior rating scales infer dental anxiety from observations of derivatives of the CFSS-DS (e.g., Folayan, Idehen, & Ufomata, 2003; ten
disruptive behavior displayed by children when undergoing dental Berge, Veerkamp, Hoogstraten, & Prins, 2002b). In terms of validity,
treatment. These scales can be grouped into two general categories. The Holmes and Girdler (2005) found scores on the CFSS-DS to be
first category examines specific behaviors and is typified by Melamed's significantly higher in youth chosen for sedation during dental treat-
Behavior Profile Rating Scale (BPRS; Melamed, Hawes, Heiby, & Glick, ment but an investigation in youth referred for dental anxiety showed
1975a). The BPRS is a list of 27 specific behaviors – 25 disruptive child no relation between CFSS-DS scores and child behavior during treat-
behaviors (e.g., verbal complaints, inappropriate mouth closing) and ment (Klaassen, Veerkamp, & Hoogstraten, 2003). Although it could be
two dentist behaviors that would likely follow from child disruptive argued that this finding may be related to range restriction given the
behaviors (using a loud voice and using restraints). Each of the nature of the sample, there are other reasons to question the validity
behaviors is weighted by a rating, which the scale's authors obtained and utility of the CFSS-DS. First, more recent versions of measures of

30
L.D. Seligman et al. Clinical Psychology Review 55 (2017) 25–40

children's fears have moved to a simpler response format due to Program (SFP-R) are more recently developed alternatives that are brief
observations that children often are unable to discriminate between – the original measure is only 4 items, while the revision is 5 – but still
choices on a 5-point scale (Muris & Ollendick, 2002; Ollendick, 1983). query about some specific dental stimuli (Buchanan, 2005, 2010). The
Moreover, it is not clear that all items on the CFSS-DS would be equally SFP queries about anticipatory anxiety (how the child would feel if she
relevant when assessing children's dental fears (e.g., “having to go to had a dental appointment the next day and how the child would feel in
the hospital” or “having a stranger touch you”). In fact, factor analytic the waiting room of the dental office) as well as fear of having a tooth
studies of the CFSS-DS and a parent version of the CFSS-DS suggest the drilled and an injection in the gum tissue. The SFP-R also queries about
15-item measure taps into three or four different underlying constructs. fear of having a tooth extracted, based on pilot data suggesting that
While some of these factors are clearly dental fears, others seem to be even children as young as four years can understand this item
made up of more general fears and non-dental medical fears (Alvesalo (Buchanan, 2010). The measures are computerized and children
et al., 1993; ten Berge, Hoogstraten, Veerkamp, & Prins, 1998; ten respond to each item by either clicking on a happy face that they can
Berge, Veerkamp, Hoogstraten, & Prins, 2002c). This seems to be make happier or a sad face that they can make sadder. A total of 7
particularly problematic given research suggesting that dental phobia different facial expressions are available to the child, including a
may be distinct from other medical phobias (Armfield, 2008; Kılıç et al., neutral choice. Both scales have demonstrated good internal consis-
2014). tency and test-retest reliability (Buchanan, 2005, 2010). Concurrent
Some of these issues are addressed in another widely used self- validity with the MCDAS and CFSS-DS has also been established
report of dental anxiety: the Modified Child Dental Anxiety Scale (Buchanan, 2005, 2010). Of note, the psychometric study of the
(MCDAS; Wong, Humphris, & Lee, 1998). The MCDAS is an eight-item original SFP included children as young as six years.
scale; seven items query about a child's anxiety in specific situations As indicated above, increasing research in both children and adults
related to visiting the dentist (e.g., “having your teeth looked at,” suggests a link between poor oral health and a plethora of negative
“having a tooth taken out,” “being put to sleep to have treatment”), social and health consequences that affects a child's quality of life.
while one item asks about overall feelings about going to the dentist Given the barrier that dental anxiety and dental phobia present to
(“going to the dentist generally”). Reflecting this specific focus, items obtaining adequate oral health care (as depicted in Fig. 1), it seems
appear to be measuring one unified construct (Wong et al., 1998). likely that many youth with dental anxiety do experience compromised
However, like the CFSS-DS, the MCDAS also uses a 5-point format for quality of life as a result of avoidance behaviors. Thus, assessment of
responses which may not be appropriate for young children. A more quality of life related to oral health is an important part of obtaining a
recent version of the MCDAS uses a facial image scale that may ease complete picture when evaluating youth with dental anxiety. The Child
administration in this population and children with cognitive disabil- Perceptions Questionnaire (CPQ11-14; Foster Page et al., 2005; Jokovic
ities (Howard & Freeman, 2007); it should be noted, though, that the et al., 2002) is a 35-item self-report survey designed to assess the
scale still requires children to make discriminations among five choices. domains of quality of life that may be impacted by poor dental health in
The faces version of the MCDAS has been tested in a series of studies of children between 11 and 14 years of age. The CPQ11–14 consists of four
youth between 5 and 10 years of age (Howard & Freeman, 2007). Good subscales: oral symptoms (e.g., pain), functional limitations (e.g.,
test-retest reliability was demonstrated in children as young as 8 years; difficulty eating), emotional well-being (e.g. avoiding smiling because
younger children were not included in the sample that was re- of dental appearance), and social well-being (e.g., being asked about
administered the measure, so reliability in younger children is un- teeth). The scale developers provide evidence of both reliability and
known. Scores of the Faces MCDAS were found to be higher in (1) validity (Foster Page et al., 2005; Jokovic et al., 2002). The length of
children referred for dental anxiety than those referred for other dental the CPQ11–14 may be prohibitive in many settings, especially when
problems, (2) youth with greater decay, and (3) youth who had a quality of life is being measured in conjunction with dental anxiety.
history of use of general anesthesia during dental procedures, support- More recently, however, several brief versions of the measure have
ing the construct validity of the measure (Howard & Freeman, 2007). been developed, including an 8-item version that appears promising
Again, however, a simpler scale may be more appropriate for use (Foster Page, Thomson, Jokovic, & Locker, 2008).
with younger children or those with cognitive limitations. The Venham
Picture Test (VPT; Venham & Gaulin-Kremer, 1979) may be appropriate 7. Treatment
for such samples. This measure consists of eight items with each item
consisting of two pictures – one in which a young boy displays a The first systematic attempts we could find to treat dental anxiety in
positive or neutral emotion and one in which he displays a negative children date back to the 1970s. Given this, we conducted a search of
emotion or behavior (in one he runs away!). The measure can be MEDLINE, PsychINFO, CINAHL, Science Direct, and PsycARTICLES
administered in 2 min or less, even with children as young as three using the search terms ‘dental anxiety treatment,’ ‘dental phobia
years (Venham & Gaulin-Kremer, 1979). Good internal consistency treatment,’ ‘dental phobia therapy,’ ‘dental anxiety, therapy,’ ‘children
(α = 0.84) of the VPT has been demonstrated in children between and dental anxiety,’ ‘treating childhood dental fear,’ and ‘dental fear,
three and eight years of age (Venham & Gaulin-Kremer, 1979) and some management’ from January 1970 through December 2016. All data-
evidence for concurrent validity has been found (Klorman, Ratner, bases, with the exception of Science Direct, were searched simulta-
Arata, King, & Sveen, 1978). Interestingly, Buchanan and Niven (2002) neously to minimize duplicates; we were unable to include Science
have found a one item facial image scale – a row of five pictures of a Direct in this type of search as the system used did not allow for
face ranging from very happy (a face with a big smile) to very sad (big simultaneous searching with Science Direct. We applied the methodol-
frown) – to correlate 0.70 with the VPT, suggesting that a very quick, ogy limiters ‘clinical trial,’ ‘treatment outcome,’ ‘randomized controlled
simple, and easy to administer measure may be able to capture much of trials,’ ‘clinical trial phase I,’ ‘clinical trial phase II,' ‘clinical trial phase
the information supplied in the VPT. Of course, while these instruments III,’ ‘clinical trial phase IV,’ ‘controlled clinical trial,’ ‘randomized
may be ideal for use with young children or routine use by dentists controlled trial,’ and ‘empirical study’ and narrowed results down to
before a dental examination and even for ongoing monitoring of the published studies written in English that implemented a psychosocial
effect of treatment of dental anxiety or dental phobia, their simplicity treatment designed to reduce anxiety, fear, distress, or disruptiveness
may limit their utility for treatment planning because these measures during dental treatments in youth up to 17 years of age (one study also
give a sense of how positive or negative a child feels when attending a included a small number of 18 and 19 year old participants). The
dental appointment, but, unlike the CFSS-DS and MCDAS, they do not reference sections of articles meeting these criteria were also searched.
provide any information on the types of situations the child fears. Initial screening of articles was done by the first author (LDS) - at this
The Smiley Faces Program (SFP) and the revised Smiley Faces point articles were excluded if they were clearly not germane to the

31
L.D. Seligman et al. Clinical Psychology Review 55 (2017) 25–40

Fig. 2. Study search and selection process.

topic of dental anxiety and/or did not study a child or adolescent children formally diagnosed with a specific phobia – although it is
population. A full-text review conducted by the first author was then likely that in at least some instances, some participants would have met
reviewed by the second author (JDH). Disagreements were resolved diagnostic criteria. Commonly, children were included in these studies
through discussion until a consensus was reached. The results of this because of past disruptive behavior during dental treatment or because
search and subsequent screening are depicted in Fig. 2. Of note, we of parent or dentist ratings of dental anxiety or disruptiveness. With
excluded studies that examined dental anxiety related to injections only some exceptions, the treatment used both in prevention and treatment
because, as we discussed previously, it is unclear that this type of studies was based on learning theory and, more specifically, some
anxiety should be grouped with more general dental anxiety. Studies variation on a modeling approach was often used.
that addressed dental anxiety generally – in the treatment and assess- An early example of such an approach was a case study of a 3.5 year
ment – but included fear of injections as part of the treatment or old girl who had never been to the dentist before, but her shy
assessment of the treatment were included. Combined, these processes temperament resulted in anticipation that her first examination would
resulted in a total of 52 relevant articles. We summarize key character- prove difficult (Adelson & Goldfried, 1970). The intervention involved
istics of these studies in Table 1. Although we included only papers having the girl observe the dental treatment of a similar aged non-
published in English and the majority of the investigations took place in fearful child who the dentist was treating immediately prior to her
the United States (n = 24), findings from several areas of the world scheduled appointment. After the observation, the target child was able
were represented in this literature, including England (n = 5), Iran to complete her dental treatment with no uncooperative behaviors
(n = 4), Israel (n = 3), the Netherlands (n = 3), Australia (n = 2), observed. A similar approach was also used in early group intervention
Nigeria (n = 2), Scotland (n = 2), Sweden (n = 2), Canada (n = 1), studies. For example, White, Akers, Green, and Yates (1974) reported
Brazil (n = 1), India (n = 1), Lebanon (n = 1), and Spain (n = 1). an investigation of a modeling treatment in a sample of girls between
Interestingly, as can be seen in Table 1, many of these studies are the ages of four and eight years who evidenced disruptive behavior
probably best conceptualized as preventive interventions, as the during past dental treatment to the degree that all required general
children receiving treatment were not selected to be high in dental anesthesia for dental procedures. The girls assigned to the treatment
anxiety; in fact, a key feature in several of these studies is that children observed a confederate for six sessions of 5 min each. Their behavior
were (dental) treatment naïve. Of the investigations that did select during a dental exam was compared to that of two control groups – a
participants based on some indicator of dental anxiety, none selected group that saw a dentist and dental assistant identify and manipulate

32
 Table 1
Study characteristics.

Authors Country Age N Selected due to anxiety Previous dental Psychosocial treatment(s) investigated and length of Outcome measures coded
treatment treatment
L.D. Seligman et al.

experience

Adelson and Goldfried (1970) United States 3.5 years 1 Yes No Modeling –
Aitken et al. (2002)* United States 48–83 months 45 No Yes Distraction with upbeat music Venham Picture Scale
Distraction with relaxing music North Carolina Behavior Rating
No music Scale
Al-Namankany, Petrie, and England 6–12 years 80 Yes Not Specified Video model Visual analogue scale of anxiety
Ashley (2014)* Control video
Aminabadi et al. (2011)* Iran 6–7 years 80 No No Picture story about going to dentist Modified Child Dental Anxiety
Control story Scale
Sound, Eye, and Motor Scale
Arnrup, Broberg, Berggren, and Sweden 4–12 years 94 Selected due to behavior Yes Individuated treatment including motivational –
Bodin (2003) management problems at interviewing, behavior management techniques, and
dentist nitrous oxide
Bird (1997) England 9 years 1 Yes Yes Hypnosis –
Campbell, Hosey, and McHugh Scotland 3–10 years 198 No Noa Computerized preparation –
(2005) Cartoon preparation
Control - Standard verbal preparation
Cermak, Stein Duker, Williams, United States 6–12 years 44 No Yes Regular dental environment –
Dawson, et al. (2015) Sensory adapted dental environment
Cermak, Stein Duker, Williams, United States 6–12 years 44 No Yes Regular dental environment –
Lane, et al. (2015) Sensory adapted dental environment
Chertock and Bornstein (1979) United States 5–13 years 25 No Yes Covert modeling –
Attention control

33
Number of models (1 or 2) was manipulated as was type of
model (mastery v. coping)
Farhat-McHayleh, Harfouche, Lebanon 5 to 9 years 155 No Not reported Live modeling by mother –
and Souaid (2009) Live modeling by father
Tell-show-do (1session)
Fazli et al. (2014) Iran 2 to 10 years 255 No Not reported Distraction – reading by mother –
Folayan, Ufomata, et al. (2003) Nigeria 8–13 years 81 No Not reported The number and types of interventions dentists used with –
the children during their first visit were recorded.
Folayan and Idehen (2004) Nigeria 8–13 years 84 No No Source and type of information about dental treatment was –
recorded and coded.
Fox and Newton (2006)* England 5–17 years 38 No Mixed Positive dental imagery Venham Picture Test
Neutral images
Green, Meilman, Routh, and United States 2 to 6 years 145 No Mixed Two different preparatory films –
Thomas McIver (1977) Control film
No treatment
Greenbaum et al. (1990) United States 3.5–7 years 40 Yes Yes Loud voice contingent on noncompliance –
Normal voice contingent on noncompliance
Control - Children with no noncompliant behavior
Guinot Jimeno et al. (2014) Spain 6–8 years 43 No Yes Distraction - cartoon –
No treatment control
Heitkemper, Layne, and Sullivan United States 8–11 years 45 No Not reported Paced respiration Unstandardized dentist ratings of
(1993)* Cognitive coping disruptiveness
Attention control
Herbertt and Innes (1979) Australia 5–11 years 422 No Yes Familiarization –
Preparation
Attention control
Hermecz and Malamed (1984) United States 6–12 years 20 No Not reported Stimulus imagery –
Response imagery
Howard and Freeman (2009)* Scotland 5–10 years 73 Nob Not reported After dental treatment children performed dental Modified Child Dental Anxiety
(continued on next page)
Clinical Psychology Review 55 (2017) 25–40
 Table 1 (continued)

Authors Country Age N Selected due to anxiety Previous dental Psychosocial treatment(s) investigated and length of Outcome measures coded
treatment treatment
experience
L.D. Seligman et al.

procedures on a puppet then got reinforcement Scale

Reinforcement only
Isong et al. (2014) United States 7 to 17 years 80 Yes Not reported Peer modeling –
Distraction with movie
Peer modeling + distraction
Usual care
Johnson and Machen (1973) United States 36–65 months 58 No No Desensitization –
Modeling
No treatment control
Kebriaee et al. (2015)* Iran 3–6 ½ years 45 Yes Yes Cognitive behavioral therapy Venham Picture Test
Conscious sedation
Treatment as usual control
Klesges et al. (1984) United States 4 year old 1 Yes Yes Modeling (by mother) and graded exposure with some –
relaxation training, reinforcement and positive expectancy
statements
Klingman et al. (1984) United States 8–13 years 38 Yes Mixed Participant modeling –
Symbolic modeling
Klorman et al. (1980) * United States No age range given. Average 60 Yes Yes Mastery model Unstandardized dentist ratings of
Experiment 1 age across groups was between Coping model child's nervousness during dental
7 and 8 years Attention control session
Behavior Profile Rating Scale
Klorman et al. (1980)* United States No age range reported 46 No Yes Mastery model Frankl Scale
Experiment 2 Coping model Behavior Profile Rating Scale
Attention control

34
Klorman et al. (1980)* United States No age range reported 30 No Noc Mastery model Frankl Scale
Experiment 3 Coping model Behavior Profile Rating Scale
Attention control
Machen and Johnson (1974) United States 36 and 65 months 31 No No Desensitization –
Modeling
No treatment control
Marwah, Prabhakar, and Raju India 4 to 8 years 40 No No Instrumental music distraction –
(2005) Nursery rhyme music distraction
Control
McMurray, Bell, Fusillo, Morgan, Australia 9–12 years 80 Yes Yes Rehearsal of coping skills –
and Wright (1986) Attention control
Melamed et al. (1975) United States 5–11 years 16 No No Coping model –
Attentional control
Melamed et al. (1975) United States 5 to 9 years 14 No Mixed Coping model –
Attentional control
Melamed et al. (1978) United States 4–11 years 80 No Mixed Modeling –
Demonstration of procedures without model
Attention control

Length of film used in modeling and demonstration

conditions was also manipulated.
Olumide, Newton, Dunne, and England 8–12 years 50 No Mixed Preparation Facial Image Scale
Gilbert (2009)* Control information
Paryab and Arab (2014) Iran 4 to 6 years 46 No No Filmed modeling –
Tell-show-do
d
Peterson, Schultheis, Ridley- United States 2 to 11 years 44 No No Puppet presentation of information –
Johnson, Miller, and Tracy Two version of film with child presenting information
(1984) Information preparation by hospital staff
Pickrell et al. (2007)* United States 6 to 9 years 45 No Mixed Memory restructuring + Usual care Children's Fear Survey Schedule –
(continued on next page)
Clinical Psychology Review 55 (2017) 25–40
 Table 1 (continued)

Authors Country Age N Selected due to anxiety Previous dental Psychosocial treatment(s) investigated and length of Outcome measures coded
treatment treatment
experience
L.D. Seligman et al.

Usual care + attention control Dental Subscale

Ramos-Jorge, Ramos-Jorge, Brazil 4 to 11 years 70 No Mixed Positive imagery Venham Picture Test
Vieira de Andrade, and Neutral imagery
Marques (2011)*
Schwartz and Albino (1983) United States 3–4 years 45 No Noe Play session unrelated to hospital or surgical procedures –
Play session related to hospital or surgical procedures
No treatment control
Shahnavaz, Rutley, Larsson, and Sweden 9–19 years 12 Yes Yes Cognitive behavioral therapy package –
Dahllöf (2015)
Shapiro, Melmed, Sgan-Cohen, Israel 6–11 years 19 No Mixed Sensory adapted environment –
Eli, and Parush (2007) Regular dental environment
Shapiro, Melmed, Sgan-Cohen, Israel 6–11 years 16 No Mixed Sensory adapted environment –
and Parush (2009) Regular dental environment
Shapiro, Sgan-Cohen, Parush, Israel 6–11 years 35 Not reported Not reported Sensory adapted environment –
and Melmed (2009) Regular dental environment
Siegel and Peterson (1980)* United States 42–71 months 42 No No Coping skills Behavior Profile Rating Scale
Sensory information
Attention control
Srai, Petrie, Ryan, and England 10–16 years 90 Not reported Nof DVD demonstration of procedure + verbal information –
Cunningham (2013) Verbal information only
Stokes and Kennedy (1980) Canada 7 year olds 8 Yes Yes Baseline – instructions were given to child, information –
was given about procedures, praise was given for
cooperative behavior and whenever possible uncooperative
behavior was ignored, noncontingent reinforcement was

35
given.

Treatment – All baseline activities plus contingent

reinforcement, observation of child in prior appointment
(including observing whether or not the child received
reinforcement), child was then observed by a peer that was
coming next
ter Horst, Prins, Veerkamp, and Netherlands 5-12 years 24 Half were anxious, half Not specified Treatment by dentist with experience treating fearful –
Verhey (1987) were not children
Treatment by dentist without experience treating fearful
children
Veerkamp, Gruythuysen, Netherlands 6–11 years 55 Yes Yes Behavioral management –
Hoogstraten, and van Behavioral management + nitrous oxide sedation
Amerongen (1995)
Veerkamp, Gruythuysen, van Netherlands 6–11 years 55 Yes Yes Behavioral management –
Amerongen, and Behavioral management + nitrous oxide sedation
Hoogstraten (1993)
White et al. (1974) United States 4–8 years 15 Yes Yes Modeling –
Familiarization with treatment equipment
No treatment control
Williams, Hurst, and Stokes United States 4–9 years 5 Yes Yes Baseline – Treatment as usual –
(1983) Treatment – Observation of a peer followed by observation
by a peer.

Studies included in the meta-analysis are marked with a *.

a
Treatment was addressing anxiety in children undergoing dental general anesthetic; participants were required to have no previous experience with any type of general anesthesia.
b
Sample consisted of consecutive admissions. Children were not selected because of anxiety but some in the sample were referred due to anxiety.
c
Participants required a filling but had no previous experience with dental restoration or extractions.
d
Children were undergoing oral surgery, none had previous experience with surgery.
e
Children were being treated for a dental restoration or extraction under general anesthesia; they had no previous surgical experience.
Clinical Psychology Review 55 (2017) 25–40

f
Participants were receiving orthodontic treatment; none had history of prior orthodontic treatment.
L.D. Seligman et al. Clinical Psychology Review 55 (2017) 25–40

the same equipment that was used in the modeling condition (attention phobic youth or even youth with any significant level of dental anxiety.
control) and a second group that received no treatment. Results were The one group study that included participants most likely to be
partially supportive in that the modeling group evidenced more classified as phobic and in need of treatment – girls who had evidenced
cooperative behavior than the no treatment group; however, their disruptive behavior that had interfered with dental treatment on at
behavior did not significantly differ from that of the girls in the least two occasions, all of whom required general anesthesia for dental
attention control group. In fact, few significant differences were procedures on at least one occasion, found that the modeling treatment
observed between the modeling group and the attention control group tested was better than no treatment, but not significantly more effective
with one notable exception - the girls receiving the modeling treatment than an attention control condition which involved simple exposure to
were less likely to request that a significant other be present during the (dental) treatment environment (White et al., 1974).
treatment when compared to both control groups. It should be noted, This finding brings up a second significant shortcoming in our
however, that the sample studied here was very small (n = 15), extant knowledge of treatments for youth with dental anxiety; exposure
particularly given that there were three treatment groups; this likely treatments, currently thought to be a first-line treatment for children
resulted in very low power to detect effects – even those of the with anxiety disorders, including phobias (Davis, Ollendick, & Öst,
magnitude that would be considered clinically meaningful. 2009), are largely missing from the literature on dental anxiety in
Other studies have looked more specifically at manipulating the youth. An interesting exception is a case study of a four year old girl
parameters of modeling treatments to determine the optimal method who was refusing dental treatment due to anxiety (Klesges,
for treatment delivery, but these efforts have been largely unsuccessful. Malott, & Ugland, 1984). The child's mother also had a history of dental
For example, Melamed, Yurcheson, Fleece, Hutcherson, and Hawes anxiety. A multicomponent treatment package that included graded
(1978) examined whether length of time a child observed the model exposure but also relaxation training, modeling (by the mother),
(10 min vs. 4 min) affected treatment outcome. Although both reinforcement strategies, and some cognitive interventions was effec-
modeling treatments were more effective than the control treatments tive in reducing the child's anxiety and gaining treatment compliance.
included in the study – a long and short demonstration presenting Interestingly, however, despite the widespread use of exposure treat-
information on dental procedures – no significant differences were ments for youth with anxiety disorders more generally and specific
found in the two modeling treatments. Similarly, the use of coping and phobias in particular, and the positive outcome for this case published
mastery models and the number of models used have been compared, over 30 years ago, we found no other examples focused on testing
but again, no differences between the treatments have been found exposure treatment for pediatric dental anxiety.
(Chertock & Bornstein, 1979; Klorman, Hilpert, Michael, In sum, it seems that there is some evidence that treatment for
LaGana, & Sveen, 1980, experiment 3); however, it should be noted dental anxiety can be effective, but that this evidence comes largely
that in the Chertock and Bornstein (1979) investigation, the active from investigations of modeling treatments and from samples that were
treatments did not outperform the control treatment which might not diagnosed with a dental phobia. When youth with significant dental
suggest the modeling treatments were not implemented properly. anxiety were included in studies, results were more equivocal. In hopes
Another early investigation by Klingman, Malamed, Cuthberg, and of providing some additional clarity, however, we undertook a brief
Hermecz (1984), however, does suggest that actively encouraging meta-analysis of these findings. More specifically, the goals of the meta-
children to use the skills they see demonstrated by models may enhance analysis were to examine (1) whether there is evidence of efficacy of
the effects of modeling treatments. In this study, 38 youth between the psychosocial treatments for dental anxiety, (2) if there is evidence of
ages of eight and 13 years with scores in the moderate range of a dental efficacy, does this hold true for youth with dental anxiety or only for
anxiety self-report measure were randomized to receive either a prevention of dental anxiety in non-anxious youth, and (3) is there
participant modeling treatment or a symbolic modeling treatment evidence of differential effects for different treatments. Additionally,
before undergoing a simple dental restoration. In both treatments, the given the limitations in the literature on assessment of dental anxiety
children observed a filmed model using imagery techniques and we discussed previously, the varied focus of self-reports measures and
controlled respiration during a dental exam. Children in the participant observer rating (disruptiveness vs. anxiety), and the fact that several
modeling group were encouraged to practice the techniques demon- treatment studies used non-standardized observer ratings of anxiety, we
strated and to choose mental imagery that would be personally wanted to explore whether treatment response varied with the type of
relevant; children in the symbolic modeling condition observed the outcome measure used.
same model using the same techniques and were told the film would
present some ideas to help them overcome their anxiety of the dentist 7.1. A quantitative analysis of treatment for dental anxiety in children and
but they were not actively encouraged to practice or use the techniques. adolescents
Across measures, the children in the participant modeling treatment
showed a greater reduction in anxiety and less disruptive behavior In addition to the criteria mentioned above, we applied the
during the exam. Of course, it is not clear from this investigation following inclusion criteria. Studies needed (1) to compare an active
whether the vicarious conditioning component was necessary or treatment to a wait list or attention control condition – given that our
effective – the study did not include a comparison with simple goal was to examine the effects of treatment, studies comparing two
instruction in the coping techniques (i.e., paced respiration and active treatments were excluded, (2) treatments needed to be clearly
imagery). This last point is important given that other studies have defined with children assigned to a specific treatment condition, (3) a
shown instruction in coping techniques to be effective quantitative self-report, observer measure, or dentist rating of dental
(Siegel & Peterson, 1980). In fact, although distraction treatments tend anxiety, distress, and/or disruptiveness needed to be included, and (4)
not to yield impressive outcomes (Aitken, Wilson, Coury, & Moursi, either means, standard deviations, and samples sizes or an independent
2002; Fazli, Kavandi, & Malekafzali, 2014) and there are some other samples t-test needed to be reported for posttreatment comparisons.
notable exceptions (see for example, Howard & Freeman, 2009), over- Case studies and small-n designs were not included nor were studies
all, studies have found that any treatment – even those performed that reported outcomes only on measures of general anxiety but not
regularly by dentists without specific training in the treatment of dental anxiety. Additionally, we decided to include only studies that
anxiety (Folayan, Ufomata, Adekoya-Sofowora, Otuyemi, & Idehen, looked at dental anxiety in a general pediatric sample, as it may be that
2003; Greenbaum, Turner, Cook, & Melamed, 1990) tend to be effec- dental anxiety in certain populations (e.g., those with developmental
tive. disorders) may require specialized treatment. Outcomes were coded at
One possible reason for this finding, and one glaring shortcoming in posttreatment only. A summary of the literature search and review is
the literature, however, is that very few studies have treated severely presented in Fig. 2. In total we were able to code 12 articles with one

36
L.D. Seligman et al. Clinical Psychology Review 55 (2017) 25–40

article reporting on three separate studies; thus our search ultimately underscore the importance of a multimethod assessment of dental
yielded 14 studies (see Table 1). These studies yielded a total of 37 anxiety as we suggest above.
effect sizes because some studies reported on multiple outcomes or
multiple treatment/control comparisons. This resulted in enough data 7.1.3. Type of treatment
to conduct analyses; however, given the small number of studies Only modeling treatments and distraction methods were investi-
included in this analysis and that three investigations were conducted gated in enough studies to justify the computation of a combined effect.
by the same research team, conclusions must be considered tentative. A coping model treatment was investigated in three studies, but it
We used Comprehensive Meta-Analysis version 3.3 to perform all should be noted that all three investigations were conducted by the
analyses. Due to the heterogeneity in methods and, to some degree, same research team (Klorman et al., 1980). The mean effect size across
treatments used across studies, a random effects model was used. To type of outcome (i.e., self-report, dentist rating, observer rating) within
calculate the overall mean effect size for treatment, the mean effect size study was used to calculate the overall combined treatment effect. The
for each study, across treatments and outcome measures, was calcu- result was not significant, g = 0.18, z = 0.84, p = 0.401 95% CI
lated so that each study contributed one effect to the overall mean. This [−0.23, 0.58]. Four studies examined a modeling treatment using a
resulted in an overall mean effect comparing treatment for dental mastery model, although again, three of these studies were conducted
anxiety to control treatment of Hedges g = 0.98, z = 2.91, p = 0.004, by Klorman and colleagues (Klorman et al., 1980). In this case, the
95% CI [0.32, 1.64], suggesting that, in general, treatment for dental overall effect was significant, g = 3.70, z = 2.46, p = 0.014, 95% CI
anxiety was effective; however, across individual studies both positive [0.75, 6.65]. At first glance, these results seem to suggest the super-
and negative effects were found. Of note, there is some evidence that iority of modeling treatments that use a mastery model; however, the
this effect size may be somewhat biased. For example, both Kendall's combined effect size of mastery modeling treatments is largely driven
tau b and Egger's test both yielded a significant p-value, suggesting the by one study (Aminabadi, Vafaei, Erfanparast, Oskouei, & Jamali, 2011)
presence of bias. However, the fail-safe N was 170. Given that we were that produced much larger effects than any other of the studies coded.
able to find only 14 studies it is unlikely that 170 studies with effect of 0 In fact, if this study is excluded and the effect for mastery modeling
were missed due to search errors or publication bias; thus, although the treatments is based on the three studies conducted by Klorman et al.
true effect of treatment may be smaller than we estimate here, it is (1980), the overall effect is not significant. Examining the differences
unlikely to be zero. between these studies, it is notable that two of the three Klorman et al.
However, no studies selected youth based on a diagnosis of dental investigations included children who had previous experience with
phobia and only three studies included youth selected to be anxious – dental treatment and one included children who had been selected
the overall effect size in these studies (g = 0.34) was not significant based at least a moderate level of dental anxiety, whereas Aminabadi
(p = 0.105). Thus, although our analysis was based on only a very et al. (2011) did not select participants based on dental anxiety and
small number of studies, these findings are consistent with our children were naïve to dental treatment. Thus again, this finding seems
impressions from the broader body of literature; it may be that the to point less to a difference between mastery model and coping model
treatments that are effective for youth without significant dental approaches than it highlights questions about whether findings from
anxiety do not necessarily transfer to those with dental phobia. studies of non-anxious youth can be generalized to the population of
youth likely to seek treatment for dental anxiety - those with dental
7.1.2. Outcome measure phobia. The only other type of intervention to be investigated in at least
To investigate further, effect sizes (across all studies) were calcu- three studies was distraction techniques. The overall effect size across
lated separately for each category of outcome measure. A mean effect the three studies using various types of distraction methods was,
size for each study for each category of outcome measure was g = 0.63, z = 1.12, p = 0.263 95% CI [−0.47, 1.74]. Thus, to date,
calculated first so that each study contributed one effect size to each the data do not support the use of these types of interventions.
analysis. Nine studies provided self-reported dental anxiety on some
type of dental anxiety instrument. The overall effect size of treatment 8. Conclusions and future directions
on self-reported anxiety was g = 1.46, z = 2.86, p = 0.004, 95% CI
[0.46, 2.46], suggesting that treatment did have a significant effect on Although we have learned a good deal about the development,
self-reported dental anxiety. Again, however, analysis suggests this maintenance, and assessment of dental anxiety and dental phobia, our
estimate may be biased, with both Kendall's tau b and Egger's test review suggests several gaps in our knowledge. First, although dental
significant. However, a fail-safe N of 110 again suggests that while the anxiety in youth seems to be linked with oral health and emerging
actual effect may be somewhat different than the estimate obtained research is beginning to suggest a link between pediatric oral health
here, it is not likely 0. and a host of significant diseases and disease processes, whether or not
A different picture emerged when examining dentist ratings of dental anxiety serves as a risk factor for later health complications such
anxiety distress and/or disruptiveness as an indicator of treatment as cardiovascular disease and obesity has not been directly investigated.
outcome. Analysis of the five studies that included dentist ratings of Given the great personal and public health costs inflicted by these
behavior suggested no effect for treatment, g = 0.35, z = 0.76, diseases, research into early predictors that can be modified is sorely
p = 0.445, 95% CI [− 0.54, 1.23]. Interestingly, however, when an needed. We do have some evidence that dental anxiety in youth is
observer other than the treating dentist was used to assess outcome a related to compromised social and emotional well-being, but this work
significant effect was found. Five studies included ratings by an is in its infancy; much more research is needed to understand both the
observer; the overall effect for these studies was g = 2.26, z = 2.05, physical and psychological consequences of dental anxiety. Second, and
p = 0.040, 95% CI [0.10, 4.35]. Although this result represents a group relatedly, although there is a clinical sense that dental anxiety and even
of studies with a wide range of effects and statistical indicators of dental phobia in youth is fairly common, we really know very little
publication bias again indicate that our estimate may be biased, the fail- about their prevalence in youth. Moreover, we do not know whether
safe N of 61, given that we were able to find only five studies in an prevalence has changed with advances in dental practice or public oral
exhaustive search, suggests that the full population of studies would not health efforts that offer better preventative measures and less painful
result in an effect of 0. Thus, taken together these results suggest that treatment procedures. In particular, it will be important to investigate
the effects of treatment on children's behavior during dental procedures the rates and phenomenology of dental anxiety in particular subsets of
may not have been clinically significant enough to impact the percep- youth – such as those with developmental disorders – as these youth
tions of the treating practitioner despite the differences picked up by may require specifically tailored interventions (Cermak, Stein Duker,
the micro-level instruments used by objective raters. As such, the results Williams, Dawson, et al., 2015). Third, although there are several tools

37
L.D. Seligman et al. Clinical Psychology Review 55 (2017) 25–40

with adequate psychometric properties to assess the symptoms asso- Bedi, R., Sutcliffe, P., Donnan, P., Barrett, N., & McConnachie, J. (1992a). Dental caries
experience and prevalence of children afraid of dental treatment. Community Dentistry
ciated with dental anxiety, some of which are brief enough to be and Oral Epidemiology, 20, 368–371.
feasible for use in routine dental practice, little research has been done Bedi, R., Sutcliffe, P., Donnan, P. T., & McConnachie, J. (1992b). The prevalence of dental
to determine the core processes that drive this anxiety. We suggest that anxiety in a group of 13- and 14-year-old Scottish children. International Journal of
Paediatric Dentistry/the British Paedodontic Society [And] the International Association of
one problem hampering research in this area is that the current Dentistry for Children, 2, 17–24.
classification of phobia subtypes in the DSM does not map onto current ten Berge, M., Hoogstraten, J., Veerkamp, J. S. J., & Prins, P. J. M. (1998). The dental
research (Armfield, 2008). Although much more research is needed in subscale of the children's fear survey schedule: A factor analytic study in The
Netherlands. Community Dentistry and Oral Epidemiology, 26, 340–343.
this area, grouping phobias by the apparent similarity of the phobic ten Berge, M., Veerkamp, J. S. J., Hoogstraten, J., & Prins, P. J. M. (2002a). Childhood
stimulus (e.g., dogs and bees, dental procedures and injections) may dental fear in the Netherlands: Prevalence and normative data. Community Dentistry
result in heterogeneous groups that obscure core vulnerabilities in and Oral Epidemiology, 30, 101–107.
ten Berge, M., Veerkamp, J. S. J., Hoogstraten, J., & Prins, P. J. M. (2002b). The dental
affected individuals (e.g., disgust sensitivity, fear of loss control).
subscale of the children's fear survey schedule: Predictive value and clinical
Identification of these vulnerabilities could lead to more targeted usefulness. Journal of Psychopathology and Behavioral Assessment, 24, 115–118. http://
theory driven treatment. This last point is particularly important as dx.doi.org/10.1023/A:1015392825448.
the treatment literature suggests that the treatments studied thus far ten Berge, M., Veerkamp, J. S. J., Hoogstraten, J., & Prins, P. J. M. (2002c). On the
structure of childhood dental fear, using the dental subscale of the children's fear
may be effective in preventing anxiety in youth if they are implemented survey schedule. European Journal of Paediatric Dentistry: Official Journal of European
prior to the first dental appointment, but less effective for youth with Academy of Paediatric Dentistry, 3, 73–78.
clinically significant concerns. Despite the gaps in our knowledge Berggren, U., Carlsson, S. G., Hägglin, C., Hakeberg, M., & Samsonowitz, V. (1997).
Assessment of patients with direct conditioned and indirect cognitive reported origin
regarding effective treatment of dental phobia, very little recent, of dental fear. European Journal of Oral Sciences, 105, 213–220.
rigorous research has been conducted to investigate alternative psy- Bird, N. (1997). Treatment of childhood dental phobia using a modified television
chosocial treatments for dental anxiety. This may be because it has visualization technique. Contemporary Hypnosis, 14, 80–83. http://dx.doi.org/10.
1002/ch.87.
become more feasible to use chemical restraint procedures in youth; Buchanan, H. (2005). Development of a computerised dental anxiety scale for children:
however, these interventions are not without complication and in the Validation and reliability. British Dental Journal, 199, 359.
long run, they circumvent opportunities for non-fearful learning and Buchanan, H. (2010). Assessing dental anxiety in children: The revised smiley faces
program. Child: Care, Health and Development, 36, 534–538. http://dx.doi.org/10.
may even reinforce the types of cognitions related to the dental
1111/j.1365-2214.2009.01033.x.
treatment experience (loss of control) that exacerbate dental anxiety. Buchanan, H., & Niven, N. (2002). Validation of a facial image scale to assess child dental
Another possible reason for the lack of recent developments in anxiety. International Journal of Paediatric Dentistry/The British Paedodontic Society
[And] the International Association of Dentistry for Children, 12, 47–52.
treatment is that investigations into the application of promising
Campbell, C., Hosey, M.-T., & McHugh, S. (2005). Facilitating coping behavior in children
treatments such as in vivo exposure would require a multidisciplinary prior to dental general anesthesia: A randomized controlled trial. Paediatric
approach – involving both experts in psychological approaches to Anaesthesia, 15, 831–838.
anxiety disorders in youth and pediatric dentistry. Although such Carrillo-Díaz, M., Crego, A., Armfield, J. M., & Romero, M. (2012). Self-assessed oral
health, cognitive vulnerability and dental anxiety in children: Testing a mediational
endeavors can be challenging, we suggest that these are exactly the model. Community Dentistry and Oral Epidemiology, 40, 8–16. http://dx.doi.org/10.
types of efforts needed to move forward in our ability to treat youth 1111/j.1600-0528.2011.00646.x.
with dental anxiety and phobias and to prevent the long-term avoid- Carrillo-Diaz, M., Crego, A., Armfield, J. M., & Romero-Maroto, M. (2012). Treatment
experience, frequency of dental visits, and children's dental fear: A cognitive
ance and concomitant oral health and quality of life problems observed approach. European Journal of Oral Sciences, 120, 75–81. http://dx.doi.org/10.1111/
in adults with dental anxiety. j.1600-0722.2011.00921.x.
Cermak, S. A., Stein Duker, L. I., Williams, M. E., Dawson, M. E., Lane, C. J., & Polido, J.
C. (2015a). Sensory adapted dental environments to enhance oral care for children
References with autism spectrum disorders: A randomized controlled pilot study. Journal of
Autism and Developmental Disorders, 45, 2876–2888. http://dx.doi.org/10.1007/
Aartman, I. H. A., van Everdingen, T., Hoogstraten, J., & Schuurs, A. H. B. (1996). s10803-015-2450-5.
Appraisal of behavioral measurement techniques for assessing dental anxiety and fear Cermak, S. A., Stein Duker, L. I., Williams, M. E., Lane, C. J., Dawson, M. E., Borreson, A.
in children: A review. Journal of Psychopathology and Behavioral Assessment, 18, E., & Polido, J. C. (2015b). Feasibility of a sensory-adapted dental environment for
153–171. http://dx.doi.org/10.1007/BF02229114. children with autism. American Journal of Occupational Therapy, 69, p1–p10. 11p
Adelson, R., & Goldfried, M. R. (1970). Modeling and the fearful child patient. ASDC http://dx.doi.org/10.5014/ajot.2015.013714.
Journal of Dentistry for Children, 37, 476. Chapman, H. R., & Kirby-Turner, N. C. (2005). The treatment of dental fear in children
Aitken, J. C., Wilson, S., Coury, D., & Moursi, A. M. (2002). The effect of music distraction and adolescents — A cognitive-behavioural approach to the development of coping
on pain, anxiety and behavior in pediatric dental patients. Pediatric Dentistry, 24, skills and their clinical application. In P. L. Gower (Ed.), New research on the
114–118. psychology of fear (pp. 105–140). Hauppauge, NY, US: Nova Science Publishers.
Al-Namankany, A., Petrie, A., & Ashley, P. (2014). Video modelling and reducing anxiety Chertock, S. L., & Bornstein, P. H. (1979). Covert modeling treatment of children's dental
related to dental injections — A randomised clinical trial. British Dental Journal, 216, fears. Child Behavior Therapy, 1, 249–255. http://dx.doi.org/10.1300/
675–679. http://dx.doi.org/10.1038/sj.bdj.2014.497. J473v01n03_03.
Alvesalo, I., Murtomaa, H., Milgrom, P., Honkanen, A., Karjalainen, M., & Tay, K. M. Costello, E. J., Angold, A., Burns, B. J., Stangl, D. K., Tweed, D. L., & A., E., & Worthman,
(1993). The dental fear survey schedule: A study with Finnish children. International C. M. (1996). The Great Smoky Mountain study of youth: Prevalence and correlates of
Journal of Paediatric Dentistry/the British Paedodontic Society [And] the International DSM-III-R disorders. Archives of General Psychiatry, 53, 1129–1136.
Association of Dentistry for Children, 3, 193–198. Cuthbert, M. I., & Melamed, B. G. (1982). A screening device: Children at risk for dental
American Psychiatric Association (2013). Diagnostic and statistical manual of mental fears and management problems. ASDC Journal of Dentistry for Children, 49, 432–436.
disorders(5 ed.). Washington, DC: Author. Davey, G. C. (1989). Dental phobias and anxieties: Evidence for conditioning processes in
Aminabadi, N. A., Vafaei, A., Erfanparast, L., Oskouei, S. G., & Jamali, Z. (2011). Impact the acquisition and modulation of a learned fear. Behaviour Research and Therapy, 27,
of pictorial story on pain perception, situational anxiety and behavior in children: A 51–58. http://dx.doi.org/10.1016/0005-7967(89)90119-8.
cognitive-behavioral schema. The Journal of Clinical Pediatric Dentistry, 36, 127–132. Davis, T. E., III, Ollendick, T. H., & Öst, L.-G. (2009). Intensive treatment of specific
Armfield, J. M. (2008). A preliminary investigation of the relationship of dental fear to phobias in children and adolescents. Cognitive and Behavioral Practice, 16, 294–303.
other specific fears, general fearfulness, disgust sensitivity and harm sensitivity. http://dx.doi.org/10.1016/j.cbpra.2008.12.008.
Community Dentistry and Oral Epidemiology, 36, 128–136. http://dx.doi.org/10.1111/ Eitner, S., Wichmann, M., Paulsen, A., & Holst, S. (2006). Dental anxiety—An
j.1600-0528.2007.00379.x. epidemiological study on its clinical correlation and effects on oral health. Journal of
Armfield, J. M. (2013). What goes around comes around: Revisiting the hypothesized Oral Rehabilitation, 33, 588–593.
vicious cycle of dental fear and avoidance. Community Dentistry and Oral Epidemiology, Farhat-McHayleh, N., Harfouche, A., & Souaid, P. (2009). Techniques for managing
41, 279–287. http://dx.doi.org/10.1111/cdoe.12005. behaviour in pediatric dentistry: Comparative study of live modelling and tell-show-
Armfield, J. M., Spencer, A. J., & Stewart, J. F. (2006). Dental fear in Australia: who's do based on children's heart rates during treatment. Journal (Canadian Dental
afraid of the dentist? Australian Dental Journal, 51, 78–85. Association), 75, 283.
Arnrup, K., Broberg, A. G., Berggren, U., & Bodin, L. (2003). Treatment outcome in Fazli, M., Kavandi, M. R., & Malekafzali, B. (2014). A method towards children's
subgroups of uncooperative child dental patients: An exploratory study. International psychological health on dental visits. Procedia - Social and Behavioral Sciences, 114,
Journal of Paediatric Dentistry/the British Paedodontic Society [And] the International 420–426. http://dx.doi.org/10.1016/j.sbspro.2013.12.723.
Association of Dentistry for Children, 13, 304–319. Fergusson, D. M., Horwood, L. J., & Lynskey, M. T. (1993). Prevalence and comorbidity of
Baier, K., Milgrom, P., Russell, S., Mancl, L., & Yoshida, T. (2004). Children's fear and DSM-III—R diagnoses in a birth cohort of 15 year olds. Journal of the American
behavior in private pediatric dentistry practices. Pediatric Dentistry, 26, 316–321. Academy of Child and Adolescent Psychiatry, 32, 1127–1134. http://dx.doi.org/10.

38
L.D. Seligman et al. Clinical Psychology Review 55 (2017) 25–40

1097/00004583-199311000-00004. quality of life. Journal of Dental Research, 81, 459–463.

Folayan, M. O., & Idehen, E. E. (2004). Effect of information on dental anxiety and de Jongh, A., Muris, P., ter Horst, G., & Duyx, M. P. M. A. (1995). Acquisition and
behaviour ratings in children. European Journal of Paediatric Dentistry: Official Journal maintenance of dental anxiety: The role of conditioning experiences and cognitive
of European Academy of Paediatric Dentistry, 5, 147–150. factors. Behaviour Research and Therapy, 33, 205–210. http://dx.doi.org/10.1016/
Folayan, M. O., Idehen, E. E., & Ufomata, D. (2003a). The effect of sociodemographic 0005-7967(94)P4442-W.
factors on dental anxiety in children seen in a suburban Nigerian hospital. de Jongh, A., Bongaarts, G., Vermeule, I., Visser, K., De Vos, P., & Makkes, P. (1998).
International Journal of Paediatric Dentistry/The British Paedodontic Society [And] the Blood–injury–injection phobia and dental phobia. Behaviour Research and Therapy,
International Association of Dentistry for Children, 13, 20–26. 36, 971–982. http://dx.doi.org/10.1016/S0005-7967(98)00064-3.
Folayan, M. O., Ufomata, D., Adekoya-Sofowora, C. A., Otuyemi, O. D., & Idehen, E. Kebriaee, F., Sarraf Shirazi, A., Fani, K., Moharreri, F., Soltanifar, A., Khaksar, Y., &
(2003b). The effect of psychological management on dental anxiety in children. The Mazhari, F. (2015). Comparison of the effects of cognitive behavioural therapy and
Journal of Clinical Pediatric Dentistry, 27, 365–370. inhalation sedation on child dental anxiety. European Archives of Paediatric Dentistry:
Folayan, M. O., Idehen, E. E., & Ojo, O. O. (2004). The modulating effect of culture on the Official Journal of the European Academy of Paediatric Dentistry, 16, 173–179. http://
expression of dental anxiety in children: A literature review. International Journal of dx.doi.org/10.1007/s40368-014-0152-x.
Paediatric Dentistry, 14, 241–245. Kılıç, C., Ak, S., & Ak, H. B. (2014). Anxiety sensitivity: Another reason to separate dental
Foster Page, L. A., Thomson, W. M., Jokovic, A., & Locker, D. (2005). Validation of the fears from blood–injury fears? Journal of Anxiety Disorders, 28, 280–282. http://dx.
child perceptions questionnaire (CPQ 11–14). Journal of Dental Research, 84, doi.org/10.1016/j.janxdis.2014.01.001.
649–652. Kiyak, H. A. (1981). Dental beliefs, behaviors and health status among Pacific Asians
Foster Page, L. A., Thomson, W. M., Jokovic, A., & Locker, D. (2008). Epidemiological Caucasians. Community Dentistry and Oral Epidemiology, 9, 10–14.
evaluation of short-form versions of the Child Perception Questionnaire. European Klaassen, M., Veerkamp, J. S. J., & Hoogstraten, J. (2003). Predicting dental anxiety. The
Journal of Oral Sciences, 116, 538–544. http://dx.doi.org/10.1111/j.1600-0722. clinical value of anxiety questionnaires: An explorative study. European Journal of
2008.00579.x. Paediatric Dentistry: Official Journal of European Academy of Paediatric Dentistry, 4,
Fox, C., & Newton, J. T. (2006). A controlled trial of the impact of exposure to positive 171–176.
images of dentistry on anticipatory dental fear in children. Community Dentistry & Oral Klesges, R. C., Malott, J. M., & Ugland, M. (1984). The effects of graded exposure and
Epidemiology, 34, 455–459. parental modeling on the dental phobias of a four-year-old girl and her mother.
Frankl, S., Shiere, F., & Fogels, H. (1962). Should the parent remain with the child in the Journal of Behavior Therapy and Experimental Psychiatry, 15, 161–164. http://dx.doi.
dental operatory. Journal of Dentistry for Children, 29, 150–163. org/10.1016/0005-7916(84)90012-0.
Frisbee, S. J., Chambers, C. B., Frisbee, J. C., Goodwill, A. G., & Crout, R. J. (2010). Self- Klingberg, G., Berggren, U., Carlsson, S. G., & Noren, J. G. (1995). Child dental fear:
reported dental hygiene, obesity, and systemic inflammation in a pediatric rural Cause-related factors and clinical effects. European Journal of Oral Sciences, 103,
community cohort. BMC Oral Health, 10, 21. http://dx.doi.org/10.1186/1472-6831- 405–412.
10-21. Klingman, A., Malamed, B. G., Cuthberg, M. I., & Hermecz, D. A. (1984). Effects of
Gatchel, R. J. (1989). The prevalence of dental fear and avoidance: Expanded adult and participant modeling on information acquisition and skill utilization. Journal of
recent adolescent surveys. Journal of the American Dental Association, 1939(118), Consulting and Clinical Psychology, 52, 414–422. http://dx.doi.org/10.1037/0022-
591–593. 006X.52.3.414.
Green, R. V., Meilman, P., Routh, D. K., & Thomas McIver, F. (1977). Preparing the Klorman, R., Ratner, J., Arata, C. L., King, J. B., Jr., & Sveen, O. B. (1978). Predicting the
preschool child for a visit to the dentist. Journal of Dentistry, 5, 231–236. http://dx. child's uncooperativeness in dental treatment from maternal trait, state, and dental
doi.org/10.1016/0300-5712(77)90010-0. anxiety. ASDC Journal of Dentistry for Children, 45, 62–67.
Greenbaum, P. E., Turner, C., Cook, E. W., & Melamed, B. G. (1990). Dentists' voice Klorman, R., Hilpert, P. L., Michael, R., LaGana, C., & Sveen, O. B. (1980). Effects of
control: Effects on children's disruptive and affective behavior. Health Psychology, 9, coping and mastery modeling on experienced and inexperienced pedodontic patients'
546–548. http://dx.doi.org/10.1037/0278-6133.9.5.546. disruptiveness. Behavior Therapy, 11, 156–168. http://dx.doi.org/10.1016/S0005-
Guinot Jimeno, F., Mercadé Bellido, M., Cuadros Fernández, C., Lorente Rodríguez, A. I., 7894(80)80016-5.
Llopis Pérez, J., & Boj Quesada, J. R. (2014). Effect of audiovisual distraction on Leutgeb, V., Schäfer, A., & Schienle, A. (2011). Late cortical positivity and cardiac
children's behaviour, anxiety and pain in the dental setting. European Journal of responsitivity in female dental phobics when exposed to phobia-relevant pictures.
Paediatric Dentistry: Official Journal of European Academy of Paediatric Dentistry, 15, International Journal of Psychophysiology, 79, 410–416. http://dx.doi.org/10.1016/j.
297–302. ijpsycho.2011.01.003.
Hammock, S. J. (1999). Dental anxiety and behavioral inhibition in young children. Liddell, A., & Gosse, V. (1998). Characteristics of early unpleasant dental experiences.
ProQuest information & learning, US. Vol. 59. Retrieved from EBSCOhost psyh database Journal of Behavior Therapy and Experimental Psychiatry, 29, 227–237. http://dx.doi.
http://search.ebscohost.com/login.aspx?direct=true&db=psyh&AN=1999-95002- org/10.1016/S0005-7916(98)00014-7.
165&site=ehost-live. Liddell, A., & Locker, D. (2000). Changes in levels of dental anxiety as a function of dental
Hayden, C., Bowler, J. O., Chambers, S., Freeman, R., Humphris, G., Richards, D., & Cecil, experience. Behavior Modification, 24, 57–68. http://dx.doi.org/10.1177/
J. E. (2013). Obesity and dental caries in children: A systematic review and meta- 0145445500241003.
analysis. Community Dentistry and Oral Epidemiology, 41, 289–308. http://dx.doi.org/ Lin, Y.-L., Yen, Y.-Y., Chen, H.-S., Liu, Y.-C., Chang, C.-S., Chen, C.-M., ... Huang, H.-L.
10.1111/cdoe.12014. (2014). Child dental fear in low-income and non-low-income families: A school-based
Heitkemper, T., Layne, C., & Sullivan, D. M. (1993). Brief treatment of children's dental survey study. Journal of Dental Sciences, 9, 165–171. http://dx.doi.org/10.1016/j.jds.
pain and anxiety. Perceptual and Motor Skills, 76, 192–194. 2013.02.022.
Herbertt, R. M., & Innes, J. M. (1979). Familiarisation and preparatory information in the Locker, D., Shapiro, D., & Liddell, A. (1997). Overlap between dental anxiety and
reduction of anxiety in child dental patients. Journal of Dentistry for Children, 46, blood–injury fears: Psychological characteristics and response to dental treatment.
319–323. Behaviour Research and Therapy, 35, 583–590. http://dx.doi.org/10.1016/S0005-
Hermecz, D. A., & Malamed, B. G. (1984). The assessment of emotional imagery training 7967(97)00016-8.
in fearful children. Behavior Therapy, 15, 156–172. Locker, D., Liddell, A., Dempster, L., & Shapiro, D. (1999). Age of onset of dental anxiety.
Holmes, R. D., & Girdler, N. M. (2005). A study to assess the validity of clinical judgement Journal of Dental Research, 78, 790–796.
in determining paediatric dental anxiety and related outcomes of management. Locker, D., Poulton, R., & Thomson, W. M. (2001). Psychological disorders and dental
International Journal of Paediatric Dentistry/The British Paedodontic Society [And] the anxiety in a young adult population. Community Dentistry and Oral Epidemiology, 29,
International Association of Dentistry for Children, 15, 169–176. 456–463.
ter Horst, G., Prins, P., Veerkamp, J., & Verhey, H. (1987). Interactions between dentists Luoto, A., Lahti, S., Nevanperä, T., Tolvanen, M., & Locker, D. (2009). Oral-health-related
and anxious child patients: A behavioral analysis. Community Dentistry and Oral quality of life among children with and without dental fear. International Journal of
Epidemiology, 15, 249–252. Paediatric Dentistry/The British Paedodontic Society [And] the International Association
van Houtem, C. M. H. H., Aartman, I. H. A., Boomsma, D. I., Ligthart, L., Visscher, C. M., & of Dentistry for Children, 19, 115–120. http://dx.doi.org/10.1111/j.1365-263X.2008.
de Jongh, A. (2014). Is dental phobia a Blood-Injection-Injury phobia? Depression and 00943.x.
Anxiety, 31, 1026–1034. http://dx.doi.org/10.1002/da.22168. Machen, J. B., & Johnson, R. (1974). Desensitization, model learning, and the dental
Howard, K. E., & Freeman, R. (2007). Reliability and validity of a faces version of the behavior of children. Journal of Dental Research, 53, 83–87.
Modified Child Dental Anxiety Scale. International Journal of Paediatric Dentistry/The Marwah, N., Prabhakar, A. R., & Raju, O. S. (2005). Music distraction—Its efficacy in
British Paedodontic Society [And] the International Association of Dentistry for Children, management of anxious pediatric dental patients. Journal of the Indian Society of
17, 281–288. Pedodontics and Preventive Dentistry, 23, 168–170.
Howard, K. E., & Freeman, R. (2009). An evaluation of the PALS after treatment McMurray, N. E., Bell, R. J., Fusillo, A. D., Morgan, M., & Wright, F. A. C. (1986).
modelling intervention to reduce dental anxiety in child dental patients. International Relationship between locus of control and effects of coping strategies on dental stress
Journal of Paediatric Dentistry/The British Paedodontic Society [And] the International in children. Child and Family Behavior Therapy, 8, 1–17. http://dx.doi.org/10.1300/
Association of Dentistry for Children, 19, 233–242. http://dx.doi.org/10.1111/j.1365- J019v08n03_01.
263X.2009.00977.x. Melamed, B. G., Weinstein, D., Katin-Borland, M., & Hawes, R. (1975a). Reduction of fear-
Isong, I. A., Rao, S. R., Holifield, C., Iannuzzi, D., Hanson, E., Ware, J., & Nelson, L. P. related dental management problems with use of filmed modeling. Journal of the
(2014). Addressing dental fear in children with autism spectrum disorders: A American Dental Association, 1939(90), 822–826.
randomized controlled pilot study using electronic screen media. Clinical Pediatrics, Melamed, B. G., Hawes, R. R., Heiby, E., & Glick, J. (1975b). Use of filmed modeling to
53, 230–237. http://dx.doi.org/10.1177/0009922813517169. reduce uncooperative behavior of children during dental treatment. Journal of Dental
Johnson, R., & Machen, J. B. (1973). Behavior modification techniques and maternal Research, 54, 797–801.
anxiety. ASDC Journal of Dentistry for Children, 40, 272–276. Melamed, B. G., Yurcheson, R., Fleece, E. L., Hutcherson, S., & Hawes, R. (1978). Effects
Jokovic, A., Locker, D., Stephens, M., Kenny, D., Tompson, B., & Guyatt, G. (2002). of film modeling on the reduction of anxiety-related behaviors in individuals varying
Validity and reliability of a questionnaire for measuring child oral-health-related in level of previous experience in the stress situation. Journal of Consulting and Clinical

39
L.D. Seligman et al. Clinical Psychology Review 55 (2017) 25–40

Psychology, 46, 1357–1367. http://dx.doi.org/10.1037/0022-006X.46.6.1357. and physiological effect of dental environment sensory adaptation on children's
Merckelbach, H., Muris, P., de Jong, P. J., & de Jongh, A. (1999). Disgust sensitivity, dental anxiety. European Journal of Oral Sciences, 115, 479–483.
blood-injection-injury fear, and dental anxiety. Clinical Psychology & Psychotherapy, 6, Shapiro, M., Melmed, R. N., Sgan-Cohen, H. D., & Parush, S. (2009a). Effect of sensory
279–285. http://dx.doi.org/10.1002/(SICI)1099-0879(199910)6:4<279::AID- adaptation on anxiety of children with developmental disabilities: A new approach.
CPP210>3.0.CO;2-R. Pediatric Dentistry, 31, 222–228.
Milgrom, P., Mancl, L., King, B., & Weinstein, P. (1995). Origins of childhood dental fear. Shapiro, M., Sgan-Cohen, H. D., Parush, S., & Melmed, R. N. (2009b). Influence of
Behaviour Research and Therapy, 33, 313–319. http://dx.doi.org/10.1016/0005- adapted environment on the anxiety of medically treated children with
7967(94)00042-I. developmental disability. The Journal of Pediatrics, 154, 546–550. http://dx.doi.org/
Muris, P., & Ollendick, T. H. (2002). The assessment of contemporary fears in adolescents 10.1016/j.jpeds.2008.10.017.
using a modified version of the Fear Survey Schedule for Children-Revised. Journal of Siegel, L. J., & Peterson, L. (1980). Stress reduction in young dental patients through
Anxiety Disorders, 16, 567–584. coping skills and sensory information. Journal of Consulting and Clinical Psychology,
Nakazono, T. T., Davidson, P. L., & Andersen, R. M. (1997). Oral health beliefs in diverse 48, 785–787. http://dx.doi.org/10.1037/0022-006X.48.6.785.
populations. Advances in Dental Research, 11, 235–244. Skaret, E., Raadal, M., Berg, E., & Kvale, G. (1999). Dental anxiety and dental avoidance
Ollendick, T. H. (1983). Reliability and validity of the Revised Fear Survey schedule for among 12 to 18 year olds in Norway. European Journal of Oral Sciences, 107, 422–428.
Children (FSSC-R). Special Issue: Fears Born and Bred: Non-associative Fear Acquisition? Srai, J. P. K., Petrie, A., Ryan, F. S., & Cunningham, S. J. (2013). Assessment of the effect
21, 685–692. of combined multimedia and verbal information vs verbal information alone on
Ollendick, T. H., & Davis, T. E., III (2001). How I feel about things. Unpublished quality of anxiety levels before bond-up in adolescent orthodontic patients: A single-center
life measure available from Thomas H. Ollendick. Blacksburg, VA: Virginia randomized controlled trial. American Journal of Orthodontics and Dentofacial
Polytechnic Institute and State University. Orthopedics, 144, 505–511. http://dx.doi.org/10.1016/j.ajodo.2013.06.013.
Ollendick, T. H., Öst, L.-G., Reuterskiöld, L., Costa, N., Cederlund, R., Sirbu, C., ... Jarrett, Stokes, T. F., & Kennedy, S. H. (1980). Reducing child uncooperative behavior during
M. A. (2009). One-session treatment of specific phobias in youth: A randomized dental treatment through modeling and reinforcement. Journal of Applied Behavior
clinical trial in the United States and Sweden. Journal of Consulting and Clinical Analysis, 13, 41–49. http://dx.doi.org/10.1901/jaba.1980.13-41.
Psychology, 77, 504–516. http://dx.doi.org/10.1037/a0015158. Sullivan, C., Schneider, P. E., Musselman, R. J., Dummett, C. O., Jr., & Gardiner, D.
Olumide, F., Newton, J. T., Dunne, S., & Gilbert, D. B. (2009). Anticipatory anxiety in (2000). The effect of virtual reality during dental treatment on child anxiety and
children visiting the dentist: Lack of effect of preparatory information. International behavior. ASDC Journal of Dentistry for Children, 67, 193.
Journal of Paediatric Dentistry/The British Paedodontic Society [And] the International Themessl-Huber, M., Freeman, R., Humphris, G., MacGillivray, S., & Terzi, N. (2010).
Association of Dentistry for Children, 19, 338–342. http://dx.doi.org/10.1111/j.1365- Empirical evidence of the relationship between parental and child dental fear: A
263X.2009.00980.x. structured review and meta-analysis. International Journal of Paediatric Dentistry /The
Öst, L.-G. (1987). Age of onset in different phobias. Journal of Abnormal Psychology, 96, British Paedodontic Society [And] the International Association of Dentistry for Children,
223–229. http://dx.doi.org/10.1037/0021-843X.96.3.223. 20, 83–101. http://dx.doi.org/10.1111/j.1365-263X.2009.00998.x.
Öst, L.-G. (1992). Blood and injection phobia: Background and cognitive, physiological, Townend, E., Dimigen, G., & Fung, D. (2000). A clinical study of child dental anxiety.
and behavioral variables. Journal of Abnormal Psychology, 101, 68–74. http://dx.doi. Behaviour Research and Therapy, 38, 31–46. http://dx.doi.org/10.1016/S0005-
org/10.1037/0021-843X.101.1.68. 7967(98)00205-8.
Paryab, M., & Arab, Z. (2014). The effect of filmed modeling on the anxious and Valencia, A., Damiano, P., Qian, F., Warren, J. J., Weber-Gasparoni, K., & Jones, M.
cooperative behavior of 4–6 years old children during dental treatment: A (2012). Racial and ethnic disparities in utilization of dental services among children
randomized clinical trial study. Dental Research Journal, 11, 502–507. in Iowa: The Latino experience. American Journal of Public Health, 102, 2352–2359.
Paulus, F. W., Backes, A., Sander, C. S., Weber, M., & Gontard, A. (2015). Anxiety http://dx.doi.org/10.2105/AJPH.2011.300471.
disorders and behavioral inhibition in preschool children: A population-based study. Veerkamp, J. S., Gruythuysen, R. J., van Amerongen, W. E., & Hoogstraten, J. (1993).
Child Psychiatry and Human Development, 46, 150–157. http://dx.doi.org/10.1007/ Dental treatment of fearful children using nitrous oxide. Part 3: Anxiety during
s10578-014-0460-8. sequential visits. ASDC Journal of Dentistry for Children, 60, 175–182.
Peterson, L., Schultheis, K., Ridley-Johnson, R., Miller, D. J., & Tracy, K. (1984). Veerkamp, J. S., Gruythuysen, R. J., Hoogstraten, J., & van Amerongen, W. E. (1995).
Comparison of three modeling procedures on the presurgical and postsurgical Anxiety reduction with nitrous oxide: A permanent solution? ASDC Journal of
reactions of children. Behavior Therapy, 15, 197–203. http://dx.doi.org/10.1016/ Dentistry for Children, 62, 44–48.
S0005-7894(84)80021-0. Venham, L. L., & Gaulin-Kremer, E. (1979). A self-report measure of situational anxiety
Pickrell, J. E., Heima, M., Weinstein, P., Coolidge, T., Coldwell, S. E., Skaret, E., ... for young children. Pediatric Dentistry, 1, 91–96.
Milgrom, P. (2007). Using memory restructuring strategy to enhance dental Venham, L. L., Bengston, D., & Cipes, M. (1978). Parent's presence and the child's
behaviour. International Journal of Paediatric Dentistry/The British Paedodontic Society response to dental stress. ASDC Journal of Dentistry for Children, 45, 213–217.
[And] the International Association of Dentistry for Children, 17, 439–448. Vowles, K. E., McNeil, D. W., Sorrell, J. T., McKee, D. R., Zvolensky, M. J., Graves, R. W.,
Ramos-Jorge, M. L., Ramos-Jorge, J., Vieira de Andrade, R. G., & Marques, L. S. (2011). ... Riel, J. R. (2005). Oral surgery appointment attendance: Effects from fears of
Impact of exposure to positive images on dental anxiety among children: A controlled dentistry and pain. In P. L. Gower, & P. L. Gower (Eds.), New research on the
trial. European Archives of Paediatric Dentistry: Official Journal of the European Academy psychology of fear (pp. 91–103). Hauppauge, NY, US: Nova Science Publishers.
of Paediatric Dentistry, 12, 195–199. Weisenberg, M., Kreindler, M. L., Schachat, R., & Werboff, J. (1975). Pain: Anxiety and
Scherer, M. W., & Nakamura, C. Y. (1968). A Fear Survey Schedule for Children (FSS-FC): attitudes in black, white and Puerto Rican patients. Psychosomatic Medicine, 37,
A factor analytic comparison with manifest anxiety (CMAS). Behaviour Research and 123–135.
Therapy, 6, 173–182. http://dx.doi.org/10.1016/0005-7967(68)90004-1. White, W. C., Jr., Akers, J., Green, J., & Yates, D. (1974). Use of imitation in the treatment
Schwartz, B. H., & Albino, J. E. (1983). Effects of psychological preparation on children of dental phobia in early childhood: A preliminary report. ASDC Journal of Dentistry
hospitalized for dental operations. The Journal of Pediatrics, 102, 634–638. http://dx. for Children, 41, 106–110.
doi.org/10.1016/S0022-3476(83)80211-X. Williams, J. A., Hurst, M. K., & Stokes, T. F. (1983). Peer observation in decreasing
Shahnavaz, S., Rutley, S., Larsson, K., & Dahllöf, G. (2015). Children and parents' uncooperative behavior in young dental patients. Behavior Modification, 7, 225–242.
experiences of cognitive behavioral therapy for dental anxiety — A qualitative study. http://dx.doi.org/10.1177/01454455830072007.
International Journal of Paediatric Dentistry, 25(317–326), 310p. http://dx.doi.org/10. Wong, H. M., Humphris, G. M., & Lee, G. T. R. (1998). Preliminary validation and
1111/ipd.12181. reliability of the modified child dental anxiety scale. Psychological Reports, 83,
Shapiro, M., Melmed, R. N., Sgan-Cohen, H. D., Eli, I., & Parush, S. (2007). Behavioural 1179–1186. http://dx.doi.org/10.2466/PR0.83.7.1179-1186.

40