Principles and techniques of applied behaviour analysis for the management of anxiety related behaviour in children’s dentistry

Student thesis: Doctoral ThesisDoctor of Philosophy


Patient management is a cornerstone of paediatric dental treatment. Applied Behavioural Analysis (ABA) provides an effective framework to develop small scale studies to research the effectiveness of behavioural interventions. 

To explore the current status of ABA in children’s dentistry and determine how it might be implemented. 

i) To determine the impact of dental anxiety on children’s oral health in the UK population at the age of 5, 8, 12 and 15 years. 
ii) To conduct a structured review of the published paediatric dental literature which has adopted ABA. 
iii) To determine the level of knowledge of the principles of ABA among specialist paediatric dentists in the UK. 
iv) To determine the feasibility of adopting an ABA technique (reinforcer choice) in a paediatric dental setting. 

This project takes the form of two parts. 
Part 1 
ABA methodology requires that the target behaviour is deemed to have a detrimental effect on the individual or be socially significant. Therefore part 1 looked to establish if dental anxiety in children predicted a worse health outcome. This was completed via a secondary and regression analysis of data from the 2013 Child Dental Health Survey, including children aged 5, 8, 12 and 15 years. 
Part 2 
To establish if ABA has the potential to be of use in resolving children’s dental anxiety and uncooperative behaviour. This takes the form of 
i) A structured review of published ABA literature related to paediatric dentistry. 
ii) A survey regarding the knowledge of ABA among specialist paediatric dentists in the UK. 
iii) Cross sectional study of children’s reward choices. 

Part 1 
i) Dental anxiety was associated with worse health in children in this population group. Dental anxiety predicted poorer oral health in 5 and 8 year olds, but not in 12 and 15 year olds. Dental anxiety predicted a detrimental effect on family life in younger children and a negative effect on everyday life of older children. 
Part 2 
i) Nineteen studies met the criteria for a published ABA study relating to paediatric dentistry. The majority of papers reported studies reported on interventions involving a small number or participants, typically at the age of 8 years or under. The study design was typically multiple baselines across subjects. Behaviours studied included disruptive behaviour in the dental surgery, digit sucking, bruxism, dietary choices, and interproximal cleaning. Interventions were mainly contingency management. 
ii) Dentist’s knowledge of ABA - Participant’s mean knowledge score was 38%, range 0 to 75%. 
iii) The children’s reward choice study showed that there was no clear preferred reward common to all children, and no child preferred a “sticker” as a reward. Approximately 35% of carers agreed with the child’s choice, with significant differences in levels of agreement between child and carer across the age groups. 

Part 1 suggests that dental anxiety, in this population group, is a socially significant problem that leads to a worse health outcome. Many of the recommended non-pharmacological behavioural techniques to manage dental anxiety are based on principles of behavioural psychology. While the structured review in Part 2 highlighted a small number of papers that used of ABA to help children cope with dental treatment, further research needs to be completed to further support its use. Our study on reinforcer preference of children under the age of 8 years demonstrates that ABA can be used to challenge existing norms as well as develop new innovative techniques. 
However, as evidenced by the results of the questionnaire survey, at present paediatric dentists in the UK do not have the requisite knowledge to implement effective ABA strategies. If this can be rectified, with the increasing emphasis on evidence-based approaches to dentistry including methods of behaviour change, ABA may be a valuable tool to the provision of innovative behavioural interventions to help dentally anxious young children cope with dental treatment.
Date of Award1 Nov 2019
Original languageEnglish
Awarding Institution
  • King's College London
SupervisorTim Newton (Supervisor) & Marie Therese Hosey (Supervisor)

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