Managing Intraoral Injection Fear in Children and Adolescents

Joel M. Laudenbach, DMD


August 14, 2017

Fear of Intraoral Injections in Kids

Every practitioner who has tried to anesthetize children, and even adolescents, has been faced with untoward reactions and fear. These emotional and physical reactions certainly get in the way of performing intraoral injections (IOIs), and can lead to cancelling a planned procedure and rescheduling for more advanced anesthesia (conscious/intravenous sedation). These behaviors often lead to treatment delays and even dental phobia

In an article published in June 2017, Berge and colleagues[1] described their randomized, delayed intervention-controlled trial, in which 10- to 16-year-olds with IOI phobia received five cognitive-behavioral therapy (CBT) sessions to assess the effect on dental fear and the number of patients receiving IOIs.

One half of the 68 patients who met the inclusion criteria were part of the active treatment group, and one half were in the wait-list control group. Four psychometric fear/phobia self-report instruments were used. Diagnostic interviews were performed by two clinical psychologists according to criteria from the Diagnostic and Statistical Manual of Mental Disorders, fifth edition. A behavioral avoidance test (BAT) was performed by specially trained dentists at all assessments.

The Behavioral Avoidance Test

The BAT consisted of multiple, progressively more difficult steps and exposures to IOI. Examples include a clinical exam with mouth mirror, application of topical anesthesia, touching the mucous membrane with the cannula enclosed in the cap, touching the mucous membrane with the cannula without penetrating, and depositing a few drops of anesthesia.

Before starting the BAT, patients were told that they could ask any questions during the test. The patients were made aware that each step of the test would be explained verbally. The patients were also told that the BAT could be discontinued whenever they wished, via verbal communication or by showing a "no" card.

If the BAT was discontinued before a few drops of anesthesia were deposited, then the IOI was deemed unsuccessful. Post-treatment assessments were performed promptly after the CBT intervention and wait-list control group time frames, and again at 1-year follow-up.

There were 67 enrollees (28 boys and 39 girls), and the mean age was 12.2 years. CBT treatment was completed by 86.6%, and 80.6% completed 1-year follow-up visits. In the CBT group, results on the fear/phobia psychometric self-report instrument improved significantly after treatment. In this group, 70.1% received IOIs during the CBT and 14.9% received a few drops of anesthesia injected into the submucosa. In the control group, there was no significant difference in completion of the BAT steps pre- and post–wait-list.

In summary, 49 patients who underwent CBT had dental treatment needs, and 69.4% of these patients received IOIs by their regular dentist during the subsequent year.


The authors performed a randomized, delayed intervention-controlled trial that examined the effect of multiple, formal CBT sessions on young patients diagnosed with a common clinical challenge: IOI phobia. Oral healthcare providers often spend valuable chair-time desensitizing and acclimating young patients to the dental operatory in an effort to gain trust and rapport. It is this trust/rapport that we rely on to complete dental procedures.

Not all children or adults can tolerate dental procedures owing to fear of IOIs. This study describes the authors' steps (BAT) that were used to help young patients tolerate IOIs over five structured visits. A prior study has also supported similar CBT sessions as being effective and successful in adults with IOI phobia.[2]

The authors note that dentists in this trial had specialized training in treating fearful patients. Providers who are interested in improving clinical skills and proficiency in patients with IOI phobia may consider postgraduate courses in CBT for dental anxiety.

However, with or without specialized training, it may be helpful for oral health clinicians to consider the various BAT steps when attempting IOIs in patients with fear of IOIs. Each provider has his or her own techniques to help anxious or fearful patients. Providers may consider tailoring the number and format of clinical visits for this patient population, with a goal of achieving successful IOI, completion of the indicated dental procedure, and future tolerance and decreased fear of dentistry. If this can be achieved, then more patients will avoid conscious/intravenous sedation, which is often the next necessary step to complete dental care.


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