Anxiety in children: What dental professionals should look for, and how they can help

Childhood has typically been viewed as a time free from stress, responsibility, and concern, providing the opportunity to enjoy life and just “be a kid.” Then came 2020, ushering in uncertainty, lockdowns, school closures, social distancing, and a worldwide health crisis. This COVID-19 global pandemic has forever changed people’s “normal,” and this is especially true in the lives of children.

In October 2021, UNICEF released the flagship report, “The State of the World’s Children 2021.” Their findings indicate that our youth may feel the impact of COVID-19 on both their mental well-being and physical health for years to come.¹ The report went on to explain that our children’s futures are shaped by genetics, experiences, and environmental factors beginning at an early age, and that the experiences of living through this pandemic will certainly have long-term effects.¹ UNICEF also stated that many safeguards, such as loving caregivers, a safe school environment, and positive peer relationships, can help reduce the risk of mental disorders.¹ Unfortunately, during the pandemic, many of these protections were disrupted or even completely unavailable.

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Since 2020, it is estimated that the prevalence of depression and anxiety has nearly doubled in children.² Some predict these numbers could even be higher, especially in girls and teens.² One study showed that in the first year of the COVID-19 pandemic, one in four youth globally were experiencing clinically elevated depression symptoms, while one in five experienced anxiety symptoms that were clinically elevated.³ The author of this study, Sheri Madigan, an associate professor of clinical psychology and Canada research chair in determinants of child development at the University of Calgary, said: “Results from this analysis suggest that the pandemic has likely instigated a global mental health crisis in youth. Children and youth have experienced extraordinary disruption and stress during the pandemic, and it’s taken a toll on their mental health.”⁴

Because of this alarming increase in such a short time, we as dental professionals need to be keenly aware of the effects and influence of anxiety on children’s oral health more than ever before. To provide the best outcome for the children in our practices, we need to be able to recognize the oral manifestations of anxiety, recommend treatment options, and refer patients to appropriate health-care providers for diagnosis as needed.

Recognize

Having some anxiety or stress is normal, but when it interferes with everyday life or has an impact on overall health and well-being, it is something that should be addressed. When anxiety levels are excessive, there can be oral manifestations of its influence on a person’s mental and physiological state. Some of the key oral manifestations to look for are:

Increased dental decay—caused by poor nutrition and poor home care. Patients may be snacking during the day and/or craving high-sugar foods which feed bacteria and lower oral pH. The patient may also have decreased motivation especially with home care, lowered moods, or mental health decline leading to a neglect in oral hygiene, which promotes dental decay.^5,6

Erosion of tooth structures—caused by acid reflux (GERD), nervous stomach, eating disorders, or drug abuse, which introduces acids that lower oral pH.⁷ Patients may also be too aggressive with brushing, which is common with some mental health issues.⁸

Xerostomia—caused by nutritional deficiencies, mouth breathing, and as a side effect of common medications, including psychotropic medications and recreational drug use.^5,6

Excessive occlusal wear or cupping—caused by acidic pH, grinding, or clenching.⁵

One of the most difficult parts of the clinical examination is determining what is causing the oral health decline in the patient. A suggestion to begin this process is to add a brief questionnaire to the dental health form that includes questions about anxiety, eating habits, and home care.

Recommend

It is important to educate and give treatment recommendations to help reduce the impact anxiety may be having on patients’ oral health. Some suggestions include:

Regular dental visits—For those who are struggling with anxiety or other mental health issues, a three- or four-month recall interval may be needed to help prevent, educate, and evaluate dental needs. Some parents are not aware that primary dentition has thinner enamel protection than permanent dentition, making it more vulnerable to damage. Children in orthodontic therapy also can be more prone to poor oral hygiene. A more frequent hygiene prophylaxis may be the best option for them, especially when anxiety is an added risk factor.

Fluoride varnish/Rx home fluoride—This can be a preventive measure against tooth decay and help with any sensitivity acid erosion may have caused. Along with the in-office application of varnish fluoride, children may benefit from a prescription home fluoride that is applied nightly.

Baking soda toothpaste—It is important to use gentle and neutralizing toothpaste, especially with the impact of acidic foods and drinks, bacteria, and stomach acids. To help stop demineralization of the tooth structures, baking soda is a great way to raise the oral pH to a more beneficial alkaline level. Baking soda also has low abrasivity, which provides a gentle clean with less impact on softened tooth surfaces.⁸

Pit and fissure sealants (PFS)/silver diamine fluoride (SDF)—Applying PFS, especially to newly erupted permanent dentition, is an added benefit in the fight against tooth decay and erosion. SDF is another dental modality that is making headlines. In October 2020, the American Dental Association recognized SDF not only as a topical desensitizing agent but also as a remineralizing and antimicrobial agent.⁹

Dietary counseling—Dietary counseling is within our scope of practice, but it is often underutilized in patient education. Recommending a diet low in sugar and acids along with a reduction in snacking during the day are important. If a patient eats treats or acidic drinks and foods, it is best to do so at a mealtime when pH is already lowered due to digestion. Also, limiting brushing to 30 minutes after eating, vomiting, or drinking acidic beverages is also helpful in allowing remineralization of tooth structure and pH neutralization. Rinsing after meals with a baking soda and water solution or a home fluoride rinse can also be helpful.

Occlusal nightguard—Some bruxing can be normal for children, but when it begins to affect the wear of permanent dentition, a nightguard may be recommended. Children with mental health issues could be unaware that they are bruxing or clenching at nighttime.

Sugar alcohol products—Oral rinses, gum, and chews containing sugar alcohols such as xylitol, maltitol, sorbitol, or erythritol can help to decrease pathogenic bacteria and their acid production, as well as stimulate salivary flow.¹⁰ Many antianxiety medications have xerostomia as a side effect, so dry mouth products containing these sugar substitutes are a great option.

Refer

Mental health disorders, such as anxiety, can be hard to recognize even for the child. As dental professionals, we could be the first to help identify these disorders in our patients due to conditions found during the dental visit. By referring patients to their primary care physician to get a medical diagnosis and needed treatment if they haven’t already done so, we can help our patients and their guardians build a team of medical professionals to support them. For patients diagnosed with anxiety, we can also partner with physicians or mental health specialists when medications are involved or when oral health is being compromised. Professor Madigan says it best: “It (the study) does not suggest that we cannot recover from this mental health crisis. If we can come together as parents, researchers, clinicians, and policymakers to develop clear and actionable ways to move forward to support child and youth mental health, we can rewrite this story in another year’s time.”⁴

COVID-19 and its detrimental effects over these last two years may have had a negative impact on our children’s mental and dental health, but we can help reduce its influence by learning to recognize manifestations, recommend treatments, and make professional referrals. Let’s do it for the kids!

Editor's note: This article appeared in the June 2022 print edition of RDH magazine. Dental hygienists in North America are eligible for a complimentary print subscription. Sign up here.

References

Impact of COVID-19 on poor mental health in children and young people ‘tip of the iceberg.’ UNICEF. October 4, 2021. Accessed February 2022. https://www.unicef.org/press-releases/impact-covid-19-poor-mental-health-children-and-young-people-tip-iceberg
McLemon LM. Depression and anxiety doubled in children, pandemic study says. Center for Infectious Disease Research and Policy (CIDRAP). University of Minnesota. August 9, 2021. Accessed February 2022. https://cidrap.umn.edu/news-perspective/2021/08/depression-and-anxiety-doubled-children-pandemic-study-says
Racine N, McArthur BA, Cooke JE, Eirich R, Zhu J, Madigan S. Global prevalence of depressive and anxiety symptoms in children and adolescents during COVID-19. JAMA Pediatr. 2021;175(11):1142-1150. doi:1001/jamapediatrics.2021.2482
Molano S. Youth depression and anxiety doubled during pandemic, new analysis finds. CNN. August 10, 2021. Accessed February 2022. https://www.cnn.com/2021/08/10/health/covid-child-teen-depression-anxiety-wellness/index.html
Kisely S. No mental health without oral health. Can J Psychiatry. 2016;61(5):277-282. doi:1177/0706743716632523
Chao S. Oral health and mental illness: yes, they are related. Mental Health Matters. September 8, 2016. Accessed February 2022. https://mhmatters.com/oral-health-and-mental-illness-yes-they-are-related/
Mark AM. What is dental erosion? J Am Dent Assoc. 2018;149(6):554. doi:10.1016/j.adaj.2018.04.011
Ciancio SG. Baking soda dentifrices and oral health. J Am Dent Assoc. 2017;148(11S):S1-S3. doi:1016/j.adaj.2017.09.009
Garvin J. ADA supports silver diamine fluoride for caries management. ADA News. October 26, 2020. Accessed February 2022. https://www.ada.org/publications/ada-news/2020/october/ada-supports-silver-diamine-fluoride-for-caries-management
Nayak PA, Nayak UA, Khandelwal V. The effect of xylitol on dental caries and oral flora. Clin Cosmet Investig Dent. 2014;6:89-94. doi:10.2147/CCIDE.S55761