Classifying Children’s Behaviour at the Dentist—What about ‘Burnout’?
Abstract
:1. Introduction and Background
2. Recognition and Identification
2.1. The Dental Burnout Concept
2.2. Signs and Symptoms of Dental Burnout
- Loss of care and motivation—the child may no longer present with the same enthusiasm as previous treatment appointments; they may become less communicative, including blunt or one-word replies, and no longer maintain eye-contact;
- Avoidance behaviours—the child who previously attended treatment without concern may attempt to avoid it completely by, e.g., refusing to come in from the car or waiting room, or may refuse to come at all and want to stay at home/school;
- Worry, anxiety and fear—the previously calm and composed child may be experiencing an increase in fear, worry or anxiety, particularly if they are approaching more invasive aspects of treatment such as exodontia—when these feelings outweigh a child’s ability to cope it may result in tears, feeling sick (including stomach aches and headaches), shaking, sweating and freezing;
- Attitude shift and emotional changes—the child’s attitude may shift from being positive, open and honest to a predominantly negative mindset—they may be less tolerant to minor setbacks such as being kept waiting a few minutes past their anticipated appointment time or recurrent loss of orthodontic separators prior to preformed metal crown (PMC) placement;
- Concentration—the child may become easily frustrated with situations or aspects they did not previously get triggered by, such as lost fillings or administration of local anaesthetic; in addition, they may find it hard to keep concentration and exhibit annoyance when required to sit for longer appointments such as during root canal treatment.
2.3. Likely Candidates for Dental Burnout
- Limited dental experience—if a child’s only dental experiences have involved check-ups or basic operative care (typically without local anaesthetic), their lack of ‘dental sophistication’ can result in limited treatment stamina and an inability to cope with longer and, on occasion, uncomfortable appointments further along a complex treatment plan [25];
- Dental trauma—in addition to the initial physical trauma itself, e.g., tooth avulsion, the experience of immediate and short-term management is often painful and frightening for a child and can significantly impact them on an emotional and psychological level; significant long-term monitoring is necessary, particularly in patients with a developing dentition, alongside knowledge of risks such as loss of vitality and the need for more invasive treatment such as root canal therapy [50];
- Medical trauma—medical trauma may occur in children as a response to single or multiple medical events; it refers to the psychological (and sometimes physiological) response of a child to pain, injury, serious illness, medical procedures and invasive or frightening treatment experiences in the medical setting, such as those involved with childhood cancer—young children are still developing their cognitive skills and process information differently, hence they may associate dental pain with punishment and believe they did something wrong. This could lead to burnout during invasive dental treatment, despite previous successful appointments [51];
- Developmental dental defects (DDD)—developmental defects of the enamel and dentine are lifelong conditions that require multidisciplinary input as well as short-term and long-term management that can be increasingly challenging in young children. Pain, sensitivity and aesthetic concerns are commonplace, alongside a reduced strength and integrity of the bond of enamel to composite that often results in failed restorations. Molar Incisor Hypomineralisation (MIH), for example, with a global prevalence of 14.2%, has a significant impact on both patients and dentists and has been shown to negatively impact a patient’s oral-health-related quality of life (OHRQoL)—a recent systematic review by Jälevik et al. [52] found that already-restored MIH molars remain within short re-treatment cycles; sensitivity becomes problematic when it hinders the possibility of obtaining sufficient pain control; and, consequently, behavioural management problems arise due to dental fear and anxiety related to the pain experienced by patients during multiple treatment appointments. In addition, the burden of other chronic developmental conditions such as amelogenesis imperfecta (AI) or dentinogenesis imperfecta (DI) may also be associated with significant medical co-morbidities, further increasing the risk of burnout due to possible previous medical trauma [53];
- Dental fear and anxiety (DFA)—DFA is common in CYP, with an estimated prevalence between 6% and 20% in those aged 4–18 years old [48]. Potentially cooperative children, especially those who exhibit ‘timid’ and/or ‘tense-cooperative’ behaviour, are at increased risk of burnout, should they be exposed to invasive and uncomfortable procedures without adequate preparation and coping strategies;
- Re-treatment—children who require extensive re-treatment because of failed or failing treatment are increasingly susceptible to burnout. This includes changes as a result of failed complex treatment or further trauma, as well as recurrently debonding restorations such as those associated with AI. Patients requiring re-treatment may be close to burnout already, due to ongoing frustrations with previous protracted treatment in addition to unanticipated problems which require subsequent further treatment;
- Personal circumstances—children who undergo a significant change in circumstances during a long treatment plan are also at risk of burnout. These are usually external to the dental setting and may be due to finding transitions into school extremely stressful, continuous exposure to stressful or traumatic events, struggling with external changes or being extremely driven to excel at school exams [47,54].
3. Minimising and Managing Dental Burnout
3.1. History Taking
“…his behavior [sic] was at times totally dysregulated. While taking a health and medical history, they learned that the child, David, had endured many painful, frightening, and invasive medical procedures beginning at 21 months of age…”
3.2. Communication
3.3. Emotional Exchanges
3.4. Continuity of Care
3.5. Cooperation vs. Compliance
3.6. Behaviour Management Spectrum
4. The Burnout Triad
5. Limitations
6. Conclusions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
Compliance with Ethical Standards:
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Category | Description |
---|---|
Cooperative | Reasonably relaxed. Minimal apprehension and may even be enthusiastic. Acceptance of treatment, at times cautious, willingness to comply with the dentist, at times with reservation but follows the dentist’s directions. Can be treated by a straightforward, behaviour-shaping approach. When guidelines for behaviour are established, these children perform within the framework provided. |
Lacking cooperative ability (Pre-cooperative) | Very young children with whom communication cannot be established. Comprehension cannot be expected. Lack cooperative abilities usually because of their age. For pre-cooperative children, time usually solves the behaviour problems. As they grow older, they develop into cooperative dental patients and treatment is provided with behaviour shaping. Another group of children who lack cooperative ability is those with specific debilitating or disabling conditions. The severity of the child’s condition prohibits cooperation in the usual manner. Although special behaviour guidance techniques are used to allow treatment to be carried out, immediate major positive behavioural changes cannot be expected. |
Potentially cooperative | Previously referred to as ‘uncooperative’ or ‘non-cooperative’. This type of behaviour differs from that of children lacking cooperative ability because these children have the capability to perform cooperatively. They have the capacity to cooperate but choose not to—this is an important distinction. They are potentially the most challenging (and most common) patients you are going to meet. When a child is characterised as potentially cooperative, clinical judgment is that the child’s behaviour can be modified; that is, the child can become cooperative. The adverse reactions have been given specific labels for descriptions of potentially cooperative patients, so that potentially cooperative group are further categorised as follows:
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Donnell, C.C. Classifying Children’s Behaviour at the Dentist—What about ‘Burnout’? Dent. J. 2023, 11, 70. https://doi.org/10.3390/dj11030070
Donnell CC. Classifying Children’s Behaviour at the Dentist—What about ‘Burnout’? Dentistry Journal. 2023; 11(3):70. https://doi.org/10.3390/dj11030070
Chicago/Turabian StyleDonnell, Christopher C. 2023. "Classifying Children’s Behaviour at the Dentist—What about ‘Burnout’?" Dentistry Journal 11, no. 3: 70. https://doi.org/10.3390/dj11030070
APA StyleDonnell, C. C. (2023). Classifying Children’s Behaviour at the Dentist—What about ‘Burnout’? Dentistry Journal, 11(3), 70. https://doi.org/10.3390/dj11030070