|Year : 2015 | Volume
| Issue : 1 | Page : 48-52
RMS Pictorial Scale (RMS-PS): An innovative scale for the assessment of child's dental anxiety
RM Shetty, M Khandelwal, S Rath
Department of Pedodontics and Preventive Dentistry, Chhattisgarh Dental College and Research Institute, Rajnandgaon, Chhattisgarh, India
|Date of Web Publication||9-Jan-2015|
Dr. R M Shetty
Department of Pedodontics and Preventive Dentistry, Chhattisgarh Dental College and Research Institute, Rajnandgaon - 491 441, Chhattisgarh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Dental anxiety assessment for young children is as important as performing their treatment. Appropriate knowledge of patient's anxiety boosts confidence and will help us to review potential management options specific to every child. Aim: This study aimed to validate (RMS) Pictorial Scale (RMS-PS) and to compare it with Venham Picture Test (VPT) and Facial image scale (FIS) in measuring dental anxiety for young children during their first dental visit. Materials and Methods: A total of 102 healthy children aged between 4 and 14 years during their first dental visit were randomly selected for the study. Childs anxiety level was measured using three different scales namely (i) RMS-PS (ii) VPT, and (iii) FIS. Statistical Analysis: Student t test was used to compare the scores obtained from all the three scales. Pearson correlation test was used to obtain correlation among the scales used in the study. Results: A strong correlation (0·76) was found between the VPT and RMS-PS, and a moderate correlation (0.5) was found between RMS-PS and FIS, indicating good validity for the RMS-PS. Conclusions: The findings of this study suggest that the RMS-PS can be a newer and easiest means for the assessment of dental anxiety for young children in a clinical context.
Keywords: Anxiety assessment scales, child dental anxiety, first dental visit, RMS pictorial scale, Venham picture test
|How to cite this article:|
Shetty R M, Khandelwal M, Rath S. RMS Pictorial Scale (RMS-PS): An innovative scale for the assessment of child's dental anxiety. J Indian Soc Pedod Prev Dent 2015;33:48-52
|How to cite this URL:|
Shetty R M, Khandelwal M, Rath S. RMS Pictorial Scale (RMS-PS): An innovative scale for the assessment of child's dental anxiety. J Indian Soc Pedod Prev Dent [serial online] 2015 [cited 2019 May 22];33:48-52. Available from: http://www.jisppd.com/text.asp?2015/33/1/48/149006
| Introduction|| |
Dental anxiety among children has continued to generate a lot of curiosity in pediatric dentistry. It has been a potential problem in patient management. Furthermore, the effects of the dental anxiety can persist in adulthood, which may lead to dental neglect. Dental anxiety is defined as "an abnormal fear or dread of visiting the dentist for preventive care or therapy and unwarranted anxiety over dental procedures" and may have psychological, cognitive, and behavioral consequences. 
Early recognition of dental anxiety among children is essential for appropriate patient management and successful treatment. Various methods have been used in literature for the assessment of dental anxiety. It can be evaluated by variety of techniques such as: Physiological measures by measuring pulse rate, blood pressure, muscle tension,  projective techniques such as children's dental fear picture test,  psychological test such as Corah's Dental Anxiety scale (CDAS)  and Modified Child Dental Anxiety Scale (MCDAS).  The children's fear survey schedule-dental subscale (CFSS-DS) is another method to measure dental fear among young children.  Venham Picture Test (VPT) has been used in a number of studies ,, to assess anxiety before dental treatment. Facial image scale (FIS) has been used Buchanan and Niven (2002)  to assess the anxiety among children.
Since all the scales described above had certain limitations, the aim of the present study was to validate a new anxiety assessment scale which was developed in the department and named as Raghavendra, Madhuri, Sujata (RMS) Pictorial Scale (RMS-PS) for the assessment of child's dental anxiety and to compare it with VPT and FIS in the assessment of dental anxiety of young children during their first dental visit.
| Materials and Methods|| |
One hundred and two children between 4 and 14 years of age, reporting to the Department of Pedodontics and Preventive Dentistry during their first dental visit were randomly selected for the study. They were asked if they would agree to take part in a study investigating how children emotionally feel about their dental visit. Children with previous dental experience and with any sort of mental or physical disability were excluded from the study.
Parents were informed regarding the study and the consents were obtained from them. The study was approved by ethical committee of the institute where it was conducted.
Child's anxiety level in their first dental visit was measured using three different scales namely:
RMS Pictorial Scale (RMS-PS)
It is a new anxiety rating scale designed in the Department of Pedodontics and Preventive Dentistry. The RMS-PS consists of original photographs of both boy and a girl child. Their photographs were taken with the permission of their parents. Parents were informed regarding the picture scale and their consent was taken for utilization of photographs of their child in the study.
RMS-PS comprises a row of five faces ranging from very happy to very unhappy. Two separate sets of photographs were used for boys [Figure 1] and girls [Figure 2]. The children were asked to choose the face they feel like about themselves at that moment. The scale was scored by giving a value of one to the very happy face and five to the very unhappy face.
The Venham Picture Test (VPT) 
It comprises eight cards, with two figures on each card, one "anxious" figure and one "non-anxious" figure. The children were asked to point at the figure they felt most at that moment. All cards were shown in their numbered order. If the child pointed at the "anxious" figure a score of one was recorded, if the child pointed at the "non-anxious" figure a score of zero was recorded. The number of times the "anxious" figure chosen was summed up to give a final score (minimum score, zero; maximum score, eight) [Figure 3]. The VPT was assessed first with every third participant to control for order effects.
The Facial Image Scale (FIS) 
It also comprises a row of five faces ranging from very happy to very unhappy. The children were asked to point a face they felt like themselves at that moment. The scale is scored by giving a value of one to the most positive face and five to the most negative face [Figure 4]. However, two children in our study were not able to choose any face in the scale as it was confusing to them, and thus were excluded from the study.
All the scales were shown to the children held at an angle such that the parent could not see the choice their child was making, parents were even asked not to contribute to their child's choice. After completion of anxiety assessment from all the three tests, children were also asked to point at the scale they like the most. All the scores were statistically analyzed by Statistical Package for the Social Sciences (SPSS) version 11.5. Student t test was used to compare the scores obtained from all the scales and Pearson correlation test was performed to obtain correlation among all the scales used in the study.
| Results|| |
One hundred and two children reporting to the department for their first dental visit were selected for the study. Among 102 children, 59 were boys and 43 were girls. The mean age of boys and girls were found to be 9.34 ± 2.13 years and 9.98 ± 4.12 years, respectively, and the difference was not found to be significant [Table 1].
The mean anxiety scores of males and females in RMS-PS, VPT, and FIS anxiety rating scales were tabulated [Table 2]. However, no statistical difference of mean anxiety scores between males and females were seen in any of the anxiety rating scales.
Correlation of the RMS-PS with VPT and FIS
A measure of the applicability of a psychometric instrument may be evaluated by its degree of correlation with another psychometric instrument designed to measure basically the same phenomenon.  It is reported that validity, whether the instrument measures what it intends to, can be assessed by correlating the instrument with another instrument designed to measure the same phenomenon.  Pearson correlation test was performed to find out the correlation between RMS-PS and VPT. A strong correlation was found between the RMS-PS and the VPT scores (r = 0.76, n = 102, P < 0.001), which indicates that RMS-PS can measure anxiety in the same way as VPT does. A moderate correlation was found between the RMS-PS and the FIS scores (r = 0.5, n = 100, P < 0.001) [Table 3].
Along with the assessment of anxiety from all the three scales used in this study, children were also asked to choose one of the anxiety rating scales which they found easy to understand and liked the most. 62.74% of children found RMS-PS as the easiest one, whereas 33.33% children found VPT as the easiest scale with only 3.92% of children selected FIS as the easiest scale [Figure 5].
| Discussion|| |
Dental anxiety can be considered as universal phenomenon. The prevalence of dental anxiety among children between 5-10 years of age in a study population in India was found to be 6.3%.  Dental anxiety has shown to affect approximately 9% of children and adolescents in Europe and in countries such as Australia, Canada, and the US.  It has been observed that a wide range of instruments have been developed to measure dental anxiety and fear.
According to Buchanan,  an ideal anxiety assessment scale should be:
- Short in length to maximize the response from the children and minimize the time for its administration.
- Include items which are most relevant to the child's dental experience.
- Easily grab the attention of the child.
- Allow for limited cognitive and linguistic skills.
- Simple to score and interpret.
The VPT  and FIS  were selected for this study for their comparison with the RMS-PS, as they are also picture scales that are intended for young children to measures the state of anxiety, and are administered before the treatment starts.
This study has shown high levels of agreement between the scores of RMS-PS and VPT as well as between RMS-PS and FIS in the assessment of child's anxiety. The validity of the RMS-PS in the dental setting in the assessment of child's dental anxiety is supported by its strong correlation with the VPT scores. The RMS-PS measured the state dental anxiety better than VPT which may be attributed to the limitations of VPT like the figures on the cards are all male, which may have caused problems for the young girl patient to identify her situation of anxiety. In addition, some of the figures are very similar to each other and are confusing for the child to select and is time consuming.
The moderate correlation between the RMS-PS and FIS score is also seen. In FIS, younger children misinterpret the drawings of facial expressions, therefore not lending itself to good discrimination between them. In addition, some of the pictures are ambiguous in what they portray and do take time to complete.  Two children in our study were not able to choose any face in the scale and thus were excluded from the study. There was a moderate correlation between the VPT and the FIS scores in this study [Table 3] in contrast with the study by Buchanan and Niven (2002)  who reported strong correlation between FIS and VPT in their study.
In the present study, no significant difference was found in the anxiety scores between males and females. Similar findings were observed in the previous studies. ,, However, in contrast, ratings of dental anxiety were higher in females than males as observed by Klingberg et al.,  Chellapah et al.,  and Raadal et al.
Very young children lack the cognitive ability to complete questionnaires, e. g., Children's Fear Survey Schedule-Dental Subscale. Therefore with young children, indirect behavioral measures are the only real alternative.  In similar situation, RMS-PS can be employed with very young children.
The RMS-PS has many advantages such as:
- Attractive as it is colorful and easily understood by children.
- It takes very short time (less than a minute) to complete the test.
- It gives immediate feedback about the anxiety of the child to the dental team, in the waiting room itself. It can also be used to get the feedback in subsequent visits also so that we can treat accordingly with the appropriate behavior management technique.
- With original color photographs in RMS-PS, the child can identify themselves better with them as compared to black and white and cartoon figures used in VPT and FIS.
- RMS-PS is kept separate for girls and boys to maximize its acceptability among both the genders.
Also, when the children were asked to choose the easiest test among all the three anxiety rating scales, majority of children chose RMS-PS as the easiest one. However, further studies on a larger subjects are required.
| Conclusions|| |
- The RMS-PS can be a new and alternative anxiety assessment scale for measuring child's dental anxiety. It can be used alone or in combination with other methods to improve assessment of dental anxiety.
- The RMS-PS has many advantages over the former anxiety assessment measures. It offers simple, quick, efficient evaluation of anxiety for a pediatric dental clinic, and also assists in establishing a good dental experience and a trusting relationship between pediatric dentists, patients, and parents.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3]