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Year : 2018  |  Volume : 36  |  Issue : 1  |  Page : 2-8

Audiovisual distraction methods for anxiety in children during dental treatment: A systematic review and meta-analysis

Department of Pediatric Dentistry, School of Dentistry of Ribeirão Preto, University of São Paulo, Ribeirão Preto, SP, Brazil

Date of Web Publication28-Mar-2018

Correspondence Address:
Dr. Erika Calvano Küchler
Department of Pediatric Dentistry, School of Dentistry of Ribeirão Preto, University of São Paulo, Avenida do Café s/n, Monte Alegre, 14040-904, Ribeirão Preto, SP
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JISPPD.JISPPD_188_16

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Background: Dental treatment can cause symptoms such as fear and anxiety. Audiovisual distraction (AD) is a simple and low-cost technique that does not interfere with the dental treatment. Aim: The aim of this study was to perform a systematic review and meta-analysis to evaluate the effectiveness of AD methods for children who experience anxiety during dental treatment. Materials and Methods: Two reviewers performed a database search of the studies published between January 1950 and November 2015. The inclusion criteria were papers published in the English language, child samples aged 4–10 years, and use of AD. All potentially relevant studies were identified by the title and the abstract. After the full-text analysis of the potentially relevant studies, the selected studies were included in the systematic review. A meta-analysis calculation was performed for the overall data and the subgroup data. Results: Thirty-seven nonduplicated studies were found. However, after reviewing the articles, only five were included. A high variability was observed among the papers. Tools and questionnaires used to measure the anxiety during dental treatment presented the most common variability. Meta-analysis demonstrated a lower anxiety level in AD method groups when Modified Child Dental Anxiety Scale was used (P = 0.02) with a mean difference (confidence interval) of −8.72 (−16.7, −1.38). Conclusion: The AD method is effective for controlling dental anxiety in children.

Keywords: Children, dental anxiety, distraction

How to cite this article:
Barreiros D, de Oliveira DS, de Queiroz AM, da Silva RA, de Paula-Silva FW, Küchler EC. Audiovisual distraction methods for anxiety in children during dental treatment: A systematic review and meta-analysis. J Indian Soc Pedod Prev Dent 2018;36:2-8

How to cite this URL:
Barreiros D, de Oliveira DS, de Queiroz AM, da Silva RA, de Paula-Silva FW, Küchler EC. Audiovisual distraction methods for anxiety in children during dental treatment: A systematic review and meta-analysis. J Indian Soc Pedod Prev Dent [serial online] 2018 [cited 2022 May 21];36:2-8. Available from: https://www.jisppd.com/text.asp?2018/36/1/2/228740

   Introduction Top

Dental treatment can cause symptoms such as fear and anxiety for children.[1] Children who have dental anxiety are afraid of dental treatments and they are often difficult to treat.[2]

There are basic techniques of behavior management that are used routinely to reduce a child's anxiety during dental treatment, such as talk-show-do, positive reinforcement, nonverbal communication, voice control, and distraction.[3],[4],[5],[6] Distraction is a common technique in the dental practice which diverts the child's attention from what may be perceived as an unpleasant procedure,[6],[7] shifting their focus to engrossing and fascinating distractors.[8],[9]

There are two distraction methods widely used in dentistry: audio and audiovisual distraction (AD).[10],[11],[12],[13],[14],[15],[16] Audio distraction includes music, audio presentation through headphones, and storytelling,[17],[18] whereas AD includes story presentation on television,[19] virtual reality,[20] and three-dimensional video glasses.[21]

AD is a simple and low-cost technique that does not interfere with the dental treatment. This technique partially occludes the environment, while allowing child–clinician communication.[14] It is widely accepted by children and is easy to execute.[22] AD also presents a variety of programs that can be chosen according to the child's preference.[14]

Although there are several studies about the effect of the AD technique on anxiety during pediatric dental treatments, they are controversial and present heterogeneous methods and results.[14],[19],[20],[21],[22] Therefore, our aim was to systematically and critically review the AD techniques used on children during dental treatment to reduce their anxiety.

   Materials and Methods Top

Eligibility criteria

This study was carried out in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analyses Statement [23] and was registered with PROSPERO (CDR42015024128).

The inclusion criteria were as follows: (1) Papers published in the English language, (2) child samples aged between 4 and 10 years, (3) AD used for dental treatment, and (4) randomized, controlled trials and case–control studies. Publication dates, sample sizes, and statistical analyses were not a restriction. Unpublished manuscripts and theses, book chapters, case studies, and other types of distraction techniques were excluded.

Literature search and search strategy

The inclusion criteria comprised of clinical investigations with case and control groups that addressed AD as a technique for reducing the anxiety of children during dental treatment without restriction on the AD method. The Population, Intervention, Comparison and Outcome and search strategy are presented in [Table 1].
Table 1: Population, Intervention, Comparison and Outcome, and search strategy in databases

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The following electronic databases were used for the selection of the primary studies: PubMed (1966–November 2015), Web of Science (1900–November 2015), Scopus (1960–November 2015), and Cochrane (1993–November 2015). The search was conducted using the following terms from Medical Subject Heading terms (MeSH) or Text Word (tw) and their combinations: “child” (MeSH terms) OR “children” (tw) OR “preschool” (tw) OR “kid” (tw) or “infant” (tw) AND “audiovisual distraction” (tw) OR “virtual reality” (MeSH terms) AND “dental care” (MeSH terms) OR dental treatment (tw) or dental treatments (tw). To ensure the widest possible search, no language filters were applied.[24] In addition, the bibliographies of the final selected articles were handsearched to identify any relevant publications that were not identified earlier. The authors of the included studies were contacted by e-mail for the identification of additional information.

Study selection

Two reviewers (DB and DSBO) independently read all retrieved titles and abstracts. If one assessor regarded a publication as having met the inclusion criteria, the full text was obtained. Abstracts considered as potentially eligible, as well as those that did not supply enough information, were reserved for full-text assessment. Any differences concerning eligibility after evaluation of the full text were resolved through consensus, and when differences still persisted, a third reviewer (ECK) was consulted before a final decision was reached.

Data extraction

Two reviewers (DB and DBSO) independently conducted data extraction. General information such as authors, year of publication, and country were collected from each study. In addition, the following specific characteristics were also collected: (i) Setting of the dental treatment, (ii) age range in years, (iii) dental treatment at each visit, (iv) sample size, (v) interventions, (vi) previous dental experience, (vii) distraction period, (viii) dental anxiety outcome measurement by questionnaires, and (ix) outcome.

The authors (DB and ECK) also performed a critical review of the included studies.

Assessment of risk of bias

Quality assessment of the studies was performed to control the influence of bias. Four criteria were analyzed in all the included papers. The criteria items were: (1) Eligibility criteria for the participants, (2) randomization, (3) sample size calculation, and (4) statistical analyses. Two of the reviewers (DB and ECK) assessed the included studies for risk of bias and were blinded to each other's assessments. Disagreements were resolved through discussions with a third reviewer (FWPS). Domains from the Cochrane Collaboration risk of bias tool were assessed for each study. Data were entered into Review Manager Version 5.3 (Cochrane Collaboration, Copenhagen, Denmark) for graphical representation.


The calculation was performed for the four included studies that clearly presented data regarding dental anxiety. A random-effects model was used for the meta-analysis of the overall data. We used a random-effects model because it takes into account the clinical heterogeneity of the included studies.[24] The subgroup analyses were performed grouping the studies according to the tool that was used to measure dental anxiety. One analysis was performed for the Venham's picture test results and the other analysis was performed for the Modified Child Dental Anxiety Scale. Higher values indicate a higher dental anxiety level. The weighted mean differences between AD and no intervention control groups were performed using the inverse-variance meta-analysis. The meta-analysis calculation and forest plot creation were performed with RevMan 5.3 (Cochrane Database of Systematic Reviews). I2 was used to assess the statistical heterogeneity between studies, where I2 values of 25%, 50%, and 75% indicated low, medium, and high heterogeneities, respectively.[25]

   Results Top

The flow diagram is presented in [Figure 1]. Five papers met the inclusion criteria [Figure 1]. [Table 2] presents a summary of the findings of each included study. A high variability was observed among the papers. The topic that presented the most common heterogeneity was the tools and questionnaires used to measure dental anxiety during dental treatment.
Figure 1: Flow diagram of the literature search

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Table 2: Reviewed treatment outcome studies for dental anxiety

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Six questionnaires and four visual scales were used to evaluate dental anxiety and behavior in the included studies. Three tools were used to measure dental anxiety, as follows: (1) Venham's picture test comprises eight cards, with two figures (anxious and nonanxious). If the child pointed at the “anxious” figure, a score of “1” was recorded, and if the child pointed at the “nonanxious” figure, a score of “0” was recorded. Total scores ranged from “0” to “8”; (2) Faces version of the Modified Child Dental Anxiety Scale Questionnaire consists of eight questions that incorporate inquiry about dental procedures. Total scores ranged from “5” to “40”; and (3) visual analog scale comprises a row of five faces ranging from very happy to very unhappy. The children were asked to point the face they most liked at that moment. Total scores ranged from “0” to “10.” Also, two studies used pulse rate and oxygen saturation as additional tools.

Four studies were performed in the Middle East and India, and only one study was performed in the Occident (Spain). Two studies used another group of children without AD treatment for anxiety as a comparison group, while two other studies used the child as his or her own control in a paired design. Only one study used nitrous oxide and was compared with AD. [Figure 2] demonstrated the quality assessment of the included studies.
Figure 2: Quality assessment of the included studies (the Cochrane collaboration tool for assessing risk of bias)

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The analysis of the subgroups according to tool of measurement found an association when the Modified Child Dental Anxiety Scale was used (P = 0.02) [Figure 3]. When Venham's picture test was used, there was no association (P = 0.29) [Figure 4].
Figure 3: Forest plot of the two studies that used Modified Child Dental Anxiety Scale

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Figure 4: Forest plot of the two studies that used Venham's picture test

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   Discussion Top

The aim of all pediatric dentists, when managing patients, should be to reduce fear and anxiety through behavior management techniques.[26],[27],[28],[29],[30] Managing the behavior of pediatric patients allows the establishment of communication with the children and completion of the dental treatment without a pharmacological approach to reduce anxiety.[6],[31]

AD is a behavior management method used during pediatric dental treatment,[22] which has been poorly explored by dental researchers. In this study, we performed a systematic review and meta-analysis to evaluate the studies as well as AD's effectiveness for dental anxiety of the children.

Our systematic review emphasizes that, regardless of the type of AD, this technique successfully decreased anxiety during dental treatment, enhancing positive attitudes of pediatric patients toward their experience at dental appointments, as previously reported.[19],[20],[21],[22] Only one study [14] did not find an improvement in behavior with the AD method. However, the same study compared AD with nitrous oxide in the control group and found both techniques to have similar effectiveness. This result could be explained by the level of anxiety of the studied children; they were probably highly anxious to require nitrous oxide treatment. It is well known that nitrous oxide/oxygen inhalation reduces anxiety.[32] A recent systematic review evaluated the effect of many nonpharmacologic interventions in behavior, anxiety, and pain perception in children undergoing dental treatment. The authors also proposed that a range of nonpharmacologic techniques may be used as an approach for behavior management.[33]

Our study included papers that evaluate children aged between 4 and 10 years. This was due to the fact that children at this age exhibit the most negative behavior during dental procedures and are difficult to control.[19] Also, the children in this age group are mature enough to interact with the AD technique, while those under 4 years are in infancy and early childhood and might not have the attention for AD techniques. On the other hand, children over 10 years old are not interested in children's movies, because they are in late childhood and in adolescence. This result corroborates with that of Asl Aminabadi et al.'s study,[20] which reported that behavior management techniques should be used in children who can understand the situation, since different age groups exhibit different cognitive characteristics and behavioral patterns.

Our forest plots demonstrated an association only when the “Modified Child Dental Anxiety” was used. This might be explained by the fact that Venham's picture test is a subjective evaluation method, while Modified Child Dental Anxiety Scale is a questionnaire. Another possibility to explain this difference is the type of distraction that these studies used. The studies that did not find an association used an ordinary AD technique. Prabhakar et al. used television presentation and Guinot Jimeno et al. used projector presentation. It is important to emphasize that anxiety has cognitive and behavioral manifestations. It is possible that some of these techniques alter one, but not the other, anxiety manifestation.

Although our systematic review and meta-analysis suggested that AD plays an important role in the symptoms of dental anxiety in children, it is important to highlight that there were no studies performed in the American and African continent and only one was performed in Europe. Childhood is a phase with a high risk for the development of anxiety symptoms and syndromes, ranging from transient mild symptoms to phobic anxiety disorders.[34] This type of information during pediatric dental treatment is particularly needed from a scientific and clinical perspective.

Therefore, future studies with a randomized clinical trial designs should be performed. The studies should also attempt to evaluate the baseline level of anxiety in order to assess the effect of the AD in patients with different anxiety levels. In addition, more studies should be performed in different populations in order to establish the AD effectiveness in other cultural backgrounds.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

  [Table 1], [Table 2]


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