Key points

Introduction

Dental caries is the most common disease of childhood and adolescence and yet almost all dental treatment in the United States is performed without sedation or general anesthesia. In addition to providing competent clinical care, dentists must also use techniques to shape behavior, allay anxiety, and promote coping. This process has traditionally been called behavior management, where the dentist focuses on obtaining cooperation to complete the needed procedures regardless of long-term effects. A more contemporary approach is behavior guidance, where the dentist acts as a coach to promote coping and lifelong positive views of dentistry.

The literature on behavior guidance in dentistry has focused primarily on promoting cooperation with preschool-aged or school-aged patients. Even within this body of literature there are few techniques that are clearly supported by evidence to be superior to others. ^, With populations less frequently studied, such as adolescents, evidence supporting different interventions is more scarce, despite it being a critical time for acquisition or remission of dental fear. This article reviews salient features of adolescent development in conjunction with conceptual issues related to dental fear, anxiety, and phobia. It reviews nonpharmacologic strategies to improve acceptance of dental treatment that can be provided by dental teams as well as guidance about when to involve mental health professionals (further guidance on pharmacologic management can be found in the Matthew Cooke and Thomas Tanbonliong’s article, “ Sedation and Anesthesia for the Adolescent Dental Patient ,” in this issue).

Developmental considerations for behavior guidance in adolescence

Adolescence is a critically important developmental stage of transition from childhood to adulthood. The American Academy of Pediatrics has outlined numerous aspects of, and health challenges encountered during, this developmental stage, describing the needs of individuals 11 to 21 years old as “unique.” Several defining characteristics of adolescence have important implications for interactions with adolescent dental patients and also have implications for these young people’s oral health–related behaviors and experiences.

In addition to physiologic changes (namely puberty), adolescence involves other significant biological as well as psychosocial changes. Ongoing brain development is experienced throughout adolescence. Changes in the regions of the brain that regulate impulse control and changes in the brain’s reward system increase not only risk-taking behavior but also the intensity of adolescents’ response to emotionally loaded situations. This observation is especially true in early and middle adolescence, with capacity for emotion regulation increasing across adolescence. These changes and their effects are a normal part of development, and conceptualizations of adolescence as a period of disturbance and problem behavior have long been debunked by developmental scientists. That is, the supposed problems most adolescents experience typically are transitory, part of the process of development, and resolved by adulthood. However, these changes may result in emotional sequelae that have relevance to adolescents’ experience of potentially emotionally loaded dental encounters. Thus, emotionality should be considered by dental clinicians. Beginning in early adolescence and coinciding with white matter increases, noteworthy and often fairly rapid improvements in reasoning, information processing, and complex cognitive abilities are typical. ^, The result of these changes is increased abstract, multidimensional, and planned thinking as well as adaptive behavior. ^, Adverse childhood experiences can affect various aspects of this cognitive development.

Adolescents’ social development is just as profound as their cognitive development. It is true that the adolescent-parent relationship goes through significant transformations during adolescence; however, this transformation is rarely as negative and riddled with alienation and rebellion as is often portrayed in popular culture. More typical adolescent-parent relationship changes include a movement from hierarchical to egalitarian relationships through a process that involves less intense, but still complicated and sometimes difficult, conflict, distancing, and separation. This process is normal and, compared with no conflict or frequent conflict, some conflict with parents is linked to better adjustment. ^, Culture, economic security, structural changes (eg, divorce), and parenting styles can affect this process. As the adolescent-parent relationship transforms, adolescents simultaneously spend increasing time alone and with friends. Contrary to some portrayals of peer influences on adolescents as potentially largely negative, most adolescent-peer relationships are characterized by increasing closeness, disclosing, and support. However, adolescent-peer relationships can be complicated, particularly when considering the larger social context, and this may result in interpersonal difficulty and emotional distress. Note that the influence of peers on adolescents can be both positive and negative and that the influence is less often coercive and more often the product of admiration and respect. This social development in adolescence is mediated by brain and cognitive development.

A defining feature of adolescence is increasing independence. Refinement of the social self and a deepening and cementing of the adolescents’ identity occur across adolescence. Beginning in early adolescence, people’s self-concept becomes more abstract and nuanced. Although there is often some instability during middle adolescence, by late adolescence most people have developed an organized sense of self. Along with changing parent and peer relationships, this results in an identity, beliefs, and behaviors that are unique to the individual and that can persist well into adulthood. An adolescent’s transition to independence has implications for health behaviors, including the future patterns of health that are established during this critical period. As such, the National Institute of Dental and Craniofacial Research importantly suggests that healthy behaviors and health promotion during adolescence can benefit oral and overall health into adulthood. Likewise, adolescents’ experiences with health care and the coping skills they develop to manage potential distress during health care visits can have lifetime influence.

Fear, anxiety, and phobia: conceptual issues

Understanding dental care–related fear, anxiety, and phobia as the complex, multifactorial, and highly individualized experiences they are is essential to applying the appropriate behavior guidance techniques and other strategies for effective management. Although much of what is known about fear, anxiety, and phobia (including that related to dental care) is universal across the lifespan, some of the aforementioned developmental considerations unique to adolescence are helpful for fully appreciating the emotional experience and its consequences. Within the dental care–related fear and anxiety literature, limited specialized attention has been paid to adolescents, but certain developmental considerations can be mapped onto what is known.

Although overlapping and often described interchangeably, dental care–related fear, anxiety, and phobia represent 3 distinct emotional and behavioral phenomena. Briefly, fear is an immediate emotional response to stimuli perceived to be threatening and is often characterized by physiologic arousal (ie, sympathetic responding or panic symptoms), reports of apprehension, and avoidance behavior. This response is distinguished from anxiety, which often also involves physiologic responsivity, though frequently less robust, and typically is much more cognitively involved, characterized by more pronounced negative thoughts and worries about possible or future encounters with stimuli perceived to be threatening. In other words, fear is the in-the-moment emotional response to potentially dangerous situations and anxiety is what occurs distally in time with respect to the situation. Most succinctly, phobia describes an impairing and emotionally distressing experience wherein avoidance resulting from fear and/or anxiety is so significant that it affects functioning and health (eg, consistent excessive delaying of dental treatment because of fear/anxiety that leads to unmet treatment needs, pain, and poorer quality of life). ^, Phobias typically are diagnosed by a mental health professional.

Although most patients with fears and anxieties about dental treatment experience both emotions, it is often the case that patients experience one more than the other. Appreciating the distinction is thus helpful in selecting the most appropriate behavior guidance techniques and other strategies for management. Pediatric providers may find it especially useful to distinguish between fear and anxiety in adolescents. Because they have increasingly developed abstract thinking skills and higher-level cognitive processes as they age, they may be more likely to present with worry or rumination (ie, anxiety). Moreover, they may be experiencing this emotional reaction to dentistry for the first time. Helping these patients to manage pretreatment anxiety (and not just helping them cope with in-the-moment distress during a dental visit) thus may be especially useful.

Also critical to understanding dental care–related fear and anxiety is appreciating the patient’s experience of the phenomena occurs along a continuum. On 1 end of the continuum is a complete absence of fear and anxiety; on the other is phobia, with significant emotional distress and excessive or complete avoidance of dental stimuli. Some degree of fear and anxiety about dental treatment might be expected and considered normal, in part because there are indeed aspects of dental care that are unpleasant or uncomfortable at times (eg, potential for pain, feeling closed in, perceiving a loss of control), or at least have the potential to be. Between the normal range and phobic levels, a patient can experience increasingly distressing fear and anxiety associated with increasing behavior disruptions and avoidance or attempts at avoidance. Patients historically were thought of as being either fearful or not fearful of dental treatment; but contemporary research has revealed that the emotional experience is dimensional and involves a range of possible intensity and impact. Given adolescents’ abstract thinking skills, including more advanced numeracy, more nuanced assessment of fear and anxiety intensity is possible compared with children. Such assessment allows for the provision of more person-centered care that addresses the individualized nature of emotional experiences across the entire gradient.

The causes of dental care–related fear and anxiety are many and the influences that maintain or perpetuate fear, anxiety, and the behavioral sequelae are complex. A more specific review of the dental literature regarding all the causes of dental care–related fear, anxiety, and phobia is included later but an exhaustive review is beyond the scope of this article; instead, readers are directed to a few reviews, book chapters, and books. Briefly, numerous causal mechanisms and predisposing factors have been identified, including learning (especially associative learning; ie, conditioning), social learning (including intergenerational transmission), cognitive processes (ie, thoughts), temperament and personality, pain sensitivity and pain perception, and distress tolerance. ^, Three of these causal pathways/factors have particular relevance to adolescents’ experience of dental care–related fear and anxiety.

First, conditioned fear or anxiety accounts for a potentially large proportion of the dental care–related fear and anxiety experience. ^{, ,} In such a situation, patients who have painful or otherwise negative experiences in the dental setting associate the pain or distressing physical sensations with dental stimuli, such as the process of having a bib secured around the neck, the sight of a masked clinician, the sound of a drill, or the characteristic smell of the operatory. Subsequently, these patients can experience distress when they encounter those same stimuli, even in the absence of pain or discomfort, and they may show behavior management problems or avoid dental care to avoid the distress. Fear can be caused in this manner at any age, but it is known to be common and more frequent among younger people. ^, For instance, of adults who report dental care–related fear, nearly one-quarter endorse onset in adolescence (and more than half in childhood), with prior painful or otherwise negative experiences cited as the most common cause. Similarly, approximately 35% of children aged 6 to 14 years report having experienced pain during dental care. In addition to using good pain control strategies, it may be particularly helpful to adolescents to explain clinical procedures and the stimuli encountered, because they are cognitively able to use this information to cope or make sense of what otherwise might be perceived as more threatening than it actually is.

Second, social learning can account for fears and anxieties about dental treatment when a person has not previously had a painful or negative experience with dentistry. That is, fear and anxiety can be caused by communication or observational learning. In these cases, someone may hear about an aversive dental experience from a parent, friend, or other source (eg, mass entertainment or media outlets) or may witness someone else’s pain or fear reaction to dental stimuli. ^, Generalized or specific worries about dental treatment–related stimuli or fear reactions in the dental setting can follow. Considering age-related social development, adolescents’ primary source of information about dental stimuli as threatening may shift from parents to peers, and so it may be increasingly appropriate to ask questions such as, “What have you heard from your friends about this?” in order to fully understand the fear and anxiety experience. Note that the prevalence of this fear acquisition pathway likely is much lower than for direct conditioning and the evidence for this cause much less robust.

Third, for children, adolescents, and adults, cognitive factors can play a role in the development and maintenance of dental care–related fear and anxiety. ^{, ,} People’s perceptions of themselves in relation to the dental setting, and their thoughts about dental stimuli and self-efficacy related to coping, can facilitate fear and anxiety acquisition (or can be protective). Several cognitive factors influence fear, anxiety, behavior, and symptom perception in the context of dentistry, such as misperceptions and misappraisal of threat/risk (eg, cognitive distortions including catastrophizing), rumination about and overestimation of pain, worries about lack of control, beliefs about dentistry and dentists, and trust. ^, Moreover, Armfield identified 4 specific categories of misperceptions strongly associated with dental care–related fear: dangerousness, disgustingness, uncontrollability, and unpredictability. Although data for adolescents, specifically, are limited, 1 study found that perceived lack of control was highly associated with greater levels of dental care–related fear. Given the rapid cognitive development, increasing sense of self, and increasing independence that characterize adolescence, these cognitive factors may be especially important for understanding and intervening on adolescents’ fear, anxiety, and associated behavior, certainly more so than for children.

Dental fear, anxiety, and phobia in the adolescent population

As previously stated, dental care–related fear and anxiety have multifactorial origins that include patient characteristics such as intelligence, general anxiety, temperament, and context with regard to past experiences, culture, and socioeconomic status. ^,

The prevalence of dental fear/anxiety varies between 10% and 29.3% depending on the instrument and geographic location used. Conservatively, 1 adolescent out of 10 has a level of dental fear and or anxiety that is an impediment to dental care. Studies from the United States have ranged from 20% to 29.6% and anxiety is higher compared with northern Europe. ^, This prevalence is likely an underestimate of the general population because studies in dental settings do not capture individuals with avoidance.

Female sex is almost certainly a risk factor for increased risk of dental fear and anxiety. Studies conducted in diverse cultural populations identify women significantly more fearful then men, ^, although a minority of studies have not found a significant difference. ^{, ,} The relationship between anxiety and sex may be related to increasing age, and age 14 years has been identified as a turning point when boys show higher acceptance of dental treatment than girls.

It is unclear how much of the disparity in reporting of anxiety by sex is a true reflection of fear or caused by differential reporting. The acceptability of showing emotions that are considered weak is conditioned by gender in many cultures and may affect these data. It is possible that women have been conditioned to communicate fear as part of the coping process, whereas vocalizing this anxiety may exacerbate fear of failure in men. When patients’ reports of anxiety are compared with parental reports, girls report significantly more anxiety than boys, but the mothers’ reports of children’s anxiety do not differ.

Studies suggest that women and men interpret dentist characteristics differently. For men, perceived lack of control is more negatively experienced ^, and associated with fear and avoidance. Perceived belittlement was also an important factor for men; whereas, women rated trust and communication as most important. Knowledge of these general principles can help clinicians, but gender norms vary by culture and by individual so, when establishing rapport, dentists should inquire about dentists’ characteristics that would make patients most comfortable.

Younger age is a risk factor for higher dental fear and anxiety across the span of childhood. Studies suggest that, within the ages that constitute the period of adolescence, younger individuals are still significantly more fearful than older ones, ^, although others have found that age is unrelated in this subgroup. ^{, ,} The relationship between age and dental fear and anxiety in the adolescent age group is undoubtedly related to experience, own or observed, with dental treatment.

Behavior management problems have been found to be more common in children with lower socioeconomic status, and lack of parental cohabitation is also a contributor. For adolescents, lower socioeconomic status is likely a risk factor for dental fear and anxiety. ^{, ,} This relationship is probably the result of increased caries burden and poorer quality of dental experiences. However, the relationship between oral health and fear in adolescents is not necessarily straightforward. Higher acceptance of treatment has been found in adolescents with no dental needs compared with those needing dental care. Others found dental caries was only related to dental fear in boys but not girls. In addition, studies have found no relationship between caries ^, and gingival health in adolescents with or without dental fear.

Regularity of care and pain experienced during dental visits is almost certainly more important than presence or absence of disease at a specific point in time. Adolescents with regular dental care who can identify a family dentist have reported lower incidences of fear. Dental fear and anxiety are typically lower in individuals that have not had invasive procedures, but, in children and adolescents who had received invasive treatment and attended the dentist regularly, fear was not increased compared with children without regular attendence. Adolescents who only visit the dentist when in pain had more dental fear than adolescents who have more regular care patterns. A history of painful treatment affects future dental care seeking, with individuals reporting previous pain during treatment 13 times more likely to report high dental fear and more than 15 times less likely to be willing to return to the dentist. ^, Episodic or irregular dental visiting patterns can be a predictor of increased dental anxiety, ^{, ,} and the association between irregular dental care and dental anxiety can set up a vicious cycle of painful treatment and avoidance behavior.

It may be assumed that the irregularity of dental care may have originated from a negative dental experience, but adolescents who had never visited the dentist have indicated more fear than adolescents who had dental visits in some populations. Thus other factors, such as fear of pain or blood injury/injection phobia, may be predictors. ^,

Although maternal transmission of dental fear and anxiety is more commonly discussed in preschool children, there is a significant positive correlation between parental and child fear showing that the home environment is influential even at this age in contributing to intergenerational transmission of fear. ^{, , ,} In low-income children, indirect modeling was the most commonly reported pathway. Thus, these models, whether they be parents, siblings, or peers, are more influential than in higher-income counterparts. Altogether, dental fear and anxiety are likely the result of a combination of factors, including initial fear, experience of dental treatments, experience of toothache, and dental fear in the family.

Dental fear and anxiety are related to general fear and both internalizing and externalizing behavior problems. Higher general fears are more likely to be associated with high levels of dental fear but the opposite is not true: most children with high dental anxiety have low general fear. Similarly, adolescents with high state anxiety are almost 3 times more likely to report dental fear than children with low state anxiety, but trait anxiety had no relationship. No difference has been found in general anxiety between children and adolescents referred because of poor cooperation and those referred for other reasons, but higher increased impulsivity and negative emotionality have been found. ^,

In 18-year-olds, dentally anxious individuals were more likely to have a psychological disorder, and this correlation was primarily associated with highly dentally anxious individuals. The related psychological disorders were conduct disorder, agoraphobia, social phobia, simple phobia, and alcohol disorders. Teens with comorbid dental anxiety and psychological disorders were more likely to maintain their anxiety over time.

Assessment of dental anxiety, fear, and phobia

As with the treatment of dental disease or other health problems, the first step in the management of distressing or impairing emotional experiences such as fear or anxiety is assessment. Identifying patients with higher levels of dental care–related fear and anxiety, and understanding the individualized manifestations and consequences of the fear/anxiety, is critical for successful management. ^{, ,} Dental providers often rely on clinical judgment, nonsystematic observation of behavior, or informal conversations to determine whether a patient is fearful or anxious. Such assessment practices may be highly variable between dental providers, and findings are mixed regarding the validity of providers’ clinical judgment in the assessment of dental care–related fear and anxiety for children and adolescents. ^{, ,} However, informally assessing the degree and nature of an adolescent’s dental care–related fear or anxiety may be a worthwhile starting point. For instance, it can be useful to ask patients about treatment-related worries, including querying which specific aspects of dental care cause the most apprehension. It can also be useful to ask whether dental visits have been emotionally difficult in the past. This informal assessment should be intended as a conversation starter, perhaps serving as a screener, and open-ended questions (ie, not yes-no questions) and validating responses should be used by the provider. Given adolescents’ increasing capacity for emotional expression and abstract thinking, dental providers can reasonably expect increasing utility of informal assessment with age.

Especially if informal assessment is suggestive of dental care–related fear and anxiety, but even better as a matter of routine practice, dental providers should use evidence-based tools to assess fears and anxieties. ^{, , ,} As with adults, self-report instruments are the most commonly used type of validated tool for measuring dental care–related fear and anxiety among children and adolescents. ^, Although some self-report instruments have been studied with children as young as 3 or 4 years old (eg, Modified Child Dental Anxiety Scale), there is concern about the validity of such rating scales for younger children because of cognitive demands and not-yet-developed abstract thinking skills. However, adolescence represents a developmental period when self-report instruments, especially those that use continuous (eg, Likert-type) scales, have increasing validity and reliability that tracks with chronologic age and cognitive development. ^,

Several self-report measures of dental care–related fear and anxiety have been used with adolescents in research and/or clinical settings, with adolescent-specific validity and reliability data available for some. Perhaps the most commonly used measure for adolescents and adults alike is the Modified Dental Anxiety Scale (MDAS). The MDAS is a 5-item questionnaire involving rating how severe people predict their reactions would be to potentially anxiety-provoking dental stimuli. The MDAS is widely used, in part because of its short administration time; validity and reliability are good, and the instrument has been used with adolescents. ^, The other frequently used measure for assessing dental care–related fear and anxiety is the Dental Fear Survey (DFS). The DFS is a 20-item questionnaire that quantifies fear and anxiety about dental treatment in 3 domains (ie, subscales): behavioral avoidance, physiologic responses, and fear of specific stimuli. Many studies provide evidence of validity and reliability. ^, The DFS has shown validity and utility in adolescent samples. ^, Because of its length, the DFS is more often used in research applications than in regular clinical practice; however, use of longer questionnaires may be preferred given that shorter questionnaires are critiqued for having limited focus. One instrument, the Adolescents’ Fear of Dental Treatment Cognitive Inventory, was developed specifically for use with adolescents. Good validity and reliability were observed in the development study, although the instrument focuses only on cognitive aspects (and not physiologic or behavioral aspects) of fear and has not been used in subsequent studies, so the utility remains uncertain. Numerous other instruments have been developed for use with adults and, although not yet validated for adolescents, may be still appropriate for adolescent patients (see Armfield and Newton and Buck for reviews). In addition, several instruments designed and validated specifically for use with children may be appropriate for use with younger adolescents or adolescents with developmental disabilities, language difficulties, or other special health care needs. Such instruments include the Children’s Fear Survey Schedule Dental Subscale, the Modified Child Dental Anxiety Scale, and the Facial Image Scale ^{, ,} ; see Porritt and colleagues, Seligman and colleagues, and Yon and colleagues for reviews. Clinicians may also find utility in single-item instruments, most appropriately for use as screening tools. There are 2: the omnibus item of the DFS (question number 20) and the Dental Anxiety Question. ^, Most of the instruments described here, including the MDAS and DFS, have been translated into many languages.

With information gathered from a quality assessment, dental providers can tailor management approaches to the individualized presentation of fear and anxiety for any patient. For instance, behavior guidance techniques can be matched to the patient for effective management when the provider knows whether distress is experienced before treatment, during treatment, or both; whether distress is experienced physiologically in the form of panic symptoms or cognitively in the form of worry and catastrophic thinking; which dental stimuli cause the strongest fear or anxiety reactions (or whether the fear or anxiety is experienced more generally); and the extent to which someone is fearful or anxious (ie, where they are on the continuum and the degree of impact).

Behavior guidance techniques for managing dental fear, anxiety, and phobia in adolescence

There are numerous effective behavior guidance techniques for managing dental care–related anxiety, fear, and phobia. Selection of techniques should be based on characteristics of the fear, anxiety, or phobia (drawing on a thorough, evidence-based assessment), characteristics of the dental treatment to be completed, the patient’s developmental stage, and patient and/or caregiver preferences. ^, However, patient finances and access to behavioral health resources may affect some treatment options. Many of the most effective approaches for managing adolescent dental care–related fear and anxiety are the same as would be used when treating children or adults; however, some techniques may be particularly relevant when working with adolescents. These techniques are noted here as part of an overview of behavior guidance techniques, which are generally ordered from least to most intensive. Dental providers should appreciate that, in many cases, it is advisable to use more than 1 technique in any given clinical encounter. ^,

Good communication is the cornerstone of building trust and rapport. For fearful or anxious patients, especially those with lower levels of fear/anxiety, use of basic counseling skills can go a long way to mitigate distress. First, asking about possible dental care–related fear or anxiety on intake forms or in the first encounter with patients can communicate sensitivity and often is validating for patients. Focusing on patients’ concerns and expectations in a direct manner is helpful. The best way to engage in this communication is through active listening, including use of open-ended questions whenever possible, offering reflective statements in response to patients’ answers, validating patients’ emotions (vs simply providing reassurance, even if well intended), maintaining eye contact as much as possible when talking with patients, and monitoring tone for appropriateness. ^, The provision of information (sometimes referred to as patient education or psychoeducation) is another communication technique that can be helpful for preventing and managing distress associated with dental care–related fear and anxiety. Information about procedures can clarify uncertainties, dispel myths, and set expectations, all of which afford patients a sense of predictability. Note that patients have differing preferences about the amount and type of information to be shared. ^, For some patients, too much information about the treatment plan or a particular procedure can exacerbate fear and anxiety; for others, detailed information can significantly allay fears and anxieties. It is advisable to ask patients whether they would find information distressing or reassuring, and, compared with younger people, many adolescents are able to answer this question to help guide the approach. Patients may also benefit from receipt of information about fear and anxiety, specifically. Understanding the basic conceptual issues described earlier, especially if delivered in a developmentally appropriate way, can help patients make sense of their emotional experiences, which can be reassuring and therapeutic, particularly for adolescents because they are rapidly developing emotionally.

Because dental care–related fear and anxiety are strongly linked to perceived lack of control, especially among adolescents, behavior guidance techniques that offer control to patients are worthwhile. ^{, ,} Considering the provision of information, 1 way to offer a sense of control is to ask for permission before sharing details about a procedure or the nature of fear/anxiety (eg, “Is it okay with you if I share some information about the kinds of worries people your age have about dental treatment?”). Another commonly used approach for providing perceived control (and predictability) is using the tell-show-do technique. The American Academy of Pediatric Dentistry (AAPD) recommends offering a developmentally appropriate description of the procedures to be completed (ie, tell), a demonstration of the various aspects of the procedures (ie, show), and completion of the procedures in a way that does not deviate from the preceding description and demonstration. Other techniques for providing control include planned regular (and dentist-initiated) rest breaks and patient-controlled signaling for break requests (see Armfield and Heaton for detailed descriptions). ^, Consistency in the use and follow-through of these techniques is essential for building trust and managing and preventing fear/anxiety. ^, Asking adolescent patients what has been helpful for reducing fear or anxiety in the past, perhaps even before the dental provider offers any suggestions, or asking adolescent patients to teach a skill or direct its use may also engender feelings of control. Adolescence is a time of rapidly increasing understanding and exertion of autonomy, and so it is important to remember that issues of control may be particularly important for these patients.

Dental providers can minimize environmental triggers of dental care–related fear and anxiety by using stimulus control. For instance, keeping fear-inducing stimuli (eg, syringe, handpiece) out of sight can help prevent distress. For some patients, seeing the syringe, including assembly, may allay anxiety. This technique is usually a last resort before instituting pharmacologic measures, but it has been successful for select cases. For patients who have previously had frightening injection experiences, using alternatives such as computer-controlled local anesthetic devices may help distinguish past experiences from potentially painless ones. However, even with the most experienced, skilled, and compassionate clinicians, dental treatment is potentially stressful for many patients. Several behavior guidance techniques drawn from cognitive-behavior therapy are useful in the management of this stress. First, diaphragmatic breathing can be efficiently taught to and practiced by adolescents with good effect, and it is likely to be more effective with this age group than for younger children. Slow breaths are incompatible with the sympathetic (ie, fight-or flight) response that characterizes fear and anxiety, and thus induce relaxation, reducing fear/anxiety in the dental setting. ^, Second, distraction can reorient attention away from stimuli perceived to be threating to prevent fear/anxiety or induce relaxation. ^, As a general rule, more immersive distraction techniques are more effective. Studies have shown excellent benefit from various forms of distraction (eg, imagery, music, television, virtual reality) in the dental setting and especially for pediatric patients, including younger adolescents. ^{, , ,} Third, given their cognitive development, adolescents may find more benefit than younger pediatric patients in cognitively oriented behavior guidance techniques. For example, teaching patients how to identify and challenge misappraisals of risk or thoughts of disgust may be effective for managing anticipatory anxiety as well as fear reactions in the dental operatory. ^{, , ,} Given their social development, and compared with younger patients, adolescents may be especially sensitive to embarrassment, which can be a key factor in dental care–related fear and anxiety. ^, In using cognitively oriented behavior guidance techniques, and in communicating with adolescents generally, it thus may be particularly useful to attend to potential embarrassment and/or communicate in a nonjudgmental way, carefully considering word choice so as to not provoke embarrassment.

For patients with more significant dental care–related fear and anxiety, and even phobia, exposure-based behavior guidance techniques may be necessary to manage and cure fears and anxieties. Through a mechanism known as extinction learning, repeated exposure to feared stimuli desensitizes patients such that they come to no longer have a fear reaction to the stimuli. The most common exposure-based behavior guidance technique used for dental applications is systematic desensitization, which has been shown to be effective across a range of fears/phobias, including those related to dental stimuli. Briefly, patients identify a hierarchy of feared stimuli and are systematically and gradually supported in experiencing those stimuli (moving up the hierarchy) until they habituate and no longer experience a fear response. There is minimal research addressing systematic desensitization for dental care–related fear, anxiety, and phobia among adolescent patients, specifically; however, it is such a robust treatment of fear and anxiety for pediatric and adult populations that it would be considered best practice. The AAPD and numerous experts have offered guidance on the use of systematic desensitization in working with dental patients. ^{, , , ,} Moreover, computer-assisted, virtual reality, and single-session approaches to facilitating desensitization have been reported.

For dental providers interested in learning more about the behavior guidance techniques discussed earlier, and others, there are numerous meta-analyses, reviews, and books on the topic. ^{, , , ,} Note that, especially for very fearful or anxious patients, advanced cognitively oriented behavior guidance techniques and systematic desensitization most appropriately may be facilitated by a mental health care provider, in partnership with the dental provider if possible. It is also worth noting that pediatric dental care–related fear and anxiety have been acknowledged as understudied problems. If fear and anxiety are understudied in youth, they are particularly understudied in adolescents. Much more research on the cause, assessment, and management of adolescent dental care–related fear and anxiety is warranted.

Involving a behavioral health professional

Depending on the severity and impact of dental care–related fear and anxiety experienced by a patient, dental providers may consider referring the patient to a behavioral health professional for adjunctive management. In many cases, behavioral health professionals use the same approaches to assessment and the same behavior guidance techniques described here; however, they often have deeper expertise in and more time to perform such interventions, and Fig. 1 shows the typical approach.

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