Internet-Based Cognitive Behavioral Therapy for Children and Adolescents With Dental or Injection Phobia: A Randomized Controlled Trial (Preprint)

BACKGROUND Dental and injection phobia (DP/IP) in children and adolescents is common and considered one of the biggest obstacles to successful treatment in pediatric dentistry. Cognitive behavioral therapy (CBT) is an evidence-based treatment for anxiety and phobias. Because availability of CBT in dentistry is low, internet-based CBT (ICBT) was developed. Open trials have shown that ICBT is a promising intervention, but randomized trials are lacking. OBJECTIVE This study, in a randomized controlled trial, tested if therapist-guided ICBT supported by a parent could reduce fear, allowing children and adolescents with DP/IP to receive dental treatment. METHODS We enrolled 33 participants, average age 11.2 years (SD 1.9), whom a clinical psychologist had diagnosed with DP, IP, or both. After inclusion, participants were randomized to either ICBT (n=17) or a control group of children on a waiting list (n=16). ICBT is based on exposure therapy and comprises a 12-week, at-home, program combined with visits to a regular dental clinic. Participants corresponded weekly with their therapist after completing each module, and one parent was designated as a coach to support the child in the assignments during treatment. All participants completed measurements of the primary and secondary outcome variables before treatment start, and after 12 weeks (at treatment completion). The measurements included a structured diagnostic interview by a clinical psychologist. Our primary outcome measures were the Behavioral Avoidance Test (BAT), which assesses ability to approach 17 dental clinical procedures, and a positive clinical diagnosis. Secondary outcome measures included self-report questionnaires that measured self-efficacy and levels of dental and injection anxiety. The child and the parent completed the questionnaires. RESULTS All participants in the ICBT group completed the program. After treatment, 7/17 (41%) in the ICBT group no longer met the diagnostic criteria for DP or IP whereas all participants in the control group did (P=.004). Repeated measures ANOVAs showed that ICBT led to larger improvements on the child- and the parent-rated BAT compared to the control group; between-group effect sizes for Cohen d were 1.6 (P≤.001) for the child-rated PG-BAT and 1.0 (P<.01) for the parent-rated PG-BAT. Further, reductions in dental and injection anxiety and improvements in self-efficacy were significantly larger among children in the ICBT group compared to the controls. No participant reported any adverse events. CONCLUSIONS ICBT seems to be an effective treatment for dental and injection phobia in children and adolescents. It reduced fear and anxiety and enabled participants to willingly receive dental treatment. ICBT should be seriously considered in clinical practice to increase accessibility; the therapy may reduce the need for sedation and restraint and lead to better dental health in children and adolescents. More research, especially on methods for effective dissemination and comparisons with traditional CBT, is needed. CLINICALTRIAL NCT02588079