|Year : 2020 | Volume
| Issue : 3 | Page : 259-265
Effectiveness of different behavior guidance techniques in managing children with negative behavior in a dental setting: A randomized control study
Pratik Pande, Vivek Rana, Nikhil Srivastava, Noopur Kaushik
Department of Pediatric and Preventive Dentistry, Subharti Dental College and Hospital, Swami Vivekanand Subharti University, Meerut, Uttar Pradesh, India
|Date of Submission||04-Aug-2020|
|Date of Decision||06-Aug-2020|
|Date of Acceptance||10-Aug-2020|
|Date of Web Publication||29-Sep-2020|
Dr. Pratik Pande
Department of Pediatric and Preventive Dentistry, Subharti Dental College and Hospital, Swami Vivekanand Subharti University, Subhartipuram, NH-58, Meerut - 250 005, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Dental fear is a common cause of uncooperative behavior among young children, which poses a challenge in providing effective dental treatment. With the advancements in technology, several behavior guidance techniques in the form of distraction have emerged over time for managing uncooperative pediatric dental patients. Aim: The aim of this study is to compare and evaluate the effectiveness of four different behavior guidance techniques in managing uncooperative pediatric patients by measuring pre- and post-operative dental fear/anxiety levels using physiological and nonphysiological parameters. Methodology: Sixty systemically healthy children aged 5–8 years with negative behavior as per Frankl's Rating Scale, requiring restoration were included in the study and randomly divided into four equal groups (n = 15), based on the guidance techniques used: Tell-Show-Do (TSD) as a control group and audio distraction, audiovisual distraction (AVD) (virtual reality [VR]) and Mobile Phone Game Distraction as test groups. Pre- and post-intervention levels of the child's fear/anxiety were assessed using both physiological (blood pressure and pulse rate) and nonphysiological (facial image scale) parameters. The data were evaluated using t-test and one-way ANOVA test. Results: A statistically significant difference was observed in both physiological and non-physiological parameters post-intervention in the groups with a maximum decrease in the AVD (VR) group. Conclusions: AVD (VR) was found to be the most effective while TSD alone as the least effective behavior guidance technique in reducing dental fear/anxiety in uncooperative pediatric dental patients.
Keywords: Anxiety, behavior guidance, dental fear, distraction, uncooperative children
|How to cite this article:|
Pande P, Rana V, Srivastava N, Kaushik N. Effectiveness of different behavior guidance techniques in managing children with negative behavior in a dental setting: A randomized control study. J Indian Soc Pedod Prev Dent 2020;38:259-65
|How to cite this URL:|
Pande P, Rana V, Srivastava N, Kaushik N. Effectiveness of different behavior guidance techniques in managing children with negative behavior in a dental setting: A randomized control study. J Indian Soc Pedod Prev Dent [serial online] 2020 [cited 2021 Jul 30];38:259-65. Available from: https://www.jisppd.com/text.asp?2020/38/3/259/296637
| Introduction|| |
Dental fear or anxiety is one of the major causes of uncooperative behavior and avoidance of dental treatment in children, which has been portrayed as a painful procedure, and therefore, children are more prone to develop fear either due to social factors or previous unpleasant experiences. Various physiological and non-physiological parameters have been used for the assessment of fear/anxiety in dental settings. Commonly used physiological parameters are blood pressure, pulse rate, and oxygen saturation, while non-physiological parameters include Venham's Clinical Anxiety Rating Scale, Venham's Picture Test, and Facial Image Scale, etc.
The American Academy of Pediatric Dentistry has outlined various behavior guidance techniques to deal with the problem, ranging from conventional Tell-Show-Do (TSD), voice control, to distraction. Distraction techniques, in the recent past, have gained immense popularity among pediatric dentists in managing uncooperative children. These techniques work by diverting the patient's attention from what may be experienced as an unpleasant stimuli.
Audio distraction (AD) is one of the most commonly used distraction techniques, which works by partially occluding the environment while allowing child–clinician communication. It also presents a variety of programs that can be chosen as per the child's preference. In this, the patient listens to music or stories during dental treatment.
Since the last few years, an increase in behavioral research through virtual reality (VR) and the virtual world has been witnessed. Depending on the immersiveness of the presented stimuli, the attention of the person will be more or less “drained” from the real world, leaving less attention to the real-world processes, including painful stimuli. VR distraction engages and integrates many sensory experiences, thus capturing a greater degree of attention. Therefore, the attention of the child is more focused on what is happening in the virtual world rather than the surrounding environment.
Electronic games in mobile smartphones can also serve as a distraction method by involving both visual and auditory sensations, thereby increasing the attention demand.
Considering that very few studies have been conducted to evaluate and compare various behavior guidance techniques on Indian child dental patients, this study was conducted with the aim to evaluate the effectiveness of four different behavior guidance techniques in managing uncooperative children requiring dental treatment using physiological and non-physiological parameters.
| Methodology|| |
The study was conducted in the Department of Pediatric and Preventive Dentistry after obtaining permission from the Institutional Ethical Committee. Informed consent was obtained from the parents of the children participating in the study.
Based on the results obtained after conducting a pilot study, the data were analyzed, and the sample size was determined as per the standard protocol.,,
A total of sixty systemically healthy children with negative behavior as per Frankl's Rating Scale between 5 and 8 years of age requiring restoration of carious teeth were randomly selected and were called samples. Children with no previous dental experience and no learning disability were included, whereas children with physical and mental disabilities were excluded from the study.
Sample size distribution
Using the computerized lottery system, the samples were randomly and equally divided into the following four groups (n = 15) based on behavior guidance techniques used before/during the treatment of dental caries using air-rotor and G.I.C/Composite restoration.
- Group I - TSD technique (Control Group)
- Group II - AD technique
- Group III-audiovisual distraction (AVD) technique-VR
- Group IV-Mobile Phone Game Distraction technique (MG).
Preintervention assessment of children's dental fear/anxiety
Pre-treatment assessment of all the children's dental fear/anxiety level was done using a combination of physiological and non-physiological parameters, namely pulse rate, blood pressure, and Facial Image Scale. An independent assessor who was unknown about behavior guidance methods to be used noted the readings.
Dental treatment (intervention)
In Group I-TSD technique (control group), the whole procedure was demonstrated to every child patient of this group by TSD technique. The “tell” phase involved explaining the whole procedure to the children as per their developmental level. In the “show” phase, the children were made familiar with the instruments and materials, including the demonstration of the procedure in a carefully defined, non-threatening manner. Finally, “do” phase, involved operator to initiate dental treatment exactly as per the explanation and demonstration given to the children, [Figure 1].
All the child patients of Group II - AD technique were first asked about their favorite story/music and downloaded on the operator's mobile. Before the start of the treatment, earphones were put on, and patients listened to their choice of content throughout the treatment [Figure 2].
In Group III - AVD-VR, th e patients were asked about their favorite cartoon, and the same was shown to them using virtual-reality glasses during the course of dental treatment [Figure 3].
|Figure 3: Photograph of a child in AudioVisual Distraction Group (Virtual Reality) (Group III)|
Click here to view
The patients of Group IV-Mobile Phone Game Distraction Technique (MG) were asked about their favorite mobile games, which they were allowed to play on a mobile phone while dental treatment was being done [Figure 4].
|Figure 4: Photograph of a child in Mobile Phone Game Distraction Group (Group IV)|
Click here to view
Postintervention assessment of children's dental fear/anxiety
After the dental treatment, dental fear/anxiety level of all the 60 child patients were again recorded using a similar combination of three physiological and non-physiological parameters; blood pressure, pulse rate, and Facial Image Scale by the same independent assessor who was unaware of the methods used for gaining child's cooperation.
The data obtained were tabulated. The values of mean and standard deviation were calculated. T-test and one-way ANOVA were applied to determine significance using IBM SPSS v 19.0(Chicago, U.S).
| Results|| |
Mean scores and standard deviation of pre and post systolic and diastolic blood pressure in all tests, as well as the control group is tabulated in [Table 1].
|Table 1: Comparison of pre. and post.operative systolic and diastolic blood pressure|
Click here to view
The intragroup comparison showed that there was a decrease in postintervention blood pressure, both systolic and diastolic, in all the groups compared to preintervention values. Minimum decrease was observed in TSD (control) group, whereas the AVD group showed a maximum reduction [Table 1].
[Table 2] depicts the intergroup comparison of systolic and diastolic blood pressure values after employing four different behavior guidance techniques using one-way ANOVA test (P-value). A statistically significant difference was observed among all the groups (P = 0.000), with maximum reduction in AVD group followed by the MG group, AD group, and TSD (control) group [Table 1].
|Table 2: Intergroup comparison of systolic and diastolic blood pressure by using one-way ANOVA test|
Click here to view
[Table 3] shows the mean scores and standard deviation of pre- and post-pulse rate and Facial Image Scale scores in all tests and control groups.
|Table 3: Comparison of pre- and post-operative pulse rate and facial image scale score|
Click here to view
The intragroup comparison showed the decline in post-intervention pulse rate as well as facial image scale score as compared to pre-intervention values in all the groups with the minimum decrease observed in TSD (control) group and maximum decrease in the AVD group [Table 3].
When intergroup comparison of Pulse Rate and Facial Image Scale scores after implementing various behavior guidance techniques using one-way ANOVA test (P-value) was done, it was observed that there was a statistically significant difference in pulse rate among all the groups (P = 0.000), with a maximum decrease in AVD group, followed by MG group, AD group and minimum in TSD (control) group [Table 3].
During the inter-group comparison of post-intervention values of Facial Image Scale Score, a statistically significant difference was observed between TSD (control) group and AVD group (P = 0.000); between AD group and AVD group (P = 0.000) and also between AVD group and MG group (P = 0.001) [Table 4].
|Table 4: Intergroup comparison of pulse rate and facial image scale score by using one-way ANOVA test|
Click here to view
However, statistically insignificant differences were reported between TSD (control) group versus AD group, TSD (control) group versus MG Group, and AD group versus the MG group [Table 4].
AVD group showed the maximum decrease in Facial Image scale score among all the groups followed by the MG group, AD group, and finally TSD (control) group [Table 3].
| Discussion|| |
Dental fear in children is an issue of great concern to the dentists globally. The prevalence of dental anxiety among 5- to 10-year-old children in an Indian population has been found to be 6.3%. It is well documented that the frequency of dental fear is more in younger children. Children of 6 years and younger are more likely to behave negatively. The prevalence of dental fear/anxiety in children of 5–10 years has been found to be significant and ranges from 7.9% to 5.8% with a gradual decrease with age. Considering that young children are more prone to develop dental fear/anxiety, an age group of 5–8 years was selected for the present study.
Various behavioral rating scales have been used for assessing dental fear and anxiety. One of the most commonly used behavior rating scales among children is the Facial Image Scale. Buchanan and Niven evaluated the validity of a scale that uses faces as an indicator of children's dental fear/anxiety and highlighted the Facial Image Scale as a valid means of determining child dental fear/anxiety status in a clinical situation. According to them, it has good validity and is a cost-effective way of dental fear evaluation. The scale was used in the present study for these reasons.
Other significant means to assess dental fear and anxiety are physiological parameters; some of them include blood pressure and pulse rate. It is well-established that fear or anxiety-provoking situations result in sympathetic stimulation, which causes an increase in pulse rate and blood pressure. Therefore, pulse rate and blood pressure were taken as physiological parameters to predict the effectiveness of behavior guidance techniques in reducing dental fear/anxiety.
Behavior guidance has been widely agreed to be an important factor in providing dental care for children. AAPD has classified behavior guidance techniques as basic and advanced behavior guidance. Basic behavior guidance methods include TSD, voice control, and distraction techniques, etc., whereas the advanced methods include protective stabilization, sedation, and general anesthesia.
Carson and Freeman demonstrated the effectiveness of TSD in reducing anticipatory anxiety in emergency pediatric dental patients and showed that there is high acceptability of this technique by the children. Various distraction techniques have gained immense popularity in the recent past for reducing dental fear and anxiety among children. The present study used three distraction techniques; AD, AVD (VR), and mobile phone game distraction.
In AD, the music sends enough competing for sensory inputs via pathways descending to the brain to cause the brainstem to signal some of the gates shut, hence decreasing the amount of pain perceived by the patient. Singh et al., in their study, compared AD with the TSD technique and found that “AD” was efficacious in alleviating the anxiety of pediatric dental patients. A number of studies have also compared the efficacy of AD with the TSD technique and found AD as an effective way in reducing the fear/anxiety level in pediatric patients.,
Several studies in the past have been conducted to evaluate the efficacy of other behavior guidance techniques like AVD in the form of VR and television etc., and found effective.,,, Another study was done to compare AVD with counter-stimulation on dental anxiety, and pain perception also found VR distraction as a better method in reducing dental fear/anxiety in children.
With the introduction of smartphones and the ease of downloading various games for free, most of the children prefer playing games on mobiles. While playing games on mobile phones, the users become so engrossed that they become oblivious to surrounding stimuli.
In a study to compare mobile phone game distraction with AVD found mobile phone games distracting technique more effective for managing anxious pediatric dental patients.
When the blood pressure was compared after employing four different behavior guidance techniques, there was a decrease in post-intervention values as compared to pre-intervention blood pressure values in all the groups.
A statistically significant difference was observed among all the four groups (p = 0.000), with maximum reduction in blood pressure was recorded in the AVD group followed by the MG group, AD group, and TSD (control) group. This can be attributed to the fact that during VR distraction, the sights and sounds of dental treatment are screened out, thus leading to a reduction of anxiety and the resultant decrease in blood pressure. The results are in accordance with the study conducted by Singh et al., in which the AD technique was compared with the TSD technique and a greater reduction in blood pressure was observed in the AD group as compared to the TSD group.
While comparing pulse rate, a decline in the post-intervention pulse rate was seen as compared to pre-intervention values in all groups. Furthermore, the intergroup comparison depicted that there was a statistically significant difference in all groups (P = 0.000), with the maximum decrease in pulse rate observed in the AVD group, followed by the MG group, AD group, and TSD (control) group.
Similar results were observed in a study done by Marwah et al. who compared audio analgesia with the TSD technique. The reason for the pulse rate reduction can be explained with this that while listening to stories/music, children become engaged and concentrate more on the audio content than the anxiety-causing dental stimuli.
In a study by Niharika et al. which compared AVD using VR glasses with conventional TSD technique, found a greater reduction in pulse rate with AVD using VR glasses.
The reason for the effectiveness of VR glasses in reducing patient's anxiety might be due to the diverting attention from an unpleasant dental setting to a pleasant and absorbing virtual environment, at the same time, engaging higher cognitive and emotional centers of the nervous system.
In the present study, the Facial Image Scale score was compared after employing various behavior guidance techniques. The post-intervention Facial Image Scale score values were found to be lower as compared to pre-intervention facial image scale values in all groups.
The maximum decrease in the Facial Image Scale score was observed in the AVD group, followed by the MG group, AD group, and minimum in the TSD (control) group.
A study conducted by Al-Khotani et al. who also used the same scale, concluded that though the mean value of the Facial Image Scale was lower in the AVD (VR) group, the difference was statistically non-significant when compared with the conventional TSD group.
The anxiety-inducing appearance of dental clinics, including equipment and the child's focus on the close monitoring of the procedures to be carried out are amongst the most important reasons causing stress during dental treatment. Positive effects of decreasing dental fear/anxiety by the use of VR distraction in the present study might be due to the complete blockage of children's visual field along with distraction. It provides more immersive images because of occlusive headsets that project the images right in front of the user's eyes and block out the real-world stimuli, thereby reduce dental fear and anxiety. A number of studies have found similar promising results.,, However, contrasting results were obtained in a study by Al-Halabi et al. who evaluated the effectiveness of two different AVD techniques: AV eyeglasses-VR Box and tablet and concluded that distraction using video shown on tablet-device was the best in relieving dental anxiety and pain as compared to the VR box.
| Conclusions|| |
Within the limitation of the study, the following conclusions were drawn:
- Among the four behavior guidance techniques used in the study, the AVD (VR) proved to be the most effective technique for reducing dental fear/anxiety in children with negative behavior requiring dental treatment
- TSD alone was not found to be a very effective behavior guidance technique for child dental patients showing negative behavior
- The efficacy of various behavior guidance techniques was observed in decreasing order as- AVD (VR) > Mobile Phone Game Distraction > AD > TSD (Control).
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Suprabha BS, Rao A, Choudhary S, Shenoy R. Child dental fear and behaviour: The role of environmental factors in a hospital cohort. J Indian Soc Pedod Prev Dent 2011;29:95-101.
] [Full text]
Buchanan H, Niven N. Validation of a facial image scale to assess child dental anxiety. Int J Paediatr Dent 2002;12:47-52.
Navit S, Johri N, Khan SA, Singh RK, Chadha D, Navit P, et al
. Effectiveness and comparison of various audio distraction aids in the management of anxious dental pediatric patients. J Clin Diagn Res 2015;9:ZC05-9.
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.
] [Full text]
Shafi S, Manzoor S, Kaushik N. Distraction using virtual reality technology: A review. Int J Adv Res 2015;3:1465-8.
Asl Aminabadi N, Erfanparast L, Sohrabi A, Ghertasi Oskouei S, Naghili A. The impact of virtual reality distraction on pain and anxiety during dental treatment in 4-6 year-old children: A randomized controlled clinical trial. J Dent Res Dent Clin Dent Prospects 2012;6:117-24.
Jameson E, Trevena J, Swain N. Electronic gaming as pain distraction. Pain Res Manag 2011;16:27-32.
Singh RK, Gupta VK, Kumar A, Singh A, Shetty R, Pandey V. Effectiveness and comparison of various audio distraction aids in the management of anxious dental pediatric patients. Int J Contemp Med Res 2016;3:1532-4.
Connelly LM. Pilot studies. Medsurg Nurs 2008;17:411-2.
Suresh K, Chandrashekara S. Sample size estimation and power analysis for clinical research studies. J Hum Reprod Sci 2012;5:7-13.
] [Full text]
American Academy of Pediatric Dentistry. Behavior guidance for the pediatric dental patient. Pediatr Dent 2017;39:246-59.
Elicherla SR, Bandi S, Nuvvula S, Challa RS, Saikiran KV, Priyanka VJ. Comparative evaluation of the effectiveness of a mobile app (Little Lovely Dentist) and the tell-show-do technique in the management of dental anxiety and fear: A randomized controlled trial. J Dent Anesth Pain Med 2019;19:369-78.
Chhabra N, Chhabra A, Walia G. Prevalence of dental anxiety and fear among five to ten year old children: A behaviour based cross sectional study. Minerva Stomatol 2012;61:83-9.
Shapiro M, Melmed RN, Sgan-Cohen HD, Eli I, Parush S. Behavioural and physiological effect of dental environment sensory adaptation on children's dental anxiety. Eur J Oral Sci 2007;115:479-83.
Singh D, Samadi F, Jaiswal J, Tripathi AM. Stress reduction through audio distraction in anxious pediatric dental patients: An adjunctive clinical study. Int J Clin Pediatr Dent 2014;7:149-52.
Carson P, Freeman R. Tell-show-do: Reducing anticipatory anxiety in emergency pediatric dental patients. Int J Health Promot Educ 1998;36:87-90.
Marwah N, Prabhakar AR, Raju OS. Music distraction – Its efficacy in management of anxious pediatric dental patients. J Indian Soc Pedod Prev Dent 2005;23:168-70.
] [Full text]
Yamini V, Bailwad SA, Nirmala SV, Sivakumar N. Effectiveness of music distraction in the management of anxious pediatric dental patients. Ann Essences Dent 2010;2:1-5.
Nuvvula S, Alahari S, Kamatham R, Challa RR. Effect of audiovisual distraction with 3D video glasses on dental anxiety of children experiencing administration of local analgesia: A randomised clinical trial. Eur Arch Paediatr Dent 2015;16:43-50.
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.
] [Full text]
Niharika P, Reddy NV, Srujana P, Srikanth K, Daneswari V, Geetha KS. Effects of distraction using virtual reality technology on pain perception and anxiety levels in children during pulp therapy of primary molars. J Indian Soc Pedod Prev Dent 2018;36:364-9.
] [Full text]
Nunna M, Dasaraju RK, Kamatham R, Mallineni SK, Nuvvula S. Comparative evaluation of virtual reality distraction and counter-stimulation on dental anxiety and pain perception in children. J Dent Anesth Pain Med 2019;19:277-88.
Allani S, Shetty JV. Effectiveness of distraction techniques in the management of anxious children in the dental operatory. IOSR J Dent Med Sci 2016;15:69-73.
Sharar SR, Carrougher GJ, Nakamura D, Hoffman HG, Blough DK, Patterson DR. Factors influencing the efficacy of virtual reality distraction analgesia during postburn physical therapy: Preliminary results from 3 ongoing studies. Arch Phys Med Rehabil 2007;88:S43-9.
Al-Khotani A, Bello LA, Christidis N. Effects of audiovisual distraction on children's behaviour during dental treatment: A randomized controlled clinical trial. Acta Odontol Scand 2016;74:494-501.
Florella M, Sarale C, Ram RD. Audiovisual iatrosedation with video eyeglasses distraction method in pediatric dentistry: A case history. J Int Dent Med Res 2010;3:133-6.
Shetty V, Suresh LR, Hegde AM. Effect of virtual reality distraction on pain and anxiety during dental treatment in 5 to 8 year old children. J Clin Pediatr Dent 2019;43:97-102.
Al-Halabi MN, Bshara N, AlNerabieah Z. Effectiveness of audiovisual distraction using virtual reality eyeglasses versus tablet devices in child behavioral management during inferior alveolar nerve block. Anaesth Pain Intensive Care 2018;22:55-61.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4]