Background: Dental fear is a common, essential, and inevitable emotion that appears as a response to the stressful situation, which raises children's anxiety level, resulting in reduced demand for pediatric dental care. Aims: (1) To compare and evaluate the effectiveness of customized tell-play-do (TPD) technique with live modeling for behavior management of children. (2) To compare the behavioral modification techniques in managing the children during their dental visits. Materials and Methods: Ninety-eight children aged 5–7 years were enrolled in the study and randomly allocated into two groups. Phase I: first visit. Group I - children were conditioned to receive various dental procedures using live modeling followed by oral prophylaxis. Group II - TPD technique was introduced with customized playing dental objects followed by oral prophylaxis. Phase II: second visit. After 7 days interval, all the study subjects were subjected to rotary restorative treatment. Evaluation: Heart rate, Facial Image Scale (FIS), and Venham-6-point index were used before intervention, after intervention, and during dental procedure to quantify the anxious behavior. Results: All 98 children after intervention underwent oral prophylaxis on first visit and rotary restorative treatment on second visit. The average pulse rate, FIS, and Venham scale scores were significantly lower among children who received TPD intervention when compared to those who received live modeling intervention. Unpaired t-test at 5% level of significance was considered as statistical significance. Conclusions: TPD is effective in reducing children's fear and anxiety about dental treatment, children enjoy playing with customized dental object. Thus, to promote adaptive behavior, TPD could be an alternate behavioral modification technique during pediatric dentistry.
Keywords: Behavioral modification, children, live modeling, tell-play-do
How to cite this article: Vishwakarma AP, Bondarde PA, Patil SB, Dodamani AS, Vishwakarma PY, Mujawar SA. Effectiveness of two different behavioral modification techniques among 5–7-year-old children: A randomized controlled trial. J Indian Soc Pedod Prev Dent 2017;35:143-9
How to cite this URL: Vishwakarma AP, Bondarde PA, Patil SB, Dodamani AS, Vishwakarma PY, Mujawar SA. Effectiveness of two different behavioral modification techniques among 5–7-year-old children: A randomized controlled trial. J Indian Soc Pedod Prev Dent [serial online] 2017 [cited 2021 May 7];35:143-9. Available from: https://www.jisppd.com/text.asp?2017/35/2/143/206036
Dental anxiety being attributed by many as a major cause to avoid seeking dental care by children as well as young adults, proper communication is important, and is a big challenge in the dental office.
Several communicative, advanced, and pharmacological interventions have been developed to manage children's anxious and cooperative behaviors. The American Academy of Pediatric Dentistry has recommended more focus on nonpharmacologic intervention in future studies.
Dental phobia is considered as a major obstacle for dental treatment and is a serious public health issue. Various studies among 6–12-year-old children showed that 20%–43% exhibited high dental fear.,,, The sight and sensation of the anesthetic needle, and the sight, sound, and sensation of the drill, were rated as the most fear-eliciting stimuli. A Finnish study observed that 15% of the children did not seek care due to fear of dental treatment.
Two most commonly used nonpharmacological behavioral modification techniques used by pediatric dentists in management of dental anxiety at a pretreatment visit are live modeling and tell-show-do (TSD).
TSD technique introduced by Addelston in 1959 dictates that before any procedure is done, the child is to be well informed and a demonstration should be given using a simulator exactly what will happen before the procedure is started.
TSD technique is based on the principle of learning theory , and is performed by the dentists themselves in the operatory room.
Modeling refers to learning by observation and children may reproduce behavior exhibited by the model in the same situation. It was described by Bandura in 1967 as a process which can reduce children's fear and avoidance behavior. Modeling can be performed in two forms: live or filmed one. Studies on modeling have demonstrated its therapeutic effect in management of anxiety ,,,, and educational effect in improving coping skills of children in medically stressful situations.
The first dental experience is important in molding child's attitude toward dentistry and dental outcome. Cooperation of child during dental treatment is vital to render successful and quality treatment.
A child's cognitive development will dictate the level and amount of information interchange that can take place. It is difficult for a 5–7-year-old child to perceive an idea, for which he has no conceptual framework and to understand dentist's frame of reference.
It is important to communicate with the child patient briefly at the beginning of a dental appointment to establish rapport and trust.
Only by explaining, demonstrating, or observing a model, instead of it make them to play with dental imitating instrument toys, which provides more explanatory concept.
With this idea, TSD technique was modified into tell-play-do (TPD) technique, using the concept of learning by doing in reducing children's fear and anxiety to dental treatment and promoting adaptive behavior.
The aim of this study was to evaluate the effectiveness of live modeling in comparison with TPD technique among 5–7-year-old children, with null hypothesis stating no difference between two behavioral modification techniques.
Materials and Methods
This randomized clinical trial study was approved by the Ethics Committee of ACPM Dental College and Hospital and conducted in the Department of Pediatric and Preventive Dentistry from October to November 2015.
Among the patients referred to the pediatric department, 98 children aged 5–7 years (±4 months) were enrolled in the study based on the eligibility criteria. Children with initial caries cavity lesion (not involving pulp) in one of the primary mandibular molars and needed a restoration or direct or indirect pulp capping treatment with or without local anesthesia were included in the present study. It was confirmed that they had no previous experience of hospitalization and dental visit. The children with systemic diseases and developmental disorders were excluded from the study. The examination was completed and the necessary radiographs were prescribed.
Each child's parents were explained in detail about the study and written informed consent was obtained. Required and relevant information pertaining to study was collected.
Then, the child was enrolled in one of the study groups based on balanced block randomization as follows.
Study subjects were randomly allocated into two groups [Figure 1].
Live modeling procedure: the children were directed to the clinical cabin where cooperative child was undergoing dental treatment effectively. The operator explained each child about the instruments being used including syringe using appropriate euphemisms, then demonstrated and performed the treatment procedure on the patient. The duration of live modeling was standardized to 20 min. Then, the child was taken to perform oral prophylaxis in first visit.
Group II (tell-play-do group)
The child was directed to the play room, where the room was arranged with customized dental instrument toys and a cartoon character with mouth wide open [Figure 3]. The trained dental personnel explained all the customized dental objects using appropriate euphemisms and procedures in phrases appropriate to the developmental level of the child and allowed to hold dental imitating instruments including syringe to play and perform dental procedure on the cartoon character [Figure 4].
Figure 3: Customized dental imitating playing objects
The airotor noise was incorporated in the dental object resembling clinical sound effect [Video 1].
The duration of whole procedure was standardized for 20 min; then, the child was taken to clinical area and oral prophylaxis was performed in first visit.
Phase II – Second visit
The second treatment session was set 1 week later. The treatment protocol was the same for all the participants.
The child entered the operating room alone.
Then, the occlusal cavity was prepared for restoration of the teeth. During deep cavity preparation, the required injection including the use of topical anesthesia and a local infiltration was performed by the dentist.
In all children, parameters such as the attending dentist, his/her assistant, the working environment, time and duration (30 min for each child) of work, and the type of dialogs and euphemisms were all the same. Care was taken to make sure that the children were not tired and hungry.
Children were studied in following sequence.
At first visit:
Before intervention: As child entered the clinical area, team received the child and made to sit on dental chair. After 1 min heart rate (using Gibson finger oximeter), FIS  and Venham scale (VS) were noted
After intervention: The respective child was taken to a separate room to receive particular intervention (live modeling/TPD). Then, again, all parameters were noted
During procedure: The child was taken for oral prophylaxis and during this procedure, all parameters were noted. All children were appointed after 7 days.
The child's response was noted in two stages: At the injection of local anesthesia and during cavity preparation.
All children were independently evaluated for anxiety reaction by two calibrated pediatric dentists who were blind to the grouping of the children.
Mean heart rate was compared in between the two groups using unpaired t-test. Change of heart rate at different duration was compared in between the two groups using unpaired t-test after confirming the homogeneity of variance using Levene's test.
Mann–Whitney U-test was used to compare the FIS and VS of two groups depending on their mean ranks.
Contingency coefficient analysis for ordinal data of FIS and VIS was done using Gama test.
P < 0.05 was considered statistically significant.
Data analysis was performed using software package of statistical analysis (SPSS-15, SPSS Inc., Chicago, IL, USA).
A total number of 98 children, 57 boys and 41 girls participated in the study and allocated between TPD (n = 49) and live modeling (n = 49) groups. Data revealed that both groups were same in demographic characteristics including their sex, mean age, parental education and age, SES, and participation in same school.
All examinations and dental procedures were completed for each group. Levene's test confirmed the homogeneity of variances.
Mean heart rate at different intervals was significantly lower among children in Group II (TPD) than among those in Group I (live modeling) during first visit (after intervention and during procedure) P= 0.038 and 0.026, and also in second visit (during procedure), P= 0.001 [Table 1].
Table 1: Comparison of mean heart rate at different interval in between the two groups
Similarly, mean change in heart rate from before intervention to different intervals was significantly lower in Group II when compared with that of Group I children P \= 0.007 and P= 0.042 at first and second visits, respectively [Table 2].
Table 2: Comparison of mean change of heart rate from before intervention to different interval in between the groups
Accordingly, heart rate mean scores during restorative procedure (second visit) with local anesthesia (n = 18, Group I and n = 20, Group II) and nonlocal anesthesia (n = 31, Group I and n = 29, Group II) group showed no significant differences P= 0.134 in Group I and P = 0.390 in Group II, respectively.
Difference of proportion of children according to FIS and Venham 6-point scale, greater number of children scored no hurt (81.6%) among Group II than children (57.1%) in Group I during procedure in second visit.
Children anxiety reaction (FIS and Venham 6-point scale) after intervention, during procedure in first visit and during procedure of second visit was significantly lower in Group II than those in Group I [Table 3] and [Table 4].
Table 3: Intra group comparison of Facial-Image-Scale. Ranks Mann-Whitney U test
Based on Piaget's classification, children aged 4–7 years are in the preoperational phase. The increment in the vocabulary, attention, and concentration abilities in this period is sign of their readiness for social communications.
Hence, the dentist must have a basic understanding of the cognitive development of the child. Hence, this age group is ideal for behavioral modification techniques.
This study was designed to evaluate and compare the efficiency of live modeling and TPD technique in reducing child anxiety during dental treatment.
The results of this study showed that TPD technique was more effective than live modeling on child anxiety levels and increased the cooperative behavior during dental treatment among 5–7-year-old children.
The comparison between two groups showed that TPD technique was more effective than live modeling in reducing the heart rate and mean change in the heart rate.
TPD technique is based on learning theory where interchange of thoughts and two-way interchange of information takes place, by performing dental treatment on dental imitating toys where child understands the dentist's frame of reference and feels more comfortable and develops cooperative behavior.
The study results of Alrshah et al. and Farhat-McHayleh et al. showed that children who received live modeling with mother as a model had a lower heart rate than those who received live modeling with the father as model and those who prepared by the TSD method.
Sharma and Tyagi  in 2011 have reported that techniques such as live modeling and TSD are very effective in modifying a child's behavior.
Many dentists have firm views on whether a parent should be present when dental treatment is carried out. Shindova and Belcheva found that the parental presence or absence in the treatment room has no impact on the anxiety level of the children aged 6–12 years.
In modeling approach, the ability of the child to imitate others is used and by imitating the child learns complex behavior patterns where the desirable behavior may or may not be obtained as in this younger age group participated in our study.
TSD technique remains the most commonly used technique in pediatric dentistry and is still considered the technique with which the dentists and the parents are comfortable ,,, and justifies being the method of choice as the backbone of child education and behavior guidance during first dental visit.
The competent modification of TSD to TPD is significantly effective than live modeling in reducing not only the heart rate (physiological index) but also the cooperative behavior (FIS and VS).
Analysis of FIS and VS revealed that fear perception range by Group II (TPD) was significantly lower compared to Group I (live modeling). Using similar scale studies reported that live modeling was better technique than TSD in reducing child's anxiety.,
Child's behavior reactions were quantified by an unaware observer using FIS and VS as these are easy and quick methods with reliability and validity for statistical analysis.
Most of the children are anxious to local anesthesia. In the present study, both the group children were equally anxious to local anesthesia. Similar results were found in the study conducted by Paryab and Arab, when compared between film modeling group and TSD group. Further research has to be carried out to explore the effect of TPD technique on behavioral changes.
In the present study, before intervention to after intervention, number of children showing better response had increased in both the groups.
Number of children showing positive response and cooperation had reasonably increased from first visit to second visit among TPD group than live modeling group.
Similar studies conducted by Sharma and Tyagi, Frankl, Howitt and Stricker  also concluded that child's arousal level was reduced as they became accustomed to the dental situation.
According to our study, TPD technique among 5–7-year-old children is impressively effective and can create an extremely good patient at this stage of life as 40 (81.6%) were definitely positive during second visit of restorative procedure.
In the present study, comparison between males and female was not done as we assumed less significance of gender on behavioral changes in this younger age group.
By simple modification, TPD can have a greater impact on younger children, so that they can feel comfortable and accept the dental treatment.
This is especially important in our set up as parents are increasingly apprehensive and less willing to allow the use of conscious sedation or undertake general anesthesia.
Child's home environment and parents' attitude and behavior could impact child's behavior toward seeking health during the study period with a week gap between the first and second phase of experiment. This is an inherent limitation of our study as it is not under operator control
The age of children, number of intervals, and treatment procedures were restricted in the present study.
According to the methodology and based on the results of the present study, we can conclude that:
TPD technique is more efficient than live modeling technique to control 5–7-year-old children's anxiety and achieve cooperative behavior during dental treatment
TPD technique may be an alternate method to TSD and live modeling technique
TPD is a technique worth practicing in pediatric dentistry.
The dentist should consider the cognitive development of the patient to communicate effectively for developing sound rapport and trust
Each dental visit should be designed to receive proper behavioral guidance techniques such as TPD, TSD, and modeling; these can help the child to develop a positive attitude toward oral health.
We would like to thank all the children participated in the study and Dr. Prashant Patil, Biostatistician, Hire Government Medical College, Dhule, for helping us with statistical analysis.
Wilson S. Non-pharmacologic issues in pain perception and control. In: Casa Massimo PS, Fields HW, McTigue DJ, Nowak AJ, editors. Pediatric Dentistry – Infancy through Adolescence. 5th ed. Philadelphia: Elsevier Saunders; 2013. p. 94.
Wright GZ, Stigers JI. Non-pharmacologic management of children's behaviors. In: Dean JA, Avery DR, McDonald RE, editors. Dentistry for the Child and Adolescence. 9th ed. St. Louis: CV Mosby Co.; 2011. p. 30.
Yahaya WA, Salam SN. Usability Design Strategies for Children: Developing Children Learning and Knowledge in Decreasing Children Dental Anxiety. Proceedings of the International Conference on Primary Education, Hong Kong; 2009. p. 25-7.
Paryab M, Arab Z. The effect of Filmed modeling on the anxious and cooperative behavior of 4-6 years old children during dental treatment: A randomized clinical trial study. Dent Res J (Isfahan) 2014;11:502-7.
Farhat-McHayleh N, Harfouche A, Souaid P. Techniques for managing behaviour in pediatric dentistry: Comparative study of live modelling and tell-show-do based on children's heart rates during treatment. J Can Dent Assoc 2009;75:283.
Afshar H, Baradaran Nakhjavani Y, Mahmoudi-Gharaei J, Paryab M, Zadhoosh S. The effect of parental presence on the 5 year-old children's anxiety and cooperative behavior in the first and second dental visit. Iran J Pediatr 2011;21:193-200.