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Within the United Kingdom it is well recognised that the process of receiving dental care may be anxiety provoking. The reason for this includes fear of pain, a feeling of vulnerability or lack of control and many other factors. In children, anxiety can derive from a negative influence from peers or relatives and also from their own experiences. The need to prevent such anxieties in early life and establish a positive and fear-free attitude towards dental care is essential in establishing continuing care for life. Two basic concepts underline the treatment of children.

  • It is important to treat children in a way that encourages them not to be afraid of the dentist.

  • If they are afraid they should be treated in a way that encourages them not to be afraid of the dentist.

The generally accepted approaches to patient management using local anaesthesia are:

  • The use of tender loving care (TLC) and a variety of behavioural management techniques.

  • The use of these techniques along with effective conscious sedation, such that care can be properly carried out and without causing anxiety to the patient. The effectiveness of the conscious sedation technique is of paramount importance.

A half effective technique may be the worst of both worlds, as it may be regarded as a failure by the patient and further enhance anxiety.

To be effective the treatment should be acceptable to not only the child and parent/carer but also the whole dental team. The use of conscious sedation in the UK requires techniques that provide a calm and controlled response within the child such that treatment can be safely and effectively completed.

Acceptability of treatment to the dental team within the UK would not include the use of restraint. This is not necessarily just a reflection of the current expectation of present day society but a professional stance. The image of the professional dentist using restraint is one that is considered inappropriate, unattractive and one that UK dentists would find repugnant.

In the course of treatment, reassurance may be required through physical contact by the dentist and/or nurse. The use of restraint would not be considered to be a reassuring and comforting technique by dentists in the UK. On the contrary, such a policy would be regarded as one of creating anxiety rather than a management strategy to alleviate anxiety. The child may cry for reasons that are not related to fear or anxiety but rather stem from the child's self interest ie 'I want my own way'. In such situations a positive management technique may well be appropriate but physical restraint crosses the boundaries of what is considered acceptable in terms of civil liberty for the child.

In the UK, children are often treated as part of a family and although under parental care, even at a young age the wishes of the child as an individual in their own right are both respected and protected. An expression of resistance may also be considered in many ways a natural response as it may reflect the normal development of the child ('terrible twos') and with patience and good effective management may be transformed into an accepting child and grateful parent.

The quiescent and extremely reserved child who offers no communication is probably more of a worry to the UK paedodontist than the lively resistant youngster. A child's freedom of will whilst on some occasions is regarded as inconvenient remains an essential tenant of UK society.

It may be suggested that a modern attitude towards children is softer than in years gone past and this fosters the 'nanny society'. Pain threshold varies between societies and cultures. Tolerance of discomfort is almost certainly a requirement for dental treatment and may be considered to be at one end of the spectrum of the pain threshold.

There may be an unwritten perception in some cultures that a low pain threshold is considered weak and reflects inadequacies in a person and that a high tolerance to pain is an admirable quality. However the days of dental treatment without the use of local anaesthetic along with the child management line of 'don't make a fuss' or 'be good' are surely something now to be avoided. Far from strengthening resolve such an approach may have created many of our dentally anxious patients. Fear is a protective and natural response and not a sign of weakness.

Situations of conflict arise when it is considered in the interest of the child's health that action is taken against the will of the child. Weighing the balance between the child's best interest against the will of the child when reaching a decision has a professional and legal aspect. The extent to which the professional aspect (of the child's best interest) is pursued may depend on the severity of the condition and the effectiveness of the proposed treatment and/or prevention.

For example in the case of treatment of a grossly decayed lower first molar in a seven year old various options are available. Restoration or extraction with: local anaesthetic, local anaesthetic with effective conscious sedation, or general anaesthesia. If the first two are not possible due to the child's non-compliance then the general anaesthetic route would be appropriate. The use of conscious sedation with restraint to avoid general anaesthetic 'at all costs' would be considered to be a totally unacceptable technique in order to affect what is considered best for the child (getting the job done).

The idea of general anaesthesia in the UK for dental work is very tightly controlled. Current standards demand facilities such as proximity to critical care, which is a requirement not necessarily applied in other surgical specialities. Contrary to some popular feeling general anaesthetic is a safe procedure. At a risk level of 1:180,000 death relating to general aneasthesia is less risky that death relating to, having an accident at home (1:11,000) or on the roads (1:8,000).1 Although of course such statistics enable us to make these dispassionate comparisons, for the very rare case where death of a child occurs, for the parent of that child the tragic loss is 100%. Therefore although general anaesthetic is a safe procedure, it is a further intervention and its use should be carefully considered.

The opening premise to this comment identified a need for the management of anxiety in some patients attending for dental care. Conscious sedation without the use of restraint is an excellent technique for safely providing an environment of calm control in which good dentistry can be provided. This is well recognised in the United Kingdom where both intravenous and inhalation sedation are taught at undergraduate and postgraduate level. Conscious sedation is as essential to dentistry as are windscreen wipers to a motorcar, both in their own way wiping away the tears and making things clear. It is interesting to learn of different approaches to pain and anxiety management which may be well accepted in other cultures and societies but which are completely unacceptable within UK dentistry.