|Year : 2014 | Volume
| Issue : 1 | Page : 48-52
Comparison of behavioral response to caries removal methods: A randomised controlled cross over trial
PR Geetha Priya1, Sharath Asokan1, J Baby John1, R Punithavathy1, K Karthick2
1 Department of Pediatric Dentistry, KSR Institute of Dental Science and Research, Tiruchengode, Tamil Nadu, India
2 Department of Conservative Dentistry, KSR Institute of Dental Science and Research, Tiruchengode, Tamil Nadu, India
|Date of Web Publication||15-Feb-2014|
Department of Pediatric Dentistry, KSR Institute of Dental Science and Research, Tiruchengode - 637 215, Tamil Nadu
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: The issue of dental fear and anxiety still poses a significant problem in treating children. Various caries management protocols have been tried to make the dental visit more compatible to the child patients. Aim: The aim of the study was to evaluate and compare the behavioral and physiological responses to chemo-mechanical caries removal (CMCR) and conventional drilling method (CDM). Materials and Methods: A total of 20 children with an age range of 7 to 11 years with bilateral frank carious lesions were included in this study. They were randomized into two groups: Group A - treated with CDM first followed by CMCR and Group B - treated with CMCR first followed by CDM. The physiological signs (pulse, blood pressure and oxygen saturation) were noted prior to treatment, during treatment, post treatment and 5 min after treatment. The behavioral responses were assessed by face, legs, activity, cry, and consolability scale and facial image scale. The participants were interviewed about pain, discomfort, taste, smell, preference and overall experience after every procedure. The pediatric dentist filled in details about patient behavior, time utilized and need for local anesthesia. The results were statistically analyzed using t-test and Chi-square test appropriately (SPSS version 11). Results: There was no significant difference in any of the physiological parameters assessed between the two groups. Discomfort was significantly more (P < 0.025) in the CDM group than CMCR group. The time taken by the dentist was significantly lesser (P < 0.01) in the CDM group. Conclusion: Techniques which enhance the behavioral response in children should be considered for a better pediatric dental practice.
Keywords: Behavioral response, chemo-mechanical caries removal, conventional drilling method
|How to cite this article:|
Geetha Priya P R, Asokan S, John J B, Punithavathy R, Karthick K. Comparison of behavioral response to caries removal methods: A randomised controlled cross over trial. J Indian Soc Pedod Prev Dent 2014;32:48-52
|How to cite this URL:|
Geetha Priya P R, Asokan S, John J B, Punithavathy R, Karthick K. Comparison of behavioral response to caries removal methods: A randomised controlled cross over trial. J Indian Soc Pedod Prev Dent [serial online] 2014 [cited 2019 Nov 13];32:48-52. Available from: http://www.jisppd.com/text.asp?2014/32/1/48/127055
| Introduction|| |
Pain still continues to be a problem in dentistry. The issue of dental fear and anxiety has been studied extensively and presents a significant problem to both patients and the dentists. The first response to a feared object or stimulus is to avoid or escape the fearful situation. Avoidance reduces fear and dental avoidance acts as a barrier to oral health. Holmes and Girdler have shown that 49% of respondents were anxious about visiting the dentist, while the incidence in children was reported between 3% and 21% respectively.  It is believed that adults often acquire fear in childhood and it is of great importance for the dental health professional to identify dentally anxious children as early as possible. Instilling a positive behavior toward dental care has become increasingly significant.
Newer ways of treating caries are still being searched in order to make the dental visit comfortable and easy for both the patient and the dentist. Traditionally, carious lesion removal is performed using conventional drilling method (CDM) and sharp-edged hand instruments. These mechanical preparations though considered as quick technique, often induce pain or discomfort. There is also generation of heat, vibration, noise and excessive removal of sound tooth structure.  To overcome these drawbacks, alternative methods have been proposed including chemomechanical techniques, air abrasion, sono-abrasion, ultrasonic instrumentation and lasers. Chemomechanical caries removal (CMCR) is a non-invasive technique, which eliminates infected tissues, preserves healthy tooth structures and avoids pulp irritation, thus minimizing patient discomfort. It also has the benefits of antibacterial and anti-inflammatory action. Literature search showed few studies on the behavioral perspectives of children to caries removal. A study done by Attari et al. found no significant difference in the anxiety levels before and after treatment in both CMCR and CDM group.  Bergmann et al. reported anxiety levels and lower degrees of pain with CMCR group when compared to the CDM group.  Since these studies were restricted to the anxiety of children and were carried out in non-Indian population, this study was planned to evaluate and compare both the behavioral and physiological responses to CMCR and CDM in children.
| Materials and Methods|| |
This randomized controlled trial with crossover design was carried out in the Department of Pediatric Dentistry, KSR Institute of Dental Science and Research, Tamil Nadu. The study protocol was approved by the Institutional Review Board. Informed consent was obtained from all participants and their parents. Children with adequate cognition and communication skills were included. Twenty otherwise normal children consisting of 10 boys and 10 girls in the age range of 7 to 11 years with bilateral frank deep carious lesions (Black's class-I occlusal dentinal caries) were included in the study. These children had no previous dental history and were visiting the dentist for the 1 st time. Their behavioral rating was either Frankel III or IV during the first dental visit and examination. Teeth indicated for pulp therapy and teeth with abscess or sinuses were excluded, since pulpal pain can be overlooked as pain due to the dental procedure. Children with Frankel I and II behavioral rating were excluded because the children needed to not only undergo dental treatment, but also participate in the assessment of the procedures. The study samples were divided into group A and B; group-A received CMCR first, followed by CDM and group-B received CDM first, followed by CMCR. For CMCR, Carie Care (UniBiotech, Biosynergies India Pvt. Ltd, Bengaluru) was used and number 2 round diamond bur was used for caries removal in CDM.
Before the commencement of the treatment procedure, pulse oximeter probe and blood pressure cuff were fixed on the right hand index finger and on the left arm respectively. All the dental procedures were carried out by the same operator/primary investigator, to ensure that the results were not influenced by inter-operator variability. The physiological signs (pulse, blood pressure, oxygen saturation) were measured before, during, after and 5 min post each treatment procedure. Once the clinical procedure was completed the participants were interviewed using a specially prepared questionnaire. The facial image scale was used four times to assess the following: (a) Discomfort, (b) preference for further treatment, (c) presence of bad taste/smell and (d) overall acceptance. The primary investigator filled a separate questionnaire with the details of the child's behavior and pain response using the face, legs, activity, cry and consolability (FLACC) scale. The time elapsed for the treatment procedures and the needs for local anesthesia were also recorded. The results were statistically analyzed using t-test and Chi-square test appropriately (SPSS version 11, IBM Corporation, USA) and P ≤ 0.05 was considered to be statistically significant.
| Results|| |
CDM group showed a significant increase (P = 0.025) in the discomfort level compared with the CMCR group as shown in [Table 1]a. There were no significant differences between the two groups considering the preference of treatment type, the overall acceptance and the presence of bad smell/taste as shown in [Table 1]a and b. [Table 2]a shows the time taken by the pediatric dentist for complete caries removal and the need for local anesthesia during the procedures. CDM showed a statistical significant reduction (P = 0.01) in the time needed for caries removal. [Table 2]b shows there was no statistically significant difference in behavioral response of child during CDM and CMCR procedure. However, CDM group children showed more facial expressions and leg movements. There was no statistically significant difference between the two caries removal methods when the physiological parameters were compared in the 4 time periods as shown in [Table 3]a and b.
| Discussion|| |
Pediatric dentists prefer techniques and strategies that help to enhance the behavior of the children in the dental office. Successful dental treatment in a child depends not only on the quality of treatment, but also in instilling a positive attitude toward dental care. Dental anxiety and fear are strongly related to the impairment of having a quality oral health care in an individual's life. The CDM in caries management is associated with fear and discomfort, especially in children. Hence, the CMCR method was accepted as an alternative for CDM. Many studies have assessed the efficacy of caries removal, time taken, micro flora alterations and physiological parameters during CMCR procedure. Only few studies have focused on the behavioral aspects of the child during caries removal. Hence, our study was planned to highlight the behavioral and physiological responses during CMCR and CDM procedure in children aged 7-11 years.
Facial image scale is a very reliable scale used to assess the child's dental anxiety status.  In this study, the facial image scale with a row of five faces ranging from very happy to very unhappy was used by the children to grade their discomfort, preference, presence of bad taste/smell and overall acceptance. There was a statistically significant increase in the discomfort level during CDM (P = 0.025) than CMCR procedure. Similar results were shown by Balciuniene et al.  and Bergmann et al.  in their study, that CDM group had more discomfort when compared to the carisolv group during caries removal procedure. They concluded that CMCR was better for the following reasons: (a) Lack of sound and vibrations and (b) gel could have a thermal insulating function by altering the distribution of sensory fibers in the injured pulp. Bergmann et al.  reported a reduced anxiety level in both the children who underwent carisolv treatment and the dentists who treated them.
There were no significant difference between the two groups, considering the presence of bad taste or smell, preference of treatment type and the overall acceptance of the treatments. Only one child reported of bad taste in CMCR group. Kavvadia et al.,  Balciuniene et al.  reported the same, regarding the taste and smell during the two procedures. Though CMCR was more time consuming, some children preferred it, probably because of fear towards drilling, sound and pain. Some children preferred CDM, since it was less time consuming and they could spend more time in the play area. Maragakis et al.  reported that 11 out of 16 children indicated that they preferred the drill due to the shorter treatment time and the absence of bad taste in their mouth during the treatment. They concluded that the patients preferred traditional method to CMCR. Lozano-Chourio et al.  showed that 71% of the sample preferred CMCR, though clinical treatment time was 3 times longer. The most feared events in dental treatment as ranked by the patients were cavity cutting, induction of anesthesia and tooth extraction. Therefore, CMCR method was more preferable for persons with dental anxiety. ,
FLACC scale is a validated and a reliable scale used in assessing pain in critically ill adults and children post general anesthesia. In this study, for the 1 st time this scale was used to assess the pain experienced by the child during each dental procedure. The facial expressions, leg movements, activity, cry and consolability were evaluated by the primary investigator on a scale of 0-2 for each item. Scores were recorded for each item during both the treatment procedures and the mean value was calculated for CMCR and CDM. There was no statistically significant difference in the mean FLACC scores between the two procedures. But there was a trend indicating that the overall behavior was better for the CMCR group, based on the scores obtained in each item. The CDM group children showed more facial expressions and leg movements during caries removal procedure, indicating pain/discomfort.
The time taken by the pediatric dentist for complete caries removal using CMCR method was significantly higher than the CDM method and this was in accordance with the studies done by Attari et al.,  Maragakis et al.  and Kavvadia et al.  There was no significant difference in the need for local anesthesia between the two types of caries removal procedures. However, two children in the CDM group needed local anesthesia for complete caries removal. CMCR softens only the infected dentin thereby reduces the pressure required for caries removal. On the other hand, CDM can remove both infected and affected dentin simultaneously, thereby opening more dentinal tubules. This can cause pain and may necessitate the need for local anesthesia. 
The physiological parameters are usually influenced by the outcome of any treatment procedure done. Anxiety, stress and hence the behavior of a child in/to a dental situation can be detected by measuring the physiological parameters. In this study, the four physiological parameters systolic and diastolic blood pressure, pulse rate and oxygen saturation level were recorded during 4 time periods. There were no significant differences in the parameters assessed between both the groups. Singer et al.  found no alternation in systolic blood pressure during dental treatment. However, Brand  noticed a statistically significant difference in mean systolic arterial pressure when compared with baseline values during LA, caries removal and 5 min after the end of restoration. They also found heart rate decreased for children using Carisolv. Poiset et al.  noted an increase in heart rate when using a high-speed hand piece and during atraumatic restorative technique. Guaré Rde et al.  reported that the pattern of diastolic blood pressure were higher during caries removal, followed by restoration placement, anesthesia, end of the restoration and 5 min before starting dental treatment. In the same study, a decrease in heart rate during CMCR and an increase during CDM was reported.
Considering the cost, this trial was run with an adequate sample size of 20 children. Children visiting the dentist for the 1 st time, with frank bilateral dentinal caries and no pain were difficult inclusion criteria to be met. Studies with increased sample size, funding and patient friendly minimal invasive methods could give us a clearer picture of the behavioral response of children to caries management. This could also help to prevent avoidance of dental health care.
| Conclusion|| |
Techniques, which enhance the behavioral response in children should be considered for a better pediatric dental practice. The present study has shown that CMCR was effective in caries removal and ensured excellent patient comfort. The discomfort level was less in CMCR group though the time taken for caries removal was more than CDM. However the prolonged treatment time did not seem to affect the child's behavioral response.
| Acknowledgments|| |
The authors would like to thank all the children who willingly participated in this study.
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[Table 1], [Table 2], [Table 3]