Patient Education and Counseling 85 (2011) 4–13

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Patient Education and Counseling

journal homepage: www.elsevier.com/locate/pateducou

Review

Systematic review of the effect of dental staff behaviour on child dental patient
anxiety and behaviour
Yuefang Zhou a,*, Elaine Cameron b, Gillian Forbes a, Gerry Humphris a
a
Bute Medical School, University of St Andrews, UK
b
Birmingham Children’s Hospital NHS Foundation Trust, UK

A R T I C L E I N F O A B S T R A C T

Article history: Objectives: To review the literature, of the past 30 years, on the effects of dental staff behaviour on the
Received 19 April 2010 anxiety and behaviour of child dental patients; especially to determine staff behaviours that reduce
Received in revised form 6 July 2010 anxiety and encourage cooperation of children.
Accepted 3 August 2010
Methods: A systematic literature review was conducted using PubMed, Web of Science, The Cochrane
Library, PsycINFO, Embase and CINAHL.
Keywords: Results: Initial search returned 31 publications of which 11 fulfilled the criteria for review. Among seven
Dentist
studies that measured anxiety, four used validated measures. Five observational studies coded
Children
Behaviour
behaviour using Weinstein et al.’s (1982) coding scheme [1]. An empathic working style and appropriate
Dental anxiety level of physical contact accompanied by verbal reassurance was found to reduce fear-related
behaviours in children. Findings regarding positive reinforcement and dentists’ experience increasing
cooperative behaviour were inconsistent.
Conclusions: Measures for anxiety and behaviour varied across studies. Relationships between certain
dental staff behaviours and child anxiety/behaviour were reported. However, limited work was
identified and research using improved sampling, measurement and statistical approach is required.
Practice implications: Understanding what routine clinical behaviour of dental staff affects children’s
dental anxiety/behaviour will inform investigators of how children comply and help staff be aware the
significance of their daily behaviour on treatment success.
ß 2010 Elsevier Ireland Ltd. All rights reserved.

1. Introduction
It is widely accepted in the area of paediatric dentistry that
children’s dental fear and anxiety (DFA) and dental behavioural
management problems (DBMP) often create barriers to successful
treatment [2]. A recent review [3] referred to DFA as ‘‘strong
negative feelings associated with dental treatment’’ and DBMP as a
‘‘collective term for uncooperative and disruptive behaviours’’ in a
dental situation. The review suggested that DFA and DBMP each
affects approximately 9% of the child and adolescent population
although the relationship between DFA and DBMP is not always
consistent [4–7].
There is considerable interest in how to reduce child dental
anxiety. Dentists are generally discouraged from using sedative
drugs to achieve compliance in dentally anxious children [8];
* Corresponding author at: School of Medicine, University of St Andrews, North
Haugh, St Andrews, Fife, KY16 9TF, Scotland, UK. Tel.: +44 1334 463564;
fax: +44 1334 467470.
E-mail address: yz10@st-andrews.ac.uk (Y. Zhou).
hence research has explored potential risk factors for development
of DFA/DBMP. The origins of DFA/DBMP are likely to be multi-
factorial [3], including general fear, negative dental experience,
temperament and parental dental anxiety [9]. Research has
emphasized the investigation of acceptability [10], effectiveness
[11] and attitude [12] towards different behavioural management
techniques with regard to types and outcomes of treatment.
Paediatric dentists in the UK generally favour less restraining
methods of behavioural management, such as voice control and
dentists spending time with children in the waiting room prior to
treatment [13]. The ‘‘tell-show-do’’ method is favoured although
dentists frequently resort to general clinical rather than formal
behavioural management techniques to gain children’s coopera-
tion. Understanding dentist’s dental practice behaviour is vital for
investigators to learn how children may accept treatment without
formal intervention. Little attention has been directed at examin-
ing the effects of dental staff behaviour that occur during routine
clinical practice on anxiety and behaviour of the dental child
patient. It is, therefore, important to examine the relevant
literature of how children react to clinical behaviour without
special formal intervention. In addition, a knowledge of those

0738-3991/$ – see front matter ß 2010 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.pec.2010.08.002
 Y. Zhou et al. / Patient Education and Counseling 85 (2011) 4–13 5

dentists’ routine behaviours that reduce child anxiety and
disruptive behaviour can construct new complex interventions
[14] to ultimately enhance treatment outcomes.
Accordingly, the aim of this review was to examine the recent
literature on the effects of dental staff behaviour and experience on
the anxiety and behaviour of child dental patients. Specific
objectives were to (a) identify the literature in this area over
the past 30 years; (b) report publication patterns, quantity and
quality of studies especially including measurement issues and
analytic techniques; (c) determine specific staff behaviours that
reduce anxiety and encourage cooperative behaviours of children.
2. Methods
2.1. Search strategy
A systematic review was conducted between April and May
2008 using the terms shown in Table 1. Six electronic databases
were searched: PubMed, Web of Science, The Cochrane Library,
PsycINFO, Embase and CINAHL. To ensure completeness, function-
al search characters were used to search for word variations, for
example, ‘‘behavi*r’’ returned results that included both ‘‘behav-
iour’’ and the American spelling ‘‘behavior’’. Similarly, ‘‘dent*’’ was
used to obtain results containing ‘‘dentist’’, dentists’’ and ‘‘dental’’.
A database of the first search results was created into which
subsequent database search results were entered and duplicate
entries removed. An updated search took place in January 2010
within the six databases and was followed by hand search in
Google Scholar.
2.2. Inclusion criteria
Table 1
Databases and terms used for literature search.
Database Search Terms
 Abstract was available in English.
 A substantial proportion (>50%) of children were aged
3–12 years. These are the approximate ages when the
majority of problem behaviours during treatment occur.
Furthermore, children beyond this age range might experience
different causes of treatment anxiety (e.g., orthodontics) and
associated management (e.g., habituation of dental environ-
ment from regular attendance to attend to orthodontic
appliance and orthodontists). Thus, their behaviour in
response to that of the dentist would have been significantly
different to our group of interest and were excluded from the
review.
 Children undergoing a dental check-up or treatment which did
not involve any type of sedative or behaviour-altering medica-
tion.
 Observed or manipulated behaviour of a dental professional
(including dentists, dental assistants and dental hygienists).
 Dental staff behaviour associated to the behaviour and/or
anxiety level of child patients during a dental procedure.
 Studies published from 1980 onwards.
2.3. Exclusion criteria
 Standard behaviour management technique or package (e.g.,
tell-show-do).
 Complex intervention that involved several components.
2.4. Procedure
Initial selection was based on the titles and abstracts of the
studies obtained. Whenever fulfillment of these criteria was not
clear from the abstract, a full text of the study was obtained for
verification. Two of the authors iteratively applied inclusion and
exclusion criteria, resolving disagreements through discussion
with the remaining authors. Study authors were not contacted for
additional information.

PubMed Dentist AND child AND behaviour

2.5. Data extraction categories
Dentist AND child AND dental anxiety
Paediatric dentistry AND dentist–patient relations
Paediatric dentistry AND behaviour Full text copies of the final studies for review were obtained.
Dentist–patient relations AND child Data were then extracted from the articles as follows:
Dental assistants AND child AND behaviour
Dental assistants AND paediatric dentistry
 Year of publication
Dental assistants AND dentist–patient relations
Child AND behaviour AND dental anxiety  Journal title
Dental auxiliaries AND child AND behaviour  Country where study was conducted
Dental auxiliaries AND paediatric dentistry  Main study objectives
Dental hygienists AND paediatric dentistry
 Context: type of dental procedure and number of sessions
Dental hygienists AND child AND behaviour
Web of Science Dentist* child* behavi$r*
observed
P*diatric dent* behavi$r*  Child characteristics: age, previous dental experience, expected
Child* dent* anxiety behavi$r* level of anxiety or expected behaviours prior to treatment
The Cochrane Library Dentistry AND child behaviour (MeSH terms)  Dental staff characteristics: professional status (e.g., paediatric
Dentist–patient relations (MeSH terms)
dentist, dental assistant) and level of experience in treating
Child behaviour AND dental anxiety (MeSH terms)
Dentist* child* behavi*r dentally anxious children
P*diatric dent* behavi*r  Child outcome measures: levels of anxiety and behaviour during
Child* dent* anxiety behavi*r and/or after treatment
PsycINFO Dentist child behavi*r
 Dental staff outcome measures: staff behaviour or reports on
Child dental anxiety behavi*r
P*diatric dentist behavi*r
behavioural intervention (not complex intervention) during a
Embase Dentist child behaviour dental procedure
Dentist child behavior  Main analysis techniques
Child dental anxiety behaviour  Key study findings
Child dental anxiety behavior
CINAHL Dentist child behaviour
Dentist child behavior 3. Results
Child dental anxiety behaviour
Child dental anxiety behavior The data extraction results from the studies reviewed,
Dentist–patient relations child behaviour
according to the categories described in Section 2, are presented
Dentist–patient relations child behavior
in Tables 2 and 3.
 6
Table 2
Overview of the studies included in the review.

Ref. Aim Analysis Context Child No/age Staff No Child measurea Staff measureb Key findings

[1] USA OB Effect of dentists’ Lag sequential Injection; 1 dentist 50; 3–5 years 25 volunteer Dentist report on Dentist self-report on Direction#*
behaviour on fear- treat 2 children for practitioners expected child behaviour; confidence & experience; reinforcement# patting/
related behaviour in 2 or 2+ sessions per (22 GP & 3 child treatment behaviour dentist behaviour video stroking# explanations!
children child; private pedodontists) video recorded & coded recorded & coded reassurances! coercion"
practice (movement, verbal (guidance, empathy, coaxing" putdowns"
behaviour & comfort) physical contact & stopping treatment"
**
verbalization) (p  0.05)
[19] USA OB Relationship between Correlation tests Rotations in the 18,440 100 male Child treatment Dentist behaviour video Dentists’ empathic style
empathic dentists’ (Spearman’s rho) oral paediatric observations no. Caucasian; behaviour video recorded recorded & classified significantly positively
behaviour and clinic; middle 2 h of not reported; 5–12 3rd & 4th & classified using the using MFS (accept correlated to cooperative
children’s cooperation a 4-h clinic years yr dental modified Flanders system feelings, ask questions, behaviour in patients
students (MFS) (talk-response, praise/encourage, give (p  0.05)
movement-response, information, give

Y. Zhou et al. / Patient Education and Counseling 85 (2011) 4–13

talk-initiated, movement- direction, criticize &
initiated & cooperative cooperative ongoing
ongoing treatment) treatment)
[20] USA OB Effects of dental Lag sequential Injection; 1 team 50, 3–5 years 30 dental Assistant report on Assistant self-report on Reinforcement#
assistants’ behaviour treat 2 children for assistants expected child behaviour; confidence & experience; questioning for feelings#
on children’s 2 or 2+ sessions per child treatment behaviour assistant behaviour video chatting to dentist#
behaviour child video recorded & coded recorded & coded using dental-orientated
using Weinstein et al. Weinstein et al. (1982) communication to
(1982) coding scheme coding scheme dentist/child# patting!
reassurances " holding"
restraining " (p  0.05)
[22] USA OB Intra-dentist t-test & ANOVA Children need 36, 3–5 years 25 volunteer Child treatment Dentist behaviour video No significant difference
behavioural variability treatment practitioners behaviour video recorded recorded & coded in real in dentist behaviour
& its relationship with requiring 2 or 2+ (22 GP & 3 & classified as fear vs. non- time; duration of each between the group of 10%
occurrence of fear- operative sessions pedodontists) fear-related behaviour behaviour calculated & children with the most
related behaviour of (derived from Weinstein compared to 2nd session fear behaviours and the
children et al., 1982 & pre-school with the same child group of 10% with the
observation scale of least fear behaviours
anxiety); real time coding (p > 0.05)
[21] the Effects of dentists’ Lag sequential 2 treatment 24, 5–12 years (12 6 dentists Anxiety prior to treatment Dentist behaviour video 22 significant effects
Netherlands OB behaviour on anxious (autocorrelations) sessions: 1st high & 12 low (3 experienced) assessed; child behaviour recorded & coded without autocorrelations
behaviour of child prophylactic, 2nd anxious) during treatment video (Weinstein et al., 1982 (22 increased and 7
patients preparation and recorded & coded coding scheme modified): decreased fearful
restoration of a (Weinstein et al., 1982 guidance (direction), behaviours in children);
cavity under local coding scheme modified) guidance (feedback), only 2 significant effects
anaesthesia (only empathy, physical contact with autocorrelations:
2nd for analysis) & verbalization working contact
decreased & no physical
contact increased fearful
behaviours in children
(p  0.05)
[23] the Child behaviour during Log linear, x2 (chi Simple amalgam 24, 5–12 years (12 6 dentists Anxiety level prior to Dentist behaviour video Children treated by more
Netherlands OB treatment in relation square) & ANOVA restoration; 2 high & 12 low (3 experienced) treatment assessed on a 5- recorded & coded experienced dentists
to child’s dental fear treatment sessions: anxious) point Likert scale; child (Weinstein et al., 1982 showed more fear-related
and dentist experience 1st prophylactic, behaviour during coding scheme modified) behaviours (p  0.05);
2nd curative treatment video recorded experienced dentists were
& coded (Weinstein et al., more communicative and
1982 coding scheme worked faster
modified)
[15] Israel OB Effects of dentists’ Correlation tests 75% invasive & 25% 24 (14 boys); 3–12 4 dentists Child self-report on an Conversation audio Factors reduced anxiety
(audio) communication (Pearson’s r) & t- non-invasive years, 2 age group: (3 females), analogue anxiety scale recorded, transcribed & and increased
strategies on children’s test procedures 3–5.5 & 5.5–12 2nd-yr residents before treatment; analyzed cooperation: empathic
anxiety, cooperation, in paediatric observer graded (unit = sentence); approach, giving sensory
treatment success & dentistry cooperation on a modified sentences divided into information and reasons,
mood Frankl’s cooperation scale permissive, empathic, giving specific
(MFCS) at start, middle personal & common instructions, persuasion,
and end of treatment; approaches; frequency of control and assertiveness;
dentist evaluated each approach computed positive reinforcement
treatment success; had little impact on child’s
observer evaluated child behaviour (p < 0.05 for
mood at the end sensory & p < 0.001 for all
others)
[7] Nigeria OB Effect of dentists’ Correlation tests Attendance at 69 (39 boys); 8–13 7 dentists Child self-report on pre- & Dentist behaviours Dentist’s behaviour did
experience on (Pearson’s r), x2 & dental clinic for 1st years (4 experienced) post-dental treatment observed & most not significantly affect the
children’s behaviour t-test time care; analysis anxiety (CFSS-DS-SF); dominant ones video anxiety level of the child,
during treatment & of one treatment treatment behaviour recorded & coded using nor did it affect the child’s
effect of dentists’ session: observed & most Weinstein et al. (1982) anxiety-related
behaviour on examination, scale, dominant ones video coding scheme behaviour; however, the

Y. Zhou et al. / Patient Education and Counseling 85 (2011) 4–13

children’s anxiety after polish or tooth recorded & assessed using anxiety level of the
treatment extraction Venham clinical rating children decreased
scale (VCRS) significantly (p < 0.02)
after treatment when
experienced dentists
managed the children
compared to
inexperienced dentists
[18] USA EX Effects of 4 different ANOVA, Duncan’s 3 restorative 42 (26 boys); 4–12 4 dentists, Expected anxiety: child Use of 4 management Punishment resulted in
reinforcement Multiple Range test sessions at 1-week years trained in all self-report on CFSS- conditions during most un-cooperation and
conditions on & correlation test intervals 4 management DS + SAM & parent restorative sessions 1&2; highest self-reported fear
children’s behaviour, (Pearson’s r) conditions to completed maternal other sessions neutral for in children; most
fear & subsequent 86% accuracy anxiety questionnaire; comparison (initial exam. susceptible to effects of
cooperation (positive anxiety after treatment: – neutral, restoration 1 & 2 punishment: older than
reinforcement (PR), self-report on SAM & – assigned conditions, 3rd 7.5 years, with previous
punishment, dentist/observer rated treatment session – dental experience and
PR+punishment, fearfulness; expected neutral, 6-month follow- initially low in fear;
neutral) behaviour: parent up – neutral) criticism led to
completed behaviour uncooperativeness
problem checklist + child (p < 0.05)
development
questionnaire & observer
rated BPRS; treatment
behaviour video recorded
& rated (BPRS); dentist–
observer rated
cooperativeness after
treatment
[16] USA EX Effects of dentists’ x2, ANOVA & Cavity restoration; 40 (23 boys); 3.5-7 3 paediatric Pre-treatment: child self- Normal tone vs loud tone; Loud voice treatment
voice control on ANCOVA university years dentists report on anxiety/feeling all saw at least one subject reduced disruptive
children’s disruptive paediatric clinic (2 males) (CFSS-DS & SAM); each condition; normal or behaviour of children
and affective behaviour video recorded a loud/sudden/firm verbal during treatment without
behaviour (loud & & scored (BPRS); dentist command delivered to increasing negative
normal voice) rated child fear and stop children’s disruptive emotional effects
cooperation; post- behaviour (p < 0.004)
treatment: child self-
report on feelings (SAM)

7
8 Y. Zhou et al. / Patient Education and Counseling 85 (2011) 4–13

Includes dental staff characteristics (professional status and level of experience in treating anxious children with fear-related behaviours) and outcome measures (observed/reported behaviour or reported behavioural
3.1. Study characteristics

than children not touched

fidgeting behaviours than

less dominance (p < 0.10)

touched reported greater
(p < 0.05); children were
Touched children (7–10

pleasure (p < 0.06) and

years) displayed less
A review of the abstracts and titles returned by the initial search
no-touch children yielded 31 studies for consideration, of which 11 fulfilled the

after treatment
review criteria. Reasons for exclusion included: inability to obtain
Key findings

the full English text (n = 5), child participants outside specified age

Includes child characteristics (previous dental experience, expected anxiety and behaviour prior to treatment) and outcome measures (level of anxiety and behaviour during and/or after treatment).
range (n = 1), use of nitrous oxide during treatment (n = 1) and the
implementation of assessment measures beyond the scope of this
review (n = 13). Eight studies reviewed were observational,
Touch = pat child on upper
arm/shoulder for about 2 s

explanation & assurance;

recording only naturally occurring behaviour of the clinician

without physical contact
examination, plus verbal

explanation & assurance

not touch = only verbal
on 2 occasions during

including one study that audio recorded dentist–child conversa-

tion. The other three studies were experimental, that is, some
aspects of the clinicians’ behaviour were manipulated and
Staff measureb

comparisons tested between experimental and control groups.

The constructs manipulated in these studies were non-procedural
touch, voice control and the use of positive and negative
reinforcement. These simple intervention studies only involved
one independent variable with two to four conditions in
& rated by observer using
Child self-report on dental

behaviour video recorded

(pre- & post-treatment);

comparison to a complex intervention where a larger number of

before treatment); SAM
fear: DFS (trait index

independent variables are included.

Years of publication ranged from 1982 to 2004, with the
Child measurea

majority of the 11 studies conducted prior to 1991 (n = 8). The

studies were performed in the USA (n = 7), the Netherlands (n = 2),
Israel (n = 1) and Nigeria (n = 1).
BPRS

The most common dental procedure reported was cavity

preparation and restoration (n = 4); others included dental
examination, tooth extraction or simply ‘‘requiring an injection’’.
A total of 397 children were observed across 10 of the studies
2 dentists

(range 24–69 per study). One paper ignored sample size. The
(1 male)
Staff No

number of participating dental staff (total N = 207) in the 11

studies ranged from 2 to 100 (Mean = 19, SD = 28.5). Of these, 67
were dentists in general practice, 15 worked in paediatric
dentistry, 100 were dental students and 25 were dental assistants.
38 (20 boys); 3.5–

The results of the review are described under the following

Child No/age

seven sections.
10 years

3.2. Effects of staff behaviour on child anxiety

Five studies [7,15–18] reported effects of dental staff behaviour

fluoride treatment

on child dental fear and anxiety. Sarnat et al. [15] audio recorded
Paediatric dental

dentist–child conversation during treatment. Prior to treatment,

prophylaxis or

Increase ("), decrease (#) and ineffectual (!) in fear-related behaviour of children.
clinic: routine

examination,

children reported their level of anxiety. Frequencies of different

communication strategies (permissive, personal and empathic)
Context

dental

adopted by dentists were counted, which were then correlated with

children’s cooperation, fear and mood at the end of treatment. They
identified that an empathic communication approach focusing on
the child’s feelings and physician’s attentiveness (e.g., ‘‘I care how
you feel.’’) and giving clear and specific instructions reduced anxiety
p-Value at the end applies to all findings unless specified.

and brought about better mood in children.

Analysis

ANOVA

Greenbaum et al. [17] found that children who were

reassuringly patted by dentists on their upper arm or shoulder
reported greater satisfaction and less dominance after treatment
OB, observational study; EX, experimental study.

than children who did not receive any reassuring touch. Touch was
behaviour (touch & not
reassuring touch on

accompanied by verbal explanation and reassurance. Children

Effects of dentist’s

children’s fear &

reported their dental fear on the dental fear scale (DFS) and their
feelings about being at the dentists on the self-assessment
mannequin (SAM). At the end of the treatment, children were
touch)

reassessed using SAM. In 1990, Greenbaum et al. [16] found that a

Aim

firm and loud voice stopped children’s disruptive behaviour

without increasing negative emotional effects. Similar to Green-
Table 2 (Continued )

baum et al. [17], children’s anxiety level was assessed before and
after treatment.
[17] USA EX

intervention).

Melamed et al. [18] in 1983 found that punishment (verbal

statements of criticism for non-compliance) resulted in the highest
Ref.

self-reported fear in children. Again, the difference in children’s

**
b
a

anxiety level before and after treatment was measured.

 Y. Zhou et al. / Patient Education and Counseling 85 (2011) 4–13 9

Table 3
Review results on child/dentist measures.

[1] [19] [20] [22] [21] [23] [15] [7] [18] [16] [17]

Child
Previous dental experience         U U? 
Expected anxiety level     U? U U U U U U
Expected behaviour prior U  U      U U? 
to treatment
Anxiety during treatment           
Anxiety after treatment       U U U U U
Behaviour during treatment U U U U U U U U U U U
Behaviour after treatment         U U 

Staff
Level of experience U  U   U?  U?   
Behaviour during treatment U U U U U U U U NA NA NA
Behavioural intervention NA NA NA NA NA NA NA NA U U U

U = measured and findings reported;  = neither measured nor reported; U? = measured only, findings not reported; NA = not applicable.

Only one study included in this review [7] reported no
significant correlations between dentist behaviour and children’s
anxiety level. Children reported their anxiety level on a short form
of the dental subscale of the children’s fear survey schedule (CFSS-
DS-SF) before and after treatment.
3.3. Effects of staff behaviour on child behaviour
The majority (n = 10) of the 11 publications examined the
effects of dental staff behaviour on fear-related behaviour of a child
dental patient during a dental procedure; two studies specifically
investigated the effects of staff behaviour on behaviour of children
after treatment [16,18]. In general, dental staff behaviours that
were found to help reduce fear-related behaviours and encourage
children’s cooperation were: giving clear and specific instructions,
an empathic communication style and appropriate level of
working contact, including verbal reassurance. Restraining and
punishment-oriented behaviours were most likely to result in
fearful behaviour.
Specifically, staff behaviours associated with cooperative
behaviours in children included: giving clear direction [1], giving
specific instruction [15], giving sensory information and reasons
[15], an empathic approach [15,19], questioning for feelings [20],
chatting to the dentist and dental-oriented communication to
dentist–child (in the case of dental assistants) [20] and persuasion
[15]. Dentists who showed a good level of control and sense of
assertiveness [15] encouraged children’s cooperation. Further-
more, a loud firm voice [16], an appropriate level of working
contact [21] and a reassuring touch accompanied by verbal
explanation of ongoing procedure and verbal reassurance [17]
reduced children’s fearful behaviour.
Dental staff behaviours associated with fear-related behaviours
in children included coercion, coaxing, putdowns, stopping
treatment [1] and holding and restraining [20]. Verbal statements
of criticism led to uncooperativeness [18].
Importantly, giving explanations was ineffective in reducing
fearful behaviour in children [1]. Inconsistent findings were
obtained for the effect of positive reinforcement in preventing
disruptive behaviours. It was effective in reducing fearful
behaviours in some studies [1,20], whereas Sarnat et al. [15]
found that it had very little impact on children’s behaviour. Other
inconsistent findings were reported for touch-related behaviours
(e.g., patting, stroking only) and verbal reassurance only. Patting
helped to reduce fearful behaviour in Weinstein et al.’s first study
[1], but ineffective in Weinstein et al.’s second study [20]. Staff
verbal reassurance induced fearful behaviours in children in one
study [20] that was not confirmed in another report [1].
Nevertheless, it was evident that children were more likely to
cooperate when an appropriate level of physical touch was
combined with verbal reassurance [17].
Two studies reported that dentist behaviour did not affect
children’s anxiety-related behaviour [7,22]. Getz et al. [22] found
no significant difference in dentist behaviour between the group of
10% children with the most fearful behaviour and the group of 10%
children with the least fearful behaviour. In 2004, Folayan et al.
[7] conducted a study with 69 children of 8–13 years old in Nigeria
and found that dentists’ behaviour and children’s fear-related
behaviour were unrelated.
3.4. Effects of dental staff experience on child anxiety and behaviour
Two studies assessed dentists’ level of professional experience
but did not relate this to child anxiety and/or behaviour during
and/or after treatment [1,20]. Another two studies [7,23] examined
specifically the association of dental staff experience and child
anxiety and/or behaviour during and/or after treatment. In 1987,
Prins et al. [23] found that experienced dentists, compared to their
less experienced counterparts, were more communicative, worked
faster and the children treated showed more fear-related
behaviours. The authors explained that, as experienced dentists
were more communicative, they might have elicited more
expressions of fear through their behaviours. It cannot be
concluded, however, that children treated by experienced dentists
also subjectively felt more fearful than those treated by inexperi-
enced dentists. In 2004, Folayan et al. [7] reported some positive
effect of dental staff experience on child anxiety. They found that
the anxiety level of children decreased significantly after
treatment when experienced dentists managed children compared
to inexperienced dentists. It is worth noting that the definition for
‘‘an experienced dentist’’ was different in the last two studies
[7,23]. In Prins et al.’s [23] study, an experienced dentist was
defined as ‘‘had a working experience of several years with mainly
high-anxious children’’; whereas in Folayan et al.’s [7] study, an
experienced dentist was defined as ‘‘had more than six consecutive
months exposure’’ (in the management of child dental patients).
3.5. Measures of child behaviour
Table 4 presents measures of children’s fearful behaviour
before, during and/or after a dental procedure. All 11 studies
measured child behaviour during a dental procedure as an outcome
variable and two studies also specifically examined child fearful
behaviour after treatment. Three studies [1,18,20] reported child
expected behaviour prior to treatment, two of which were for
screening purposes [1,20]. The third study [18] correlated initial
disruptive behaviour with amount of disruptiveness during
10 Y. Zhou et al. / Patient Education and Counseling 85 (2011) 4–13

Table 4
Measures of child fearful behaviour before/during/after a dental procedure and staff behaviour during a dental procedure.

Ref. Age Child Staff Inter-coder reliability

[1] 3–5 Before: dentist report—questionnaire Video recorded & coded—Weinstein r = 0.85–0.94 (child)
During: video recorded & coded—Weinstein et al. (1982) coding scheme
et al. (1982) coding scheme
[19] NA During: video recorded & classified—the modified Video recorded & classified—MFS r > 0.85 (both intra
Flanders system (MFS) & inter) (child & staff)
[20] 3–5 Before: dental assistant report—questionnaire Video recorded & coded in real Adequate—referred
During: video recorded & coded in real time—Weinstein et al. (1982) to study [1]
time—Weinstein et al. (1982) coding scheme
coding scheme
[22] 3–5 During: video recorded & coded in real time—coding Video recorded & duration and Referred to study [1]
scheme derived from category of behaviour measured
the Weinstein et al. (1982) coding scheme and compared
[21] 5–12 During: video recorded & coded—Weinstein et al. (1982) Video recorded & coded—Weinstein Not reported (neither
coding scheme modified et al. (1982) coding scheme modified child nor staff)
[23] 5–12 During: video recorded & coded—Weinstein et al. (1982) Video recorded & coded—Weinstein K = 0.91 (child & staff)
coding scheme modified et al. (1982) coding scheme modified
[15] 3–12 During: audio recorded & observer graded—modified Audio recorded & frequency of Not reported (MFCS)
Frankl’s cooperation scale (MFCS) communication approaches
counted/compared
[7] 8–12 During: video recorded & coded—Venham clinical Video recorded & coded—Weinstein Not reported (VCRS)
rating scale (VCRS) et al. (1982) coding scheme
[18] 4–12 Before: observer rated—behavioural profile rating scale (BPRS) Behavioural intervention reported Not reported (BPRS)
Parent report—behavioural problem checklist
Parent report—child development questionnaire
During: video recorded & observer rated (BPRS)
After: dentist–observer rated cooperativeness on a 10-point scale
[16] 3.5–7 During: video recorded & observer scored (BPRS) Behavioural intervention reported r = 0.84–0.94 (BPRS)
After: dentist rated cooperativeness on a 7-point scale r = 0.72 (staff verbal
content)
[17] 3.5–10 During: video recorded & observer scored (BPRS) Behavioural intervention reported r = 0.88–0.92 (BPRS)

treatment. All 11 studies video recorded child behaviour except
one [15] in which dentist–child conversation was audio recorded.
Many of the studies (n = 5) [1,20–23] used Weinstein et al.’s [1]
coding scheme to code child behaviour. Reports on inter-coder
reliability of this coding scheme varied considerably, from
providing Cohen’s Kappa and Pearson’s r values to limited
information being provided (see Table 4 for details). The coding
scheme divided children’s behaviour into three categories:
movement and physical positioning, verbal behaviour and
comfort. Under each category, there were a number of sub-
behaviours that can be grouped into fear and non-fear behaviours.
For example, fear-related behaviours included minor and problem
movement (in the movement and physical positioning category),
crying (in the verbal behaviour category) and discomfort (in the
comfort category). Two studies [20,22] coded child behaviour in
real time and two studies [21,23] modified Weinstein et al.’s [1]
coding scheme, mainly by clarifying specific dentist behaviours.
Three studies [16–18] used the Melamed behaviour profile
rating scale (BPRS [24]) to measure the incidence of children’s
disruptive behaviour during a dental procedure. Recorded video
tapes were scored by one or two independent raters using BPRS.
Inter-rater reliability was reported by two studies: r = 0.84–0.94
for Greenbaum et al.’s study [16] and r = 0.88 to 0.92 for
Greenbaum et al.’s second study [17]. Melamed et al. [18] did not
report inter-rater reliability results. Stave [19] used the modified
Flanders system [25] to classify children’s behaviour, which were
divided into four categories: patient talk-response, patient
movement-response, patient talk-initiated and patient move-
ment-initiated. Cooperative ongoing treatment was common to
both children and dentists. Both intra- and inter-coder reliabilities
were reported as above 0.85. Folayan et al. [7] used the Venham
clinical anxiety rating scale (VCARS [26]) to assess child behaviour.
Inter-rater reliability was not reported.
Child behaviour after treatment was also assessed in two
studies [16,18]. In Melamed et al.’s study [18], both the dentist and
an observer rated child cooperativeness on a 10-point scale; in
Greenbaum et al.’s study [16], only the dentist rated child
cooperativeness on a 7-point scale. Neither of these two studies
reported details of the scales. In Sarnat et al.’s study [15], an
outsider observer graded children’s verbal behaviours during
treatment on audio recorded transcripts using a modified Frankl’s
cooperation scale (MFCS [27]). Inter-rater reliability and the
specific modification to Frankl’s scale [28] were not reported.
Three studies [1,18,20] measured and reported children’s
expected disruptive behaviour prior to treatment. In Weinstein
et al.’s [1,20] studies, dentists or dental assistants completed a
questionnaire concerning children’s expected behaviour, which
was not explicitly related back to the child outcome variables
(anxiety and/or behaviour during/after treatment). Melamed et al.
[18] measured children’s disruptive behaviour prior to treatment
from both observer (BPRS) and parent (behavioural problem
checklist and child development questionnaire). Inter-correlations
between these three scales were absent. The authors did, however,
link children’s initial degree of disruptive behaviours (BPRS) to
disruptiveness during treatment sessions.
3.6. Measures of staff behaviour
Measurement instruments for dental staff behaviour are
presented in Table 4. Seven studies video recorded staff behaviour,
one study audio recorded dentist–child conversation and three
studies reported details of behavioural interventions. Five of the
seven studies with video recording methods used Weinstein et al.’s
[1] coding scheme to code dentist behaviour. Dentist behaviours
were categorized in this coding scheme into four groups: guidance,
empathy, physical contact and verbalization. The other two studies
[21,23] modified the coding scheme by splitting the guidance
category into two: direction and feedback. Folayan et al. [7]
grouped a number of behaviours into the four categories according
to the Weinstein et al.’s [1] coding scheme. Using the modified
Flanders system (MFS), Stave [19] classified dentists’ behaviours
according to six categories: accepts feelings, asks questions,
 Y. Zhou et al. / Patient Education and Counseling 85 (2011) 4–13 11

Table 5
Measures of child dental fear and anxiety.

Ref. Age Scale Before/after Cut off score Administered Reliability/validity

treatment to whom

[21] 5–12 Unspecified 5-point Likert scale, 1 (not anxious) Before Referred to Unspecified Not reported—general
to 5 (extremely anxious) (scale referred to elsewhere) elsewhere details referred to
elsewhere
[23] 5–12 Unspecified 5-point Likert scale, 1 (not anxious) to 5 Before 4–5 Unspecified Comparable to other
(extremely anxious) more sophisticated
means
[15] 3–12 Unspecified analogue scale, not afraid (1), in the Before NA Child self-report Not reported
middle (2), very afraid (3) After Observer
Observer evaluated child’s mood at the end
[7] 8–12 CFSS-DS-SF (8 items), 5-point Likert scale with 1 Before & after 19 Child self-report Not reported
(not anxious) to 5 (extremely anxious)
[18] 4–12 CFSS-DS (modified, 15 items) Before NA Self-report Not reported
Self-assessment mannequin rating scale (SAM) Before & after Self-report
Unspecified 10-point scale for fearfulness After Dentist & observer
[16] 3.5–7 CFSS-DS (15 items) Before NA Self-report Referred to elsewhere
SAM Before & after Self-report (CFSS); varied (SAM)
Unspecified 7-point scale for fear After Dentist referred to elsewhere
[17] 3.5–10 Dental fear scale (DFS), 15 items derived from CFSS-DS Before NA Self-report r = 0.86 (test-retest for
SAM Before & after Self-report DFS); validity (DFS)
elsewhere; validity
(SAM) elsewhere

praises or encourages, gives information, gives direction and
criticizes. The final category, cooperative ongoing treatment, was
related to both dentists and children. The study in which dentist–
child conversation was audio recorded [15] calculated the
frequency of each of the dentists’ communication strategies and
correlated these with child anxiety, behaviour and treatment
success. The three studies [16–18] with experimental designs
reported details of dentists’ behavioural interventions. Greenbaum
et al. [16] examined the punishing-reinforcing quality of the
dentists’ verbal contents by two independent raters on a 7-point
bipolar scale from extremely reinforcing (3) to extremely
punishing (+3). Inter-rater reliability was reported as r = 0.72.
3.7. Measures of child dental fear and anxiety
Seven studies included in this review reported using either
recognized or self-developed scales to measure child dental fear
and anxiety. Table 5 presents details of the scales adopted by the
studies.
Apart from three studies adopting the most widely-known
scale, the dental subscale of the children’s fear survey schedule
(CFSS [29]; CFSS-DS [30]), the use of the self-assessment
mannequin rating scale (SAM [31]) (n = 3) or unspecified scales
(n = 4) was another feature of the studies reviewed. The SAM scale
measures affect in children in three dimensions of emotion:
arousal, pleasure and dominance. Children’s fear was characterized
as high arousal, low pleasure and low dominance. The unspecified
scales were usually developed as a 5, 7 or 10-point Likert-type
scale, rated either by the child, the dentist or an observer. Reports
on reliability and validity of these unspecified scales were poor.
3.8. Data analysis approaches
The majority of the studies included in this review adopted
traditional analysis methods, such as analysis of variance (ANOVA),
correlation tests (Pearson’s r and Spearman’s rho) or Student’s t-
tests (see Table 2 for details). Three studies included in this review
[1,20,21] implemented lag sequential analyses to evaluate
whether children’s behaviours (especially fear-related behaviours)
were determined by preceding dental clinicians’ behaviours. Both
child and dental staff behaviour were video recorded and coded
using Weinstein et al.’s [1] coding scheme in all three studies. In
Weinstein et al.’s [1] study, the conditional probability of a child’s
response behaviour (i.e., the probability that a child’s behaviour
will occur given the presence of another behaviour occurred
simultaneously or previously) was calculated for six preceding
time lags in a criterion behaviour (i.e., a dentist influencing
behaviour prior to a child behaviour). The authors argued that a
criterion behaviour would lose its influence on a response
behaviour after some time; it was thus reasonable to consider
only probabilities of lag 0 to lag 7 in the analyses. Similar analysis
techniques were followed with dental assistants in another study
[20], this time with only three lags being considered.
Horst et al. [21] also implemented similar lag sequential
analyses using two lags. This study, however, took an advanced
step in that also it controlled for the child’s own preceding
behaviours. As children’s behaviours were strongly correlated with
their own preceding behaviour, lag sequential analyses were
conducted when controlling the effects of children’s own behav-
iour. Once autocorrelations were controlled, the number of
dentists’ behaviours that were significantly correlated to child
behaviour, reduced from 22 to 2. The authors of this study
challenged the findings of the previous lag sequential analysis
studies that did not control for the effects of children’s own
antecedent behaviours on their present ones.
4. Discussion and conclusion
4.1. Discussion
4.1.1. Study characteristics
The findings from this systematic review suggest that over the
past 30 years in paediatric dentistry there have been a limited
number of studies (n = 11) that investigated the effects of dental
staff behaviour on anxiety and/or behaviour of a child dental
patient. The review results have also shown that the majority of
studies (n = 7) were conducted in the USA over a 10-year period
between 1982 and 1993. Furthermore, no studies in this field were
found in the UK over the last 30 years. Considering the limited
number of studies drawn from restricted areas and an extensive
time period, the review suggests that we have much to learn in this
field. There is an urgent need for researchers to investigate further
how dental health professionals influence child anxiety and
behaviour during and after treatment.
The child sample size of the majority (n = 10) of the studies
included in the review was between 24 and 50, while the sample
12 Y. Zhou et al. / Patient Education and Counseling 85 (2011) 4–13
size for dental staff varied from 2 to 100. Furthermore, three of the
USA and the two Netherlands’ studies used the same participants
though with different foci of investigation indicating non-
independence. None of the studies justified their sample size. In
addition, participant recruitment procedures varied considerably.
Future researchers in this field should consider representative
sampling, justification of sample size to test associations with
sufficient power and recruitment standardization.
4.1.2. Effects of staff behaviour on child anxiety/behaviour
Findings confirmed that there were relationships between dental
staff behaviour that occurred in a routine clinical practice and the
anxiety and/or behaviour of child dental patients. Generally, those
staff behaviours that reduced child anxiety, that is, an empathic
communication style and appropriate level of physical contact
accompanied by verbal explanation and reassurance, were also
those that could bring about cooperative behaviours in children.
Some staff behaviours (e.g., punishment) that were found to raise
child fear also induced uncooperativeness. One important finding
was that verbal explanation and instruction only, or physical
working contact only, was not the most effective methods when
communicating with children of about 3–12 years old. A firm and
loud voice used by a dentist during treatment deterred children’s
disruptive behaviour without increasing any negative emotional
effect. This technique is obviously useful for inattentive children;
however, selective rather than universal use is recommended.
Furthermore, there is some evidence that the voice control
technique is not acceptable to all parents [10] or clinicians [32].
Future investigation is required with this approach on children of
various ages and behavioural or emotional difficulties. One study
[17] revealed that the emphasis on single elements of staff behaviour
may be partially misplaced. An alternative or supplementary
approach should explore the effects of combinations of behaviours
that may be advantageous to improving child cooperation.
Analytical techniques that enable the pairing of discrete codes by
chaining or collapsing two coincident codes would enable such a
development. An interesting possibility is raised of detecting
combined behavioural repertoires, and labelled as strategies to
assist the receipt of treatment procedures in children.
Staff behaviours associated with cooperation in children did not
necessarily reduce children’s anxiety. In future studies, it is worth
investigating whether those staff behaviours that impact on child
behaviour will also have an effect on child anxiety in the same
direction. This will have practical implications for dental health
professionals to help them work effectively with young children
without jeopardizing their psychological emotions. It will also be
useful for researchers to understand the relationship between
emotion and behaviour in general and child dental anxiety and
dental behavioural management problems in particular.
Positive reinforcement inconsistently reduced fear-related
behaviours. The two studies that found positive reinforcement to
be effective in reducing children’s fearful behaviours were
conducted in the USA with 3–5-year-olds in the 1980s with lag
sequential analyses implemented on video recorded and coded data.
Little impact of positive reinforcement on child behaviour was found
in the Israeli study with 3–12-year-olds in 2000 using audio
recording methods. It is not clear whether child age, country or time
of study and/or analysis methods had any influence on the findings.
It is important to note that dental staff behaviour and children’s
anxiety and behaviour might vary considerably among different
dental treatments. As the studies reviewed contained several types
of dental treatments, caution is warranted to conclude that
children’s anxiety and/or behaviour were influenced by certain
staff behaviours. Children’s anxiety and/or behaviour might be
affected by a combination of staff behaviour and the nature of
treatments. As none of the studies reviewed examined the effects
of staff behaviour on child anxiety and/or behaviour when
controlling the effects of the treatment types, future researchers
should explore this issue further.
4.1.3. Effects of staff experience on child anxiety and behaviour
Two findings were reported 17 years apart regarding the effects
of staff experience on child anxiety and/or behaviour. Experienced
dentists elicited more fear-related behaviours in children during
dental treatment, while in the longer term, children’s anxiety level
decreased when experienced dentists managed them. The defini-
tion for the level of staff experience was different in these two
studies. The findings were inconsistent, but not contradictory. In
future studies, it is worth considering both short-term and long-
term effects of dental staff experience on child anxiety. The level of
dental staff experience should be clearly explained. Future
research should explore the extent that the experience of dentists
contributes to fear-related behaviours in children.
4.1.4. Measures of behaviour and anxiety
Measurement instruments used to assess behaviour and
anxiety varied. Assessment of behaviour should emphasize the
reporting of coder reliabilities. Scale modifications require detailed
specification. For child dental fear and anxiety measurement,
psychometrics for the study sample are recommended.
4.1.5. Analysis approaches
The majority of the studies reviewed adopted traditional
analysis methods of the data obtained from rating or grading on
scales. A reasonable number of studies implemented the lag
sequential analysis technique to identify patterns of behaviour of
both children and dental staff. The adoption of autocorrelation in
the lag sequential analysis was a further advance as the occurrence
of certain child behaviour was not only influenced by staff
behaviour but also by the child’s own previous behaviour. No study
took into account the clustering effect of individual staff and their
possible influence on the group of children they treated. The effect
may be relevant when more than one staff member is recruited
into the study. Attempts to control for clustering should be
incorporated into sequential analysis, such as multilevel model-
ling, to take account of some participant-specific variables [33].
4.2. Conclusion
The literature search, although restricted to publications in
English, revealed a neglected field of study. The intensive
investigation into the routine clinical repertoire of individual
elements of staff behaviour is to be commended. The review
confirmed the existence of a relationship between certain dental
staff behaviours and child anxiety and/or behaviour in a dental
setting. Further systematic work is required to identify those
behaviours that have consistent effects on child cooperation. A
focus not only on single behavioural elements but also on small
combinations of staff behaviours may prove to be fruitful. In
addition research is needed to develop consistency in the
assessment of child anxiety and also sophisticated and valid
behavioural codes. Researchers are encouraged to utilize some of
the newly developing statistical methodologies that have become
available recently [34,35] to uncover some of the hidden
associations that are believed to exist between the subtle
interaction of dental personnel and the children they wish to serve.
4.3. Practice implications
Understanding whether and how some routine clinical behav-
iour of dental staff affects children’s dental anxiety and coopera-
tion is essential for investigators to learn how children may comply
 Y. Zhou et al. / Patient Education and Counseling 85 (2011) 4–13
in a dental setting. In addition, identifying daily dental staff
behaviours that have consistent effects on children’s cooperation
enhances the chances of treatment success and reduces the
likelihood of raising anxiety in children attending for dental
procedures.
Conflict of interest statement
The authors have no conflict of interest that could inappropri-
ately influence or be perceived to influence this manuscript.
Acknowledgements
The authors wish to acknowledge the support of the Childsmile
evaluation programme as part of the Scottish government’s
initiative to improve children’s oral health. We also wish to thank
Professor Martin Fischer for his critical reading during the
preparation of the manuscript as well as to the two reviewers
for their close attention to our article and helpful comments.
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