Editor’s Note: In Part One of our series on adverse childhood experiences (ACE), Incisor explored how trauma experienced in childhood can have far-reaching effects on long-term physical and mental health, including oral health and dental care utilization.

Part two introduces specific strategies dentists can utilize, including sedation dentistry, to prevent adverse childhood experiences (ACE) in the dental office, as well as mitigate pre-existing anxieties.


Pediatric dental sedation allows the clinician to provide treatment in a way that is minimally traumatic and preserves the child’s trust.

—Travis M. Nelson and Zheng Xu

The effects of adverse childhood experiences (ACE) on oral health include inadequate care for children, tooth damage, as well as the development of anxiety-based avoidance carried into adulthood. With this in mind, how can dental professionals prevent pediatric treatment itself from becoming an ACE? Further, how can sedation dentists integrate an applied understanding of the psychology of trauma to help create a positive, assuring experience that addresses previously experienced ACE in both children and adults?

Scared Child
A visit to the dentist doesn't have to be traumatic.

The developing child often lacks the coping skills necessary to navigate the dental experience, making provision of quality dental care to children challenging. While unrestored caries may contribute to pain, disordered sleep, difficulty learning, and poor growth in children, unpleasant dental experiences can cause psychologic [sic] harm. Most dental anxiety develops in childhood as a result of frightening and painful dental experiences. If appropriate precautions are not taken, dental treatment may overwhelm the child, resulting in dental fear and avoidance. These fears persist into adulthood, causing 10%-20% of the US population to avoid necessary dental care. Sedation reduces such complications and instills trust in the family and child. (Nelson, Travis M, and Zheng Xu)

However, fear of dentistry (odontophobia)—the fifth most common cause of anxiety (Agras et al.)—may not be etiologically linked to past negative dental experiences in all cases.

For example, 6.8 million adults, or 3.1% of the U.S. population, experience generalized anxiety disorder (DSM-5 300.02 [F41. 1]) in any given year. Characterized by persistent and excessive worry beyond what seems warranted about actual events, GAD causes a sufferer to struggle with an expectation of the worst, even when there is no apparent reason for concern—that is, no discernable trigger.

“Although the exact cause of GAD is unknown, there is evidence that biological factors, family background, and life experiences, particularly stressful ones, play a role,” according to the Anxiety and Depression Association of America.

Anxiety, dread, and avoidance can lead to the degradation of minor dental issues into acute conditions requiring advanced, more traumatic treatments that reinforce anxieties.

Dr. Deva Priya Appukuttan wrote in “Strategies to manage patients with dental anxiety and dental phobia,” a literature review in Clinical, Cosmetic and Investigational Dentistry:

Fearful and anxious individuals feel that something dreadful is going to happen during dental treatment, and hence do not visit the dentist. Such behavior ultimately results in bad oral health, with more missing teeth, decayed teeth, and poor periodontal status. They present to the dental office only when in acute emergency situations often requiring complicated and traumatic treatment procedures, which in turn further exacerbates and reinforces their fear, leading to complete avoidance in the future. Consequently, a vicious cycle of dental fear sets in if these patients are not managed appropriately.

Appukuttan cites the “Seattle system,” developed at the University of Washington (Milgrom et al), which groups anxious patients into four categories, based on source of fear:

  1. Anxious of specific stimuli
  2. Distrust of the dental personnel
  3. Generalized dental anxiety
  4. Anxious of catastrophe

Specific factors contributing to anxiety can include, among others:

  • Previous negative or traumatic experience(s), especially in childhood (conditioning experiences)
  • Vicarious learning from anxious family members or peers
  • Individual personality characteristics such as neuroticism and self-consciousness
  • Lack of understanding
  • Exposure to frightening portrayals of dentists in the media
  • The coping style of the person
  • The vulnerable position of lying back in a dental chair
  • Sensory triggers such as sights of needles and sounds of air-turbine drills
  • Sensations of high-frequency vibrations in the dental setting
  • Fear of pain or blood injury
  • Lack of trust or fear of betrayal
  • Fear of being ridiculed
  • Fear of the unknown
  • Fear of detached treatment by a dentist or a sense of depersonalization
  • Fear of mercury poisoning or radiation exposure
  • Fear of choking and/or gagging

Anxiety can be triggered by even the most innocuous situations, such as the encounter with the receptionist while scheduling their appointments or clinic ambiance, and thus it is essential that every aspect of the dental practice be appropriate.

— Dr. Deva Priya Appukuttan

“The etiology for dental anxiety is multifactorial, and hence there is no monotherapy for management,” wrote Dr. Appukuttan. “Anxiety can be triggered by even the most innocuous situations, such as the encounter with the receptionist while scheduling their appointments or clinic ambiance, and thus it is essential that every aspect of the dental practice be appropriate.”

Of course, dentists are trained to treat and repair teeth, but ensuring a safe, anxiety-free experience in the chair—the emotional and psychological side of treatment—requires specialized training, supplemented by continuing education to keep current.

The good news is that sedation dentistry offers a viable, highly effective way to address odontophobia and break the anxiety cycle, in concert with other strategies.

Dr. Appukuttan states emphatically that, “these patients can be managed pharmacologically using either sedation or general anesthesia.”

The good news is that sedation dentistry offers a viable, highly effective way to address odontophobia and break the anxiety cycle.

—Dr. Deva Priya Appukuttan

Other recommendations for anxiety management that Dr. Appkuttan’s report highlights include cognitive-behavioral therapy (CBT), communication skills, rapport, and building trust, along with a “sensory adapted dental environment”:

The Snoezelen environment concept aims at stimulating the primary senses of sight, touch, feel, and smell, along with patient-centered therapy. Shapiro et al adapted a “Snoezelen” dental environment for pediatric patients comprised of dimmed lighting, soothing music, and a special Velcro butterfly vest that hugs the child, providing a calming, deep-pressure sensation. Typical children and those with developmental disabilities have been shown to benefit by this SDE, as behavioral and psychophysiological measures of relaxation improved significantly in the SDE compared with a conventional dental environment.

Experienced sedation dentists combine sedation treatments with other strategies proven in their clinical setting to be effective additions to their anti-anxiety toolbox. Part 3 of this series will reveal real-life methods used by practicing sedation dentists, including both tried-and-true tips and promising new technologies.

Child and Dentist
Photo by Hush Naidoo on Unsplash


Works Cited

Agras S, Sylvester D, Oliveau D. “The epidemiology of common fears and phobia.” Compr Psychiatry. 1969;10(2):151–156.

Anxiety and Depression Association of America. Understanding GAD and the Symptoms. https://adaa.org/understanding-anxiety/generalized-anxiety-disorder-gad

Appukuttan, Deva Priya. “Strategies to manage patients with dental anxiety and dental phobia: literature review.” Clinical, cosmetic and investigational dentistry vol. 8 35-50. 10 Mar. 2016, doi:10.2147/CCIDE.S63626

Milgrom P, Weinstein P, Getz T. Treating Fearful Dental Patients: A Patient Management Handbook. Seattle: Reston Prentice Hall; 1995.

Nelson, Travis M, and Zheng Xu. “Pediatric dental sedation: challenges and opportunities.” Clinical, cosmetic and investigational dentistry vol. 7 97-106. 26 Aug. 2015, doi:10.2147/CCIDE.S64250

Shapiro M, Melmed RN, Sgan-Cohen HD, Eli I, Parush S. “Behavioural and physiological effect of dental environment sensory adaptation on children’s dental anxiety.” Eur J Oral Sci. 2007;115(6):479–483.

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