Children and parents experiences of cognitive behavioral therapy for dental anxiety a qualitative study

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1 DOI: /ipd Children and parents experiences of cognitive behavioral therapy for dental anxiety a qualitative study SHERVIN SHAHNAVAZ, SARA RUTLEY, KARIN LARSSON & G ORAN DAHLL OF Division of Pediatric Dentistry, Department of Dental Medicine, Karolinska Institutet, Stockholm, Sweden International Journal of Paediatric Dentistry 2015; 25: Background. There is a high prevalence of dental anxiety in children and adolescents. Cognitive behavioral therapy is emerging as a treatment option. Aim. The purpose of this study is to explore how children with dental anxiety and their parents experience cognitive behavioral therapy (CBT) in dentistry. Design. We interviewed 12 children and one of their parents and conducted a thematic analysis of the transcribed interviews. Results. Perspective shift emerged as overarching theme in our thematic analysis. This theme consisted of three main themes, which were mastery, safety, and reduced fear. Six subthemes were also identified according to our analyses. Mastery includes two subthemes, gradual exposure and autonomy and control. Subthemes and sources for safety feeling were therapeutic alliance and changed appraisal. The theme reduced fear also consisted of two subthemes; reduced anticipatory anxiety and coping. Conclusions. The results show that parents and children had positive experiences of CBT and its outcome and were able to benefit from this psychological treatment when dealing with dental anxiety. Introduction Oral health in children and adolescents is defined as a state of sound and well-functioning dental and oral structures as well as absence of dental fear and anxiety 1. The dental literature uses dental phobia, dental fear, and dental anxiety interchangeably to describe the overwhelming discomfort that some patients experience in dental situations. We use the term dental anxiety in this article. Studies have reported a high prevalence of dental anxiety in children and adolescents, ranging between 5.7% and 19%. Klingberg & Broberg 2 reviewed these studies and estimated that about 9% of children and adolescents suffer from the condition. Dental anxiety can lead to serious health consequences for children and adolescents, including a reduced sense of comfort in care situations and delays in obtaining adequate Correspondence to: Shervin Shahnavaz, Department of Dental Medicine, Division of Pediatric Dentistry, Karolinska Institutet, POB 4064, SE Huddinge, Sweden. shervin.shahnavaz@ki.se routine dental care. Other consequences of dental anxiety include lifelong, poor oral health, dental caries, periodontal disease, psychosocial problems (e.g., nervousness about bad breath and how carious teeth affect appearance), and reduced self-esteem and quality of life 3. Cognitive behavioral therapy (CBT) is a structured and short (1 20 sessions) psychological treatment method. The main features are behavior analysis or conceptualization, psycho-education, exposure, cognitive restructuring, assertiveness techniques, and home exercises. CBT is action and behavior oriented and helps patients focus on their problems here and now. It is the treatment of choice for many anxiety disorders including specific phobias such as dental anxiety or injection phobia 4. Despite the high prevalence and serious health consequences of dental anxiety, research on CBT for children and adolescents with dental anxiety is limited. According to randomized control trials of CBT for dental anxiety in adults, CBT reduces selfperceived dental anxiety, helping 73% of patients to manage and receive regular dental treatment after CBT 4,5. 317

2 318 S. Shahnavaz et al. The knowledge of how children and parents experience different psychological treatments in dentistry is also limited. Researchers in dentistry and behavioral science rarely ask children and their parents about their subjective experiences of treatment. Marshman et al. 6 reported that only 0.3% of published articles in pediatric dentistry focus on children s views of dental treatment and 5.3% involve parents and caregivers views to some extent. Marshman concludes that, in most studies, children were not listened to or heard, but only seen. Qualitative studies with the objective of capturing a patient s views on psychological treatments are rare: no previous study except Svensson et al. has examined phobic children s experiences of CBT 7. This may be a very important issue to address because studies have found that two-thirds of children, aged 7 15 years, experience treatment by a psychologist as something negative 8. Svensson et al. 7, however, contradicts these results and show that children and adolescents who received one 3-h session of CBT for specific phobia appreciated visiting a psychologist and were satisfied with the outcome of CBT. The purpose of this study is to explore how children with dental anxiety and their parents experiences, understand, and benefit from CBT for dental anxiety. Materials and methods Participants were all children between 7 and 19 years old treated with CBT for dental anxiety between November 2010 and October 2012 at the department of pediatric dentistry at Karolinska Institutet (n = 17). Of the 16 families contacted, four declined to participate for reasons not known. One patient had moved from Stockholm and could not be contacted. Dropout analyses performed with the assistance of dental records did not show any marked differences concerning age, gender, or treatment outcome between the group that declined participation and the study respondents. In total, 12 patients and one of their parents each (seven mothers and five fathers) were interviewed. The quality and richness of the data obtained from the interviews were suitable for thematic analysis and contained all the relevant information for our proposed model. The children and adolescents were five males and seven females with a mean age of 13 4 (range: 9 19) at the time of the interview. General dentists had referred the participants to a psychologist because of dental anxiety and dental treatment needs. Parents and their children reported negative experiences related to dentistry or health care during early childhood as the main reason for fear. The extent and nature of these experiences varied, however, intraoral injection was the main object of fear for most respondents (10 of 12 patients). The main object of fear was examined by a question in the interview guide: what in dentistry was your worst fear? One participant was afraid of all instruments entering the mouth, particularly drills or radiographs, which caused retching. One patient was afraid of tooth extraction; however, several of the patients with intraoral injection phobia also had other fears related to dental procedures. The participants had had their fear from a minimum of 6 months to a maximum of 17 years (calculated from the time of their first distressful confrontation with injections in health care according to parents). All 12 fulfilled the DSM-IV-based criteria for specific phobia (blood injection injury phobia) according to a clinical interview with a psychologist before treatment with CBT. Cognitive behavioral therapy The number of CBT sessions that patients had been offered prior to the interviews varied between 4 and 15 sessions. The therapies used a child and adolescent adjusted version of the CBT treatment described by Shahnavaz 9. The first two sessions were similar for all patients. The first session consisted of behavior analysis and a psycho-educative intervention, teaching children and parents about the mechanisms of fear and anxiety and also the rationale and principles of CBT. The second session focused on formulating an exposure list, recording different treatment

3 Children and parents experiences of CBT 319 situations in dentistry and exercises related to these treatments. Subsequent sessions were individualized and devoted to exposure by film and exposure in vivo with the psychologist or with dental assistants and dentists. The treatments also consisted of cognitive restructuring; attention shift; assertiveness training; coping techniques, such as relaxation and breathing control; and home assignments. The ambition was to offer all patients and parents a final session focused on creating a relapse prevention plan. But some patients and parents did not show up for the last session and did not complete treatment. An experienced, CBT-qualified, clinically licensed psychologist guided patients and their parents through the treatment. Parents and children were interviewed on average of 9 4 (range: 2 14) months after the treatment was completed. Interview Parents were contacted by telephone and informed about the project. They were asked to inform their children about the project and read the written project information that was sent to them (an adult and a child version were available). The researchers contacted them after 2 weeks. Parents and children who agreed to participate gave verbal consent (both parents), and we scheduled separate telephone interviews. Two interview guides were constructed, one for children and adolescents and one for parents. The interview guides were pilot-tested to check the comprehensibility of the questions before the interviews. The questions concerned parents and children s experiences with CBT. They were asked about feelings, thoughts, and memories in relation to CBT and the perceived outcome of the treatment. The patients and parents were interviewed by telephone between October and December Each interview took about 30 min, with parents and children s interviews conducted separately. We recorded and transcribed all the interviews. The two authors who conducted the interviews had not been a part of the CBT treatment. Data analyses The analysis was conducted by thematic analysis (TA), as described by Braun 10.TAis a method for identifying, understanding, and reporting themes and patterns within data. A theme gives meaning and structure to the data and captures something important, in relation to the research question and the interview texts. TA consists of six stages that were conducted as described below in our study: (1) familiarization with data: in which interviews were transcribed and two psychologists and two dental students read the transcripts separately several times; (2) code generation: in which important features (statements, words, sentences) of the data in relation to the research question were gathered; (3) searching for themes: in which codes to discover potential themes were proposed; (4) reviewing themes: which involved discussing, refining, and elaborating the codes and themes, removing themes without sufficient support, and combining others; (5) defining and naming: which created a definition for our themes and their essence. In this step, we organized the themes into a coherent structure and defined their internal relation; (6) producing the report: which involved drafting a report and revising it several times. The study used several methods for checking the credibility of the themes : (a) data source triangulation: We interviewed both parents and children. Furthermore, we checked the results against the dental records kept during treatment. The focus was to investigate whether, after CBT, children were able to manage specific situations they were afraid of, such as injections or drilling during their dental visits, (b) analyst triangulation: Two clinical psychologists (one not part of the research team) and two of the co-authors independently analyzed the data. We compared the results of these three independent analyses and combined them over the course of several meetings and with help of an experienced pediatric dentist (the fourth coauthor) who also reviewed the results, (c) search for negative cases: involved looking for cases that contradicted the results, (d) method triangulation: helped provide a clearer idea of

4 320 S. Shahnavaz et al. the perceived levels of improvement due to CBT by asking patients and their parents to estimate the level of fear before and after CBT on a subjective unit of distress (SUD) scale The regional ethics board in Stockholm approved this study (Daybook no.: /4). Results Perspective shift emerged as overarching theme at the highest level of our thematic map. This theme consisted of three main themes, which were mastery, safety, and reduced fear. Six subthemes were also identified according to our analyses. Perspective shift Perspective shift was an overarching theme that described how CBT helped children and adolescents to change their view of dentistry, but also shifting views of their own potential and capacities to deal with the challenging situations in dentistry and in some cases even in other phobic situations, for example, vaccination or fear of dark. Perspective shift had also to do with willingness to try and experiment with new behaviors here and now (being present) in a challenging context. Because it (CBT) makes you to put fear in other perspectives and find other way to control the situation. I think that s important, that you can experience the same fear, though in a different way and realize that it actually is not that bad. It (CBT) actually works very well! But you must be very motivated and really try yourself (Elsa, 19 yrs) The therapist gave my child a lot of time to integrate a new perspective. It was not about putting pressure on him and if pressuring was involved, it was in a positive way. It was about making him (the child) to feel that he manage the situation here and now (Father, girl 11 yrs) Perspective shift consisted of three main themes, which were mastery, safety, and reduced fear and six subthemes as shown in Fig. 1. The themes at the lower levels of the model could be treated as sources or mechanisms for the themes at the higher level. Mastery This main theme described how children and adolescents experience CBT and how it helped them to successfully undergo challenging procedures in dentistry, sometimes despite the fear. I ve done most of the things you usually do at the dentist (thanks to CBT). Because I know I can manage to do these things, I also manage things even if the fear is there. I can handle the fear (Peter, 12 yrs) This was a sentiment echoed by parents: He took many syringes and it does not seem to be something he feels uncomfortable with. He has overcome the fear and so far it (CBT) is a great help in every way (Father, boy 11 yrs) Another parent said: This (CBT-strategies) is for life. It s the same thing if she has another fear, something similar, for instance needles (vaccination for instance), then she knows that it will hurt for a little while, but then it s over (Father, girl, 14 yrs) Mastery was in several cases generalized to situations outside dentistry as the last quotation above indicate. This often involved coping with injection phobia during vaccination Perspective shift Mastery Safety Reduced fear Gradual exposure Autonomi & control Changed appraisal Therapeutic alliance Coping Reduced anticipatory anxiety Fig 1. Thematic map.

5 Children and parents experiences of CBT 321 or when providing a blood sample. For example, an adolescent treated for acute leukemia was able to have a disabling implanted venous access system that he had kept because of his injection phobia removed. Some parents were surprized at their child s capacity to generalize skills to new situations, and some parents were confident that CBT would have a long-lasting effect on their child. Mastery includes two subthemes: gradual exposure and autonomy and control. Gradual exposure Children and their parents found that exposure, that is, progressive-controlled confrontations with fearful situations and instruments in dentistry, was one of the most effective features of CBT. In particular, the children and adolescents highlighted the value of holding, examining, and trying different dental instruments, both with the assistance of the psychologist, dental assistants, and dentists but also on their own. Additionally, parents and children found the continuous evaluation of fear on a scale (1-10, from no fear to worst possible fear) during the exposure to be valuable. Children said: To try and experiment (with injections) actually worked (Mehdi, 18 yrs) I did not like the drilling sound so we recorded it on my phone and I could listen to it at home (Fatima, 10 yrs) Similarly parents described: I think the combination of evaluation of fear by numbers (during the exposure), trying and practicing, and breathing techniques helped (Father, boy, 11 yrs) When he holds things (dental tools) as he sat in the dentist s chair, touching the needle and holds it and plays with it and saw movies (of dental situations) made him calm down. And all this took place in his pace (Mother, boy 18 yrs) Autonomy and control This subtheme is about children s improved ability to take charge of their fear during CBT. They developed an ability to participate in decisions concerning their psychological and dental treatment. Shy children became less shy and developed better self-confidence according to parents. The process of autonomy was gradual during CBT. The need to have physical contact with parents (holding hands for instance) during the treatment was reduced, and eventually, they were able to visit the dentist on their own. Children and parents described this increased autonomy and control: Safety You dealt with the fear, got it in perspective; you could control the situation yourself (Elsa, 19 yrs) I can do this so far (when challenging dental situations) and I do not have to go any farther, it s up to me. So that was very satisfying (Johanna, 19 yrs) He used to hide behind you before, so I had to do all the talking. But now he makes contact himself and it s no problem at all. He s got a confidence that I ve never seen before (Mother, boy 18 yrs) According to both children and parents, feeling safe in a dental context was one of the major therapeutic processes that took place during the CBT. I think I feel safer now, thanks to seeing the therapist (Simon, 9 yrs) I feel safe with my feelings and things I do (Kidane, 11 yrs) He is confident that he dares to go to the dentist (Mother, boy 9 yrs) The subthemes identified and sources for feeling safety were therapeutic alliance and changed appraisal, which could be considered as sources for safety. Therapeutic alliance This theme captures the characteristics of the therapeutic relationship children developed with the psychologist. Parents and children stated that they appreciated the psychologist and became friend with him, and had fun visiting him. Children and adolescents

6 322 S. Shahnavaz et al. developed a sense of safety and calmness with the psychologist and were able to transform this sense into the dental situation and dental staff. The direct effect of this increased sense of security was increased positive feelings toward the dental staff and curiosity about dentistry. It was a good welcoming interaction; he (the psychologist) listened to me and tried to help me in the best way possible (Elsa, 19 yrs) Parents and children described the relationship between the child and psychologist, and in some cases even dental staff, in a very positive manner and found it important for the therapeutic change. He (the psychologist) was really kind actually. He understood me and it was actually fun. It became a fun thing to go to the dental clinic and meet him (Simon, 9 yrs) Other parents and children who had not yet been referred back to general dentistry clinics (from the specialist clinic) were worried about the child s ability to change to a different dental team and clinic. She wants to continue at your clinic (specialist clinic) although I think she could manage other clinics and dentists (in general dentistry), but I think she feels safer with you than with a regular dentist anyway (Mother, girl 19 yrs) A prerequisite for establishing a therapeutic alliance is that the study participants felt comfortable with the psychologist and trusted him. They felt that they were listened to and accepted. Changed appraisal This subtheme was source of safety due to change of appraisal concerning how dangerous and harmful dentistry is. Children and adolescents found the potential benefits of dentistry to be larger than potential threats (risk for harm). One can imagine (before a dental visit) that it might hurt a little, but how dangerous is it really? (Sabina, 11 yrs) I think she was nervous, and it was scary, and that she sometimes thought she might not fix it (the dental treatment) but she did it anyway. And I think sometimes she discovered that it was not as dangerous as she thought (Mother, girl 19 yrs) Reduced fear Reduced fear was a main theme that showed how CBT helped children and adolescent reduce arousal and negative emotional reactions before and during the dental visits. Children and parents described this: It actually felt that every time I met the psychologist, the fear went away a bit and it felt much better when I would go in and do the dental treatment (Kidane, 11 yrs) It was really a huge problem with dentistry before. It wasn t that she was afraid. She was terrified, really scared, and had seizures (Father, girl 10 yrs) Knowledge about dental fear and also the individual patients fears was important to discuss and to put into context. The subthemes identified and sources for reduced fear were reduced anticipatory anxiety and coping. Reduced anticipatory anxiety This subtheme described how CBT influence the emotional and physical distress and arousal that children felt just before their dental visits (before patients where offered CBT). Anticipatory anxiety was a major reason for avoidance and began on the same day or a few days before the dental visit, depending on when the parents informed the child about the visit. Patients reported that their children had sleep disturbances, nightmares, and psychosomatic problems such as stomach ache before their dental visit. Anticipatory anxiety disturbed normal life in several cases. I could not think clearly in school when I had to go to the dentist, it felt annoying several days before the visit (Sven, 12 yrs) After CBT and before a dental visit he felt: In fact I was not afraid. It felt completely normal; I felt I knew what to do (Sven, 12 yrs) Anticipatory anxiety disappeared or was reduced after CBT according to the participants.

7 Children and parents experiences of CBT 323 Parents felt that anticipatory anxiety caused conflicts between them and their children. For example, an adolescent accused his parents of power abuse, when they forced him to go to dentist. Several parents felt badly about having to force their children to go to the dentist: We hardly managed to get there (to the dentist). It was really a traumatic process (Mother, boy 9 yrs) We almost carried him in and held him down so that something (dental care) could be done. But still it was rare that anything (dental treatment) was accomplished (Mother, boy 18 yrs) The parent then described how the anticipatory anxiety disappeared after CBT and that their child s fear of fear was reduced. Coping This subtheme showed how children and adolescents were helped by various behavioral and cognitive coping strategies they learned during CBT. Participants highlighted breathing techniques as one of the most effective strategies to manage fear. Additionally, many participants benefited from shifting their focus of attention and using conscious distraction techniques in conjunction with dental treatment. Breathing and thinking of things that make me happy were best (Greta, 14 yrs) Chill out, relax and think of something funny (Kidane, 11 yrs gives advice to other children) Several other useful techniques were also mentioned for overcoming fear: I was helped when I wrote down what was positive about syringes and what was the worst thing that could happen (Sabina, 11 yrs) Decatastrophizing, muscle relaxation, and writing down the advantages and disadvantages of various dental interventions were techniques used. Credibility of the themes The agreement between parent and children concerning positive outcomes of CBT was high; however, children, particularly those who were younger, expressed themselves with fewer words and more often emphasized the value of doing things (i.e., exposure) compared to their parents. This means that all patients may not have reached the highest level of our thematic map, that is, perspective shift. Younger children formulated mostly thoughts at the concrete level of our model that is at the level of main themes and our six subcategories. Children and adolescents experienced the outcomes as more positive than their parents. Parents and children s experiences of positive outcomes reported during the interview compared to children s actual performance in a dental setting according to dental records (data source triangulation) showed that, in all cases but one, participants were able to perform the dental intervention they feared without the use of sedation or general anesthesia and without experiencing intense anxiety. In one case, a child who was afraid of tooth extraction was not able to carry out the extraction and was offered general anesthesia. We conducted analyst triangulations that led us to the current thematic map. The team that analyzed the outcome was interdisciplinary and consisted of both psychologists and dentists, which may provide some protection against pre-conceptions affecting the result. The result of search for negative cases showed that not all participants were certain about the long-lasting effect of CBT. This was because some children and adolescents found it difficult to generalize their acquired capabilities to other contexts. For instance, some children doubted their ability to manage injections outside of dentistry. Children and their parent were asked during the interview to assess the child s subjective unit of distress before and after the CBT. Children and adolescents reported SUD values that were reduced from to Parents reported reduced fear in their children from to after CBT (method triangulation). Discussion Our results show that children, adolescents, and their parents had positive experiences of

8 324 S. Shahnavaz et al. CBT and it s outcome. They were able to benefit from this psychological treatment when dealing with dental anxiety. The overarching theme found was perspective shift, which made it possible for patients to change their view of dental care but also their own capacity to manage dental treatment. This overarching theme was underpinned by three main themes. Mastery, reduced fear, and safety, the main three themes in our study, correspond well with modern theories in psychology. In social cognitive theory 13, mastery is the main source of self-efficacy that leads to therapeutic change. Mastery means successful performance despite anxiety and other challenges that an individual meets. The experience of mastery increases the individual s beliefs about their capabilities to successfully manage challenging life events (self-efficacy) such as managing dental care in presence of dental anxiety. Reduced fear is a central aspect of CBT 14. To reduce the anxiety, patients have to face the feared stimuli instead of avoiding it. In this view, it is important that coping strategies do not become safety behaviors that prevent the confrontation with the feared stimuli. Our third main theme safety partly contradicts this negative view about safety and sees safety instead as a mean of therapeutic change; however, this view is not new in psychology. Attachment theories for instance consider a safe and secure base, created through the therapist-patient alliance as the major source for a therapeutic change. Therapeutic alliance refers to the quality of the relationship between the patient and therapist when it comes to collaboration, interaction, and personal attachment 15. According to Bowlby, this is how children, in interaction with adults surrounding them are cognitively and emotionally developed 16. Safety learning is also an important line of development in the field of emotional psychology. Safety learning can diminish or inhibit fear expression 17. Safety learning is a social form of learning using a live or film model. By watching the model safely interacting with the feared stimuli (e.g., a snake or a dentist), people can vicariously learn to feel safe. The theme perspective shift which is the overarching theme in our analyses is consistent with psychological theories, referred to as third wave CBT 18. Acceptance commitment therapy for instance, focus strongly to learn patients take perspectives and view them selves; thoughts, feelings and behavior in new perspectives, which leads to psychological flexibility and change. To our knowledge, this study is the first that focuses on children and parents experiences of CBT in dentistry. CBT has a strong scientific support as a treatment for phobia 19, but it is new in pediatric dentistry. Thus, there is a need for scientific studies to investigate whether CBT is beneficial in pediatric dentistry. Our results are consistent with Svensson 7, who also reported children s positive experiences from contact with a psychologist and receiving CBT for phobias, although dental anxiety was not included in that study. It is important to compare these results against studies that suggest, and the general view (common even in dentistry), that children and parents would experience contact with a psychologist as negative and stigmatizing and, in some cases, even offensive 8. This view, when held by a dental health staff, could be a barrier for children accessing CBT to treat dental anxiety. Our choice of qualitative research method was motivated by knowledge gaps regarding children s and parents subjective experiences of treatments in dentistry 6. As the efficiency of psychological interventions is to a large extent dependent on the patient s subjective experiences, it is crucial that we ask patients about the psychological interventions they are exposed to. As with many other psychological methods, the CBT applied in this study was originally designed and tested for adults. So, it was essential to obtain both child and parent perspectives. Our findings are related to a specific treatment; CBT for dental anxiety, which was offered to children and adolescents by a psychologist; however, we think that our results have implications for dental health care and psychological management of children and adolescents in general. Exposure is one of the

9 Children and parents experiences of CBT 325 main sources for the experience of mastery according to our analyses. Children and adolescents with dental anxiety are exposed to fear stimuli when they visit dentistry. Dental health staff meeting children and adolescents should be able to offer these children tasks and challenges that are neither too difficult or too easy, if the experience of mastery shall occur. Dental care staff strategies to deal with patient anxiety are applied when patients visit the clinic, while the anxiety is evoked hours, sometimes days before the dental visit. Anxiety usually reaches its height during the visit, which make it difficult to manage. Helping children and their parents deal with anticipatory anxiety before a dental appointment is therefore important. Parents and children need information, training programs offered by dental care staff targeting anticipatory anxiety. In many parts of the world, dental care takes place under time pressure. Safety and alliance building requires presence, time, and attention from the dental staff. Therefore, dental care organizations need to examine whether their staff has the possibility to create a safe base for children, particularly for those with dental anxiety or at risk of developing dental fear. This possibility is crucial for being able to live up to definition of oral health we referred to earlier and to both prevent and offer sufficient treatment for children with fear and anxiety in dental care. We conducted telephone interviews with parents and children, which is a limitation. Face-to-face and longer interviews would be a better alternative and may produce data with higher quality; however due to our earlier experiences of parent and children, we knew that they are under time pressure, with high risk for declining to participate in the research project. Overall, our results show that children and adolescents can understand and benefit from CBT in dentistry. Children experienced increased ability to manage the dental procedure (mastery), as well as reduced anxiety and increased safety. These changes lead to new more positive way of looking at dentistry and at own capabilities to deal with challenges in this context (perspective change). Parental experiences were largely consistent with children s experiences. Although all respondents had positive experiences with CBT, it is important to highlight some parents and children s uncertainty about the future and the relapse risk. This is a valid concern since, in contrast to several other phobias; individuals with dental anxiety and intraoral injection phobia are not exposed to dentistry or injections frequently, which means a higher risk for relapse. It is thus crucial to strengthen relapse prevention programs for CBT in this group and to offer patients with dental anxiety follow-up or booster sessions with the psychologist and dentist. There is a need for further research concerning application of CBT in pediatric dentistry 20. This includes randomized controlled trials of CBT for children and adolescents with dental anxiety. It is also important to examine different types of CBT; psychologist-led, self-help, face-to-face, and internet-based CBT. Acknowledgements We thank the participants who generously shared their experiences with us. We also acknowledge psychologist Tove Hasselblad, who assisted in the process of coding and thematizing the data, and Therese Kvist for reading the article and giving constructive comments. Conflict of interest All authors (Shahnavaz, Rutley, Larsson, Dahll of) declare no conflict of interest. References 1 Koch G, Poulsen S. Pediatric Dentistry: A Clinical Approach. Copenhagen: Wiley-Blackwell, Klingberg G, Broberg AG. Dental fear/anxiety and dental behaviour management problems in children and adolescents: a review of prevalence and concomitant psychological factors. Int J Paediatr Dent 2007; 17: Wide Boman U, Carlsson V, Westin M, Hakeberg M. Psychological treatment of dental anxiety among adults: a systematic review. Eur J Oral Sci 2013; 121:

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