Shahnavaz Shervin, Hedman-Lagerlöf Erik, Hasselblad Tove, Reuterskiöld Lena, Kaldo Viktor, Dahllöf Göran
Division of Pediatric Dentistry, Department of Dental Medicine, Karolinska Institutet, Huddinge, Sweden.
Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
J Med Internet Res. 2018 Jan 22;20(1):e12. doi: 10.2196/jmir.7803.
Cognitive behavioral therapy (CBT) is an evidence-based method for treating specific phobias, but access to treatment is difficult, especially for children and adolescents with dental anxiety. Psychologist-guided Internet-based CBT (ICBT) may be an effective way of increasing accessibility while maintaining treatment effects.
The aim of this study was to test the hypothesis that psychologist-guided ICBT improves school-aged children's and adolescents' ability to manage dental anxiety by (1) decreasing avoidance and affecting the phobia diagnosis and (2) decreasing the dental fear and increasing the target groups' self-efficacy. The study also aimed to examine the feasibility and acceptability of this novel treatment.
This was an open, uncontrolled trial with assessments at baseline, posttreatment, and the 1-year follow-up. The study enrolled and treated 18 participants. The primary outcome was level of avoidance behaviors, as measured by the picture-guided behavioral avoidance test (PG-BAT). The secondary outcome was a diagnostic evaluation with the parents conducted by a psychologist. The specific phobia section of the structured interview Kiddie-Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime (K-SADS-PL) was used. Other outcome measures included level of dental anxiety and self-efficacy. The ICBT, which employed exposure therapy, comprised 12 modules of texts, animations, dentistry-related video clips, and an exercise package (including dental instruments). Participants accessed the treatment through an Internet-based treatment platform and received Web-based guidance from a psychologist. Treatment also included training at dental clinics. Feasibility and acceptability were assessed by measures of engagement, adherence, compliance, completed measures, patient and parent satisfaction scale, and staff acceptability.
The level of avoidance (according to the primary outcome measure PG-BAT) and dental anxiety decreased and self-efficacy increased significantly (P<.001), within-group effect sizes for both the primary outcome (Cohen d=1.5), and other outcomes were large in the range of 0.9 and 1.5. According to K-SADS-PL, 53% (8/15) of the participants were free from diagnosable dental anxiety at the 1-year follow-up. At the 1-year follow-up, improvements were maintained and clinically significant, with 60% (9/15) of participants who had been unable to manage intraoral injection of local anesthetics before ICBT reporting having accomplished this task at a dental clinic. The target group showed improvement in all the outcome measures. High levels of feasibility and acceptability were observed for the treatment.
ICBT is a promising and feasible treatment for dental anxiety in children and adolescents. Integrating it into routine pediatric dental care would increase access to an effective psychological treatment. The results of this open trial must be replicated in controlled studies.
认知行为疗法（CBT）是一种治疗特定恐惧症的循证方法，但获得治疗存在困难，尤其是对于有牙科焦虑症的儿童和青少年。由心理学家指导的基于互联网的认知行为疗法（ICBT）可能是一种既能提高可及性又能保持治疗效果的有效方法。
本研究的目的是检验以下假设：由心理学家指导的ICBT通过（1）减少回避行为并影响恐惧症诊断，以及（2）降低牙科恐惧并提高目标群体的自我效能，从而提高学龄儿童和青少年应对牙科焦虑的能力。该研究还旨在考察这种新型治疗方法的可行性和可接受性。
这是一项开放性、非对照试验，在基线、治疗后和1年随访时进行评估。该研究招募并治疗了18名参与者。主要结局是回避行为水平，通过图片引导的行为回避测试（PG-BAT）进行测量。次要结局是由心理学家与家长进行的诊断评估。使用了针对学龄儿童的情感障碍和精神分裂症的儿童版结构化访谈（K-SADS-PL）中的特定恐惧症部分。其他结局指标包括牙科焦虑水平和自我效能。采用暴露疗法的ICBT包括12个模块的文本、动画、与牙科相关的视频片段以及一套练习（包括牙科器械）。参与者通过基于互联网的治疗平台接受治疗，并接受来自心理学家的网络指导。治疗还包括在牙科诊所的培训。通过参与度、依从性、顺应性、完成的测量指标、患者和家长满意度量表以及工作人员可接受性等指标来评估可行性和可接受性。
回避水平（根据主要结局指标PG-BAT）和牙科焦虑水平降低，自我效能显著提高（P<0.001），主要结局的组内效应量（Cohen d = 1.5）以及其他结局的效应量在0.9至1.5范围内都很大。根据K-SADS-PL，在1年随访时，53%（8/15）的参与者没有可诊断的牙科焦虑症。在1年随访时，改善情况得以维持且具有临床意义，在ICBT治疗前无法耐受口腔内注射局部麻醉剂的参与者中，60%（9/15）报告在牙科诊所完成了这项任务。目标群体在所有结局指标上均有改善。观察到该治疗方法具有较高的可行性和可接受性。
ICBT是一种治疗儿童和青少年牙科焦虑症的有前景且可行的治疗方法。将其纳入常规儿科牙科护理将增加获得有效心理治疗的机会。这项开放性试验的结果必须在对照研究中得到重复验证。
