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ORIGINAL ARTICLE
Year : 2015  |  Volume : 33  |  Issue : 3  |  Page : 192-203
 

Comparative evaluation of the effectiveness of audio and audiovisual distraction aids in the management of anxious pediatric dental patients


1 Department of Pedodontics and Preventive Dentistry, JCD Dental College and Hospital, Sirsa, Haryana, India
2 Department of Pedodontics and Preventive Dentistry, National Dental College and Hospital, Dera Bassi, Punjab, India
3 Department of Conservative Dentistry and Endodontics, JCD Dental College and Hospital, Sirsa, Haryana, India
4 Department of oral and maxillofacial surgery, Daswani dental college and research center, Kota, Rajasthan, India

Date of Web Publication9-Jul-2015

Correspondence Address:
Dr. Rajwinder Kaur
Department of Pedodontics and Preventive Dentistry, JCD Dental College and Hospital, Sirsa, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-4388.160357

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   Abstract 

Objective: The aim of this study was to evaluate and compare audio and audiovisual distraction aids in management of anxious pediatric dental patients of different age groups and to study children's response to sequential dental visits with the use of distraction aids. Study Design: This study was conducted on two age groups, that is, 4-6 years and 6-8 years with 30 patients in each age group on their first dental visit. The children of both the age groups were divided into 3 subgroups, the control group, audio distraction group, audiovisual distraction group with 10 patients in each subgroup. Each child in all the subgroups had gone through three dental visits. Child anxiety level at each visit was assessed by using a combination of anxiety measuring parameters. The data collected was tabulated and subjected to statistical analysis. Results: Tukey honest significant difference post-hoc test at 0.05% level of significance revealed audiovisual group showed statistically highly significant difference from audio and control group, whereas audio group showed the statistically significant difference from the control group. Conclusion: Audiovisual distraction was found to be a more effective mode of distraction in the management of anxious children in both the age groups when compared to audio distraction. In both the age groups, a significant effect of the visit type was also observed.


Keywords: Anxiety, audio and audiovisual distraction, behavior, pediatric dental patients


How to cite this article:
Kaur R, Jindal R, Dua R, Mahajan S, Sethi K, Garg S. Comparative evaluation of the effectiveness of audio and audiovisual distraction aids in the management of anxious pediatric dental patients. J Indian Soc Pedod Prev Dent 2015;33:192-203

How to cite this URL:
Kaur R, Jindal R, Dua R, Mahajan S, Sethi K, Garg S. Comparative evaluation of the effectiveness of audio and audiovisual distraction aids in the management of anxious pediatric dental patients. J Indian Soc Pedod Prev Dent [serial online] 2015 [cited 2018 Dec 13];33:192-203. Available from: http://www.jisppd.com/text.asp?2015/33/3/192/160357



   Introduction Top


As McElory (1895) wrote "Although operative dentistry may be perfect, the appointment is a failure if a child departs in tears." This was the first mention in literature where behavior management of child was given outmost importance than technical excellence. Dental treatment is openly viewed as an unpleasant experience in our society. Fear and anxiety associated with dental treatment are well recognized factors and have a negative impact on patient's willingness to get dental treatment. [1] The pediatric patient with his/her first visit to dentist are mostly found anxious and apprehensive because of dental equipments and the newness of the experience. [2]

  1. The role of a dentist in managing a child firstly, to control and treat the problem with which the child report with anxiety, so as to make the child a co-operative patient is 3-fold.
  2. Secondly, to teach the child appropriate ways of managing the anxiety.
  3. Thirdly, to modify and shape the behavior of a child towards a positive dental response.


It is essential to identify anxious children at the earliest age possible in order to institute a precocious behavioral treatment. For this purpose, four kinds of anxiety measuring parameters have been used to assess dental fear and anxiety like physiological means (e.g., pulse rate, basal skin response), psychological/psychometric means (e.g., Venham's picture test, children fear survey schedule-dental subscale, dental anxiety scale), projective means (e.g., children's dental fear picture test), and behavioral means (e.g., Frankel scale). [3]

Although to manage anxious children many management techniques are successful, but the attitude of the parents and dental professionals towards aversive techniques is changing [4] and because of litigation concerns, the popularity of nonaversive techniques like distraction becoming high among the dental professional to make cognitive orientation and promote coping ability for a positive dental response. "Distraction" is a tactic designed to divert a patient attention away from their current behavior to focus their interest in something else. It is a behavioral strategy useful in helping patients cope with brief stress. [5] Distractors are stimuli that may gain some control over a patient's responding that is incompatible with disruptive behavior. Different means of distraction includes video games, [6],[7] and sound, [8] watching video (Weisenberg et al. 1995) [9] and television, [7] pictures, cartoons and audiotaped stories etc. [10]

Because of distraction success in medical settings [11] and in adult patients, [12] many dentists believe that this technique may be successful and fruitful in the management of anxious pediatric dental patients.

Therefore, the aim of this study was to evaluate and compare audio and audiovisual distraction aids in management of anxious pediatric dental patient of different age groups.


   Materials and Methods Top


The present study was conducted on two age groups, that is, 4-6 and 6-8 years comprised of 60 children, with 30 patients in each age group, on their first dental visit, who were well oriented to time and place and who had at least one carious tooth required cavity preparation without the administration of local anesthesia and one tooth required the administration of local anesthesia for extraction or endodontic procedure were selected for the purpose of study. Children with lack of orientation and mental and physical disabilities were excluded. Before beginning with the study, the study design had been approved by the ethical committee of National Dental College and Hospital, Dera Bassi, Mohali, Punjab (India) and a written consent was obtained from patient's parents along with brief dental and medical history of patients.

The children of both age groups were randomly divided into three different subgroups, with 10 patients in each age group, as follows:



The patients in the audio and audiovisual groups listened and viewed to choice based audio (either English or Hindi or Punjabi songs) and audi-ovisual (either English or Hindi or Punjabi short dramatic clips, video songs and cartoons) presentations through headphones through-out the treatment procedures during all the visits respectively. Each child in all the sub groups had gone through three dental visits for following dental procedures.

  1. First visit: Screening or diagnosis.
  2. Second visit: Cavity preparation without the need of administration of local anesthesia.
  3. Third visit: Administration of local anesthesia for invasive procedures like extraction or endodontic procedure.


Child anxiety level in each visit was assessed by using combination of following anxiety measuring parameters:

Physiological means

Heart rate

Heart rate (physiological parameter) was recorded using fingertip pulse oximeter (Phoebus P121) "before," "during" and "after" the treatment procedure in all three treatment visit.

Psychological means

Dental sub-scale of children's fear survey schedule-short scale

The child patients were evaluated with dental sub-scale of children fear survey schedule-short scale 8-item questionnaire. [12] The score ranges from 8 to 40. A cut-off score 19 indicates clinical dental fear; scores 19 and above indicating dental anxiety while scores above 23 indicating high dental anxiety. Folayan and Kolawole. [3] This questionnaire was filled by every child twice during the course of treatment, that is, pretreatment and posttreatment on every visit in the waiting room only. In case of young children parents fill the questionnaire for evaluation of dental anxiety levels because of the child's inability and probable difficult to comprehend the content of the questionnaire.

Behavioral means

comprised of:

  1. Clinical anxiety rating scale
  2. Co-operative behavioral rating scale.


To access the behavioral means each child patient was video captured on every visit. The video was made after making the child sit on the dental chair either for diagnosis or treatment till the completion of the procedure on second visit and administration of local anesthesia at third visit. Ratings of these parameters was done by two judges after independently viewing the video tapes of the visits by using six point rating scales, the scores ranged from 0 to 5. Both the judges were blind to the distraction device.

The data obtained were collected and tabulated and subjected to statistical analysis using ANOVA and Tukey honest significant difference post-hoc tests at 0.05% level.


   Results Top


Heart rate

At first visit [Table 1] no statistically significant difference of pulse rate values between the sub-groups "before" and "during" the first visit, but control group was significantly different from audiovisual group "after" the first visit indicating children were most relaxed in audiovisual group in both the age groups.
Table 1: Mean heart rate of 4-6 and 6-8 years age group "before," "during" and "after" the first visit and Tukey HSD post-hoc test values for multiple comparisons among control, audio and audiovisual group


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At second visit [Table 2] both the age groups showed no statistically significant difference of pulse rate values between the sub-groups "before" the second visit. "During" the second visit control group was significantly different from audiovisual group in both the age groups. "After" the second visit control group was significantly different from audio group and statistically highly different from "audiovisual group" in 4-6 years patients whereas in 6-8 years all the sub-groups were significantly highly different with each other indicating children were most relaxed in audiovisual followed by audio and were least relaxed in control group.
Table 2: Mean heart rate of 4-6 and 6-8 years age group "before," "during" and "after" the second visit and Tukey HSD post-hoc test values for multiple comparisons among control, audio and audiovisual group


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At third visit [Table 3] in both the age groups no statistically significant difference of pulse rate values between the sub-groups "before" the third visit. "During" third visit audiovisual group was significantly highly different from control group and significantly different from audio group in both the age group. "After" the third visit, control group was significantly highly different from audiovisual group and significantly different from audio group. Audiovisual group revealed statistically significant difference from audio group indicating children were most relaxed in audiovisual, followed by audio and were least relaxed in control group in both the age groups.
Table 3: Mean heart rate of 4-6 and 6-8 years age group "before," "during" and "after" the third visit and Tukey HSD post-hoc test values for multiple comparisons among control, audio and audiovisual group


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Comparison of heart rate between both the age groups

T
-test [Table 4] revealed no statistically significant difference of mean scores of pulse rate of both the ages, that is, 4-6 and 6-8 years in control, audio and audiovisual group "before," "during" and "after" the procedures at "first," "second" and "third" visits. Thus indicated "control group" patients of both the age groups, that is, 4-6 and 6-8 years revealed equal anxiety level, whereas audio distraction had equal level of distraction effect on both the age groups.
Table 4: T-test for the comparison of heart of control, audio and audiovisual groups of 4-6 and 6-8 years age group "before," "during" and "after" the procedure under all the three visits


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Similarly, audiovisual distraction aids equally distracted children of both the age groups.



Psychological means

Dental subscale of children's fear survey schedule-short form (DFSS-SF).

At first visit [Table 5] in both the age groups no statistically significant difference of DFSS-SF scores between the sub-groups "before" the first visit. In 4-6 years group "after" the first visit control group was significantly different from audio group and significantly highly different from audiovisual group. Audio group revealed significant difference from audiovisual group. Whereas in 6-8 years age group, audiovisual group was significantly highly different from control group and audio group indicated children were most anxious in control group followed by audio and were least anxious in audiovisual group.
Table 5: DFSS-SF scores of 4-6 and 6-8 years age group "before" and "after" the first visit and Tukey HSD post-hoc test values for multiple comparisons among control, audio and audiovisual group


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At second visit [Table 6] "before" and "after" the procedure statistically highly significant difference between all the sub groups in both the age groups indicated children were most anxious in control group followed by audio and were least anxious in audiovisual group.
Table 6: DFSS-SF scores of 4-6 and 6-8 years age group "before" and "after" the Second visit and Tukey HSD post-hoc test values for multiple comparisons among control, audio and audiovisual group


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At third visit [Table 7] "before" and "after" the procedure statistically highly significant difference between all the sub groups in both the age groups indicated children were most anxious in control group followed by audio and were least anxious in audiovisual group.
Table 7: DFSS-SF scores of 4-6 and 6-8 years age group "before" and "after" the third visit and Tukey HSD post-hoc test values for multiple comparisons among control, audio and audiovisual group


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Comparison of DFSS-SF between both the age groups

T
-test [Table 8] revealed that in control group 4-6 years age group depicted higher DFSS-SF scores "before" and "after" all the three visits as compared to 6-8 years age group. Thus indicating control group patients of 4-6 years age were more anxious as compared to 6-8 years age group whereas audio distraction had equal level of distraction effect on both the age groups. Similarly audiovisual distraction aids equally distracted children of both the age groups.
Table 8: T-test for the comparison of DFSS-SF scores of control, audio and audiovisual groups of 4-6 and 6-8 years age group "before" and "after" the procedure under all the three visits


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Clinical anxiety rating scale and co-operative behavior rating scale

Pearson co-relation between the two observers was statistically highly significant at 0.01% level with value of 0.759.

At first visit [Table 9] and [Table 10] no statistically significant difference of mean clinical anxiety rating scale scores and mean co-operative behavior rating scale scores between all the sub-groups in 4-6 years age group indicating patients were equally co-operative and anxious in all the subgroups whereas for 6-8 years patients inter-group comparison of means of these 2 parameters was not required as mean scores were found zero which were statistically nonsignificant.
Table 9: Mean clinical anxiety rating scale and co-operative behavior rating scale scores of 4– 6 years age groups at first, second and third visit and Tukey HSD post-hoc test values for multiple comparisons among control, audio and audiovisual group


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Table 10: Mean clinical anxiety rating scale and co-operative behavior rating scale scores of 6-8 years age groups at first, second and third visit and Tukey HSD post-hoc test values for multiple comparisons among control, audio and audiovisual group


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At second visit [Table 9] and [Table 10] both the age groups showed control group was significantly highly different from audio group and audiovisual group and audio group revealed statistically significant difference from audiovisual group indicating patients were most co-operative and relaxed in audiovisual followed by audio group and least co-operative and relaxed in control group.

At third visit [Table 9] and [Table 10] in both the age groups, control group was significantly highly different from audio group and audiovisual group and audio group revealed statistically significant difference from audiovisual group, indicating patients were most co-operative and relaxed in audiovisual, followed by audio group and least co-operative and relaxed in control group.

Comparison of mean clinical anxiety rating scale and mean co-operative behavior rating scale scores between both the age groups

T -test [Table 11] revealed no statistically significant difference of mean clinical anxiety rating scale and mean co-operative behavior rating scale scores of both the ages, that is, 4-6 and 6-8 years in control, audio and audiovisual group at "first," "second" and "third" visits. Thus indicated control group patients of both the age groups, that is, 4-6 and 6-8 years revealed equal anxiety level whereas audio distraction had equal level of distraction effect on both the age groups. Similarly audiovisual distraction aids equally distracted children of both the age groups.
Table 11: T-test for the comparison of scores clinical anxiety rating scale and co-operative behavior rating scale scores of control, audio and audiovisual groups of 4-6 and 6-8 years age group at all the three visits


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Effect of audio and audiovisual distraction aids on children's response to sequentional dental visits

Wilcoxon signed rank test [Table 12] and [Table 12](a) revealed patients of all the subgroups showed statistically significant difference in mean co-operative behavior rating scale scores among the three dental visits, that is, between first, second and third visit in both the age groups. Mean scores were highest in third visit, followed by second visit and lowest in first visit.
Table 12: Mean rank and sum of the ranks of cooperative behavior rating scale scores of control, audio & audiovisual groups of 4-6 and 6-8 years age group of all the three visits


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   Discussion Top


The age group of 4-8 years was selected for the study because dental problems are difficult to treat in this age group as they exhibit more disruptive behavior and dental anxiety and are most difficult to manage Ram et al., 2010. [13] The selected age group was further divided into two age groups, that is, 4-6 years old and 6-8 years old. The division was done keeping in mind that psychology and mental status of 4-year-old children is different from that of 8-year-old children.

We opted three dental visits because the routine/basic dental procedures, which include diagnosis, restorations and procedure under local anesthesia, are most anxiety provoking procedures and can be performed in three dental visits. Therefore, these three dental visits were considered sufficient enough to measure the anxiety or fearful nature of the children. The three visits were in accordance with Yamini et al., 2010. [14] In another study four visits were conducted Prabhakar et al., 2007. [2] Where as in another study conducted by Venham et al., 1977, [15] six dental visits were there to know the child response to sequential dental visit.

Heart rate, which was used in the study according to Mccarthy, 1957 [16] acted as a reliable indicator of stress and anxiety. The Dental Subscale of the Children's Fear Survey Schedule (DFSS-SF) was tested for reliability and validity by Folayan et al., 2003. [17] Clinical anxiety rating scale and co-operative behavioral rating scale, are valid and reliable rating scales and have proven useful for assessing children's responses to dental stress Venham et al., 1980. [18]

The overall results revealed by all the parameters indicated children were most relaxed in audiovisual followed by audio group and were least relaxed in control group during three dental visits. Similar results were found in the study by Prabhakar et al., 2007 [2] and Florella et al., 2010 [19] in which statistically significant difference was found between control group and audiovisual group. This might be due to the reason that the child while watching the cartoon movie or other audiovisual distraction aids, concentrated on the screen, thereby screening out the sight of dental treatment. But unlike the results of Prabhakar et al., 2007 [2] study, in the present study there was also significant difference between audio group and control group during the second visit. This might be due to child listening to music tends to close his or her eyes thereby screening out the sight. Moreover, music helped to cut down the unpleasant noise of hand pieces or other anxiety inducing stimuli and these two advantages coupled with the effect of choice based music provided relaxation might be due to playing familiar songs helped child gain control over the unpleasant stimulus and gave them a feeling of being in the familiar environment. This was in accordance with the study conducted by Marwah et al., 2005 [20] in which the choice of music was left to the child dental patient. Parkin, 1981 [21] also found significant reduction in the rating of clinical anxiety during dental treatment when child patients were exposed to ambient music for 5 min beforehand. In a study by Yamini et al. 2010, [14] anxiety during dental treatment was assessed by psychological means and it was concluded that audio distraction did reduce the anxiety level in music group significantly in procedure under local anesthetic.

Whereas according to Aitken et al., 2002 [22] music distractions did not affect heart rate of the pediatric dental patient. This could be due to the methodological differences like choice of audio presentation was not allowed to the patients.

In addition to this another objective of the present study was to study effect of audio and audiovisual distraction aids on children's response to sequentional dental visits and the result revealed that there was increase in mean clinical anxiety rating scale and mean co-operative behavior rating scale scores from first to second to third visit in both the age groups and in all the three subgroups: Control, audio and audiovisual group. It indicated children were most co-operative and least anxious in first visit followed by second visit and were least co-operative and most anxious in third visit. It might be because the children were able to distinguish between stressful and nonstressful situations in the operatory as only the diagnosis was done at the first visit. In the subsequent visits, complex dental treatment procedures were performed by using air-rotor, local anesthesia and dental equipments. This made the children more anxious during treatment and further decreased the cooperation level of children in spite of the use of different distraction aids. These findings are in accordance with study by Venham et al., 1977. [15]

Comparison of both the age groups, 4-6 years and 6-8 years age groups as revealed by all the anxiety measuring parameters indicated control group patients of both the age group, that is, 4-6 and 6-8 years revealed equal anxiety level. Audio distraction had equal level of relaxation effect on both the age groups. Similarly, audiovisual distraction aids equally distracted children of both the age groups at "first," "second" and "third" visits.


   Conclusion Top


  1. Audio and audiovisual distraction techniques provided effective distraction on both the age groups. Although when compared audiovisual distraction aids perform better than audio distraction aids.
  2. Audio and audiovisual distraction techniques reduced the fear and anxiety in both the age groups as depicted by heart rate and DFSS-SF. However, maximum clinical anxiety/fear reduction was found in audiovisual group followed by audio group.
  3. In both the age groups a significant effect of visit type was observed on four indices: Clinically rated anxiety, uncooperative behavior, pulse rate. The pattern of response was consistent on all three measures; negative responses intensified from first visit to second visit to third visit in both the age groups. Moreover, according to our study we found that cooperation level of patients depends on the type of procedure which has to be carried out rather than the number of visits of treatment.


Therefore it is suggested that both audiovisual and audio distraction aids may be considered a good alternative in managing anxious child patients in dental operatory.

 
   References Top

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Speirs AF, Taylor KH, Joanes DN, Girdler NM. A randomised, double-blind, placebo-controlled, comparative study of topical skin analgesics and the anxiety and discomfort associated with venous cannulation. Br Dent J 2001;190:444-9.  Back to cited text no. 1
    
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Prabhakar AR, Marwah N, Raju OS. A comparison between audio and audiovisual distraction techniques in managing anxious pediatric dental patients. J Indian Soc Pedod Prev Dent 2007;25:177-82.  Back to cited text no. 2
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Folayan MO, Kolawole KA. A critical appraisal of the use of tools for assessing dental fear in children. Afr J Oral Health 2004;1:54-63.  Back to cited text no. 3
    
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Lahmann C, Schoen R, Henningsen P, Ronel J, Muehlbacher M, Loew T, et al. Brief relaxation versus music distraction in the treatment of dental anxiety: A randomized controlled clinical trial. J Am Dent Assoc 2008;139:317-24.  Back to cited text no. 4
    
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Klassen JA, Liang Y, Tjosvold L, Klassen TP, Hartling L. Music for pain and anxiety in children undergoing medical procedures: A systematic review of randomized controlled trials. Ambul Pediatr 2008;8:117-28.  Back to cited text no. 11
    
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Carson P, Freeman R. Assessing child dental anxiety: The validity of clinical observations. Int J Paediatr Dent 1997;7:171-6.  Back to cited text no. 12
    
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    Figures

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11], [Table 12]



 

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