EUROPEAN JOURNAL OF PAEDIATRIC DENTISTRY • 1/2004 15 Dental anxiety and behavioural problems: what is their influence on the treatment plan? C. GOUMANS*, J.S.J. VEERKAMP*, I.H.A. AARTMAN** ABSTRACT . Aim This was to investigate the influence of emotional and behavioural problems on the choice of treatment type. In addition, the actual contents of the treatment of dentally fearful children was studied in an attempt to develop dental treatment protocols for children with such problems. Methods The parents of 265 children (144 girls, mean age 88.4 months, SD±34.2 months), referred to a centre for special dental care, were asked to complete the Child Behaviour Check List (CBCL) before their first appointment. The CBCL was used to assess behavioural problems. All selected children were dentally anxious (score ≥35 on the Children’s Fear Survey Schedule Dental Subscale, CFSS-DS). After treatment, the children’s records were analysed on treatment type and contents. Results The CBCL score was related to the type of treatment. Children treated with the aid of nitrous oxide sedation scored significantly higher on the CBCL than children treated with behavioural management or under intravenous anaesthesia (IVA). In the IVA group more surfaces were treated than in the other groups. The CBCL score was not related to the treatment contents (number of surfaces filled, amount of radiographs, sealants, stainless steel crowns or pulpotomies), the time spent on the child’s treatment or the number of sessions. Conclusion Dentally anxious children with behavioural problems as assessed by the CBCL have dental treatment (contents and length) comparable with that of dentally anxious children without those problems. However, anxious children with behavioural problems are more often treated with nitrous oxide sedation. Therefore, there seems to be an urgent need for access to nitrous oxide sedation for dentists working in special dentistry. KEYWORDS: Children, Dental anxiety, Behavioural problems, Sedation, Nitrous oxide. Introduction Dental anxiety is a common complex phenomenon in adults as well as in children. In the Dutch population about 6% of children have a high anxiety level and another 8% are at risk of becoming fearful [Ten Berge et al., 1998]. It is important for paediatric dentists to know more about the development of dental fear. Rachman [1977] described a pathway theory of the development of fear comprising three pathways: direct conditioning, modeling and information. In later research it was concluded that these three pathways are interactively related [King et al., 1998]. The direct pathway together with the modeling pathway were significantly related to the development of dental fear [Milgrom et al., 1995]. Dental anxiety can complicate the treatment of the child. On the other hand, it is clear that behavioural problems are not always based on dental fear. In a Departments of: *Cariology Endodontology Pedodontology **Orthodontics and Social Dentistry, Section Social Dentistry and Dental Health Education, ACTA, The Netherlands Swedish child population only 27% of the children who showed behavioural problems during treatment were dentally anxious. It was also found that 61% of the children who were anxious showed behavioural problems during dental treatment [Klingberg et al., 1994]. As dental anxiety is related, in general, to a history of earlier dental treatments, children suffering from dental anxiety are treated by graduated exposure, aiming at counter conditioning of their negative experiences. Past experiences need to be replaced by positive new dental ones, secondarily reducing their anticipatory anxiety [Freeman, 1985]. Paediatric dentists sometimes use additional medical support, when dental treatment causes too many stimuli for the child. How the treatment mode should be chosen depends on the anxiety level and/or the mental age of the child. However, when the child develops personality or psychological problems, these might interact with dental anxiety. In a study conducted in a Dutch population referred for dental anxiety to a secondary dental care centre, 25% of the children had psychological problems possibly needing extra atten-