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Journal of Indian Society of Pedodontics and Preventive Dentistry Official publication of Indian Society of Pedodontics and Preventive Dentistry
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Year : 2022  |  Volume : 40  |  Issue : 3  |  Page : 253-259

Effectiveness of self-designed dental storybook as behavior modification technique in 5 – 7 year-old children: A randomized controlled study

1 Department of Pediatric and Preventive Dentistry, K. M. Shah Dental College and Hospital, Vadodara, Gujarat, India
2 Department of Pediatric and Preventive Dentistry, K. M. Shah Dental College and Hospital, Sumandeep Vidyapeeth, Vadodara, Gujarat, India
3 Department Management, Sumandeep Vidyapeeth, Vadodara, Gujarat, India

Date of Submission14-May-2022
Date of Decision08-Sep-2022
Date of Acceptance13-Sep-2022
Date of Web Publication18-Oct-2022

Correspondence Address:
Anshula Deshpande
Department of Pediatric and Preventive Dentistry, K.M. Shah Dental College and Hospital, Sumandeep Vidyapeeth (Deemed to be University) Vadodara, Gujarat
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jisppd.jisppd_237_22

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Background: Dental anxiety is one of the key factors that prevent children from obtaining dental treatment and raises anxiety levels in children. The first dental visit is usually fearful for the child and contributes to managing the child patient in a dental operatory. A pediatric dentist's role is to perform effective treatment using various nonpharmacological behavior management techniques. Aims: The aim of the study was to evaluate and compare the effect of self-designed dental storybook on behavior and pulse rate before and after dental procedures in 57-year-old children. Settings and Design: The study was a prospective, randomized, controlled trial. Materials and Methods: The study was conducted on 380 aged 57 years. Children were randomly allocated into two groups, namely, Group A − Behavior modification using a self-designed dental storybook and Group B – Behavior modification without storybook. Research was carried out in two dental visits (screening, examination, and preventive and restorative treatment) wherein, before and after intervention, pulse rate, Facial Image Scale (FIS), and Venham Scale (VS) were recorded. Descriptive statistical analyses followed by the paired t-test and Wilcoxon signed-rank test were applied and tabulated using the SPSS software version 23.0. Results: There was a significant difference observed in the interventional group as compared to the control group for pulse rate, FIS, and VS. Conclusion: Self-designed dental storybook as an adjuvant was found to be promising behavior modification technique for 57-year-old children.

Keywords: Behavior therapy, communication, dental anxiety, dental care, Facial Image Scale, reinforcement, storybook

How to cite this article:
Deshpande A, Jain A, Shah Y, Jaiswal V, Wadhwa M. Effectiveness of self-designed dental storybook as behavior modification technique in 5 – 7 year-old children: A randomized controlled study. J Indian Soc Pedod Prev Dent 2022;40:253-9

How to cite this URL:
Deshpande A, Jain A, Shah Y, Jaiswal V, Wadhwa M. Effectiveness of self-designed dental storybook as behavior modification technique in 5 – 7 year-old children: A randomized controlled study. J Indian Soc Pedod Prev Dent [serial online] 2022 [cited 2022 Dec 3];40:253-9. Available from: http://www.jisppd.com/text.asp?2022/40/3/253/358834

   Introduction Top

Dental anxiety is one of the critical factors that prevents children from obtaining dental treatment.[1] Dental fear and anxiety can be attributed to various factors such as age, subjective fear, previous medical and dental experiences, and parental attitudes. These attributes have its implication on child's behavior in dental operatory. In such circumstances, the role of the dentist is to manage patients in two folds. First, to have control and treat the patient and second, to teach the child appropriate ways of coping anxiety.[2] Worldwide, dental anxiety affects children aged 3 − 18 years and is more common in school age and preschool children than in teenagers. A recent study found that the combined prevalence among preschoolers, school children, and adolescents was 36.5% (95% confidence interval [CI] 23.8, 49.2), 25.8% (95% CI 19.5, 32.1), and 13.3% (95% CI 9.5, 17.0), respectively.[3]

The first dental experience is vital in determining a child's attitude toward dentistry and the outcome of their dental treatment.[4] It is important to change the individual's preconceived ideas of dental care or specific treatment procedures to obtain a better outcome. Patients of varying ages exhibit varying levels of cognitive and/or perceptional functioning, verbal and nonverbal communication skills, and social interaction. Hence, different ways of nonpharmacological techniques depending on the same are used. They can be tell-show-do, relaxation, distraction, systemic desensitization, modeling, etc.[5] It has been documented in the literature that patients who have comprehensive knowledge of their oral condition or the treatment procedure have better outcomes than those who lack such knowledge. Hence, providing patients with comprehensive information generally improves compliance in patients.

When it comes to providing health education, there are different media available: demonstration models, leaflets, video films, and computers. Moreover, patients who belong to the rural areas in developing countries have little or no knowledge regarding the dental procedure, and hence, they should be provided a book, based on an explanation of the dental procedure for their better understanding.[1] In addition, several communication-aided approaches, such as applied behavioral analyses, visual pedagogies, pictorial or iconic images, and audio-visual aids, have been proposed to aid behavioral changes among people.[5] Newer studies have been conducted on a variety of behavioral interventions, such as social stories,[6] visual pedagogy, and comic strips. They are often used to generate a desired behavior or prepare a child for a new experience. Like other behavior management techniques, they were effective, relatively inexpensive, and simple to use.[6] According to Simpson RL, social stories were simply a “promising method” as an intervention.[7]

Gray and Garand's early recommendations emphasized the importance of stories written from the child's perspective and presented in a print size appropriate for the child in order for the child to understand the dentist's frame of reference and correlate with them in a much easier way.[8] The American Academy of Pediatric Dentistry recommended focusing more on nonpharmacological intervention of behavior modification techniques.[9] There are sparse studies on preoperative behavior modification using storybook in the available literature. Furthermore, very limited studies have yet assessed how well a dental storybook works to lessen dental anxiety over the course of several visits. Therefore, the study's objective was to determine whether a self-designed dental storybook was effective at modifying the behavior of 5-7 year old children during the examination and treatment planning visits, followed by a restorative dental appointment.

   Materials and Methods Top

Study design

The research was initiated after obtaining approval from the Institutional Ethical Committee. (SVIEC/EC/ON/DENT/RP/19107) and copyright number (L-101026/2021) was also issued for a self-designed dental storybook titled as Tooth Factory: A Trip to Child's Dentist [Figure 1] and [Figure 2]. The Consolidated Standards of Reporting Trials guidelines were followed to design the present research [Figure 3].
Figure 1: Cover page of storybook entitled as tooth factory: A trip to child's dentist

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Figure 2: Glimpse of story from tooth factory: A trip to child's dentist storybook

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Figure 3: CONSORT flow diagram. CONSORT = Consolidated standards of reporting trial

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Sample selection

The sample consisted of 380 children from 5 to 7 years of age, which were included based on the following inclusion criteria: medically fit children with American Society of Anesthesiologists (ASA) I (normal healthy patients) according to the ASA Classification,[10] children/parents able to read and understand English, children whose parents gave written informed consent for preventive resin restoration/pit and fissure sealants procedures; and had no previous experience of hospitalization and dental visit. Children with previous dental experiences were excluded from the study. All participants were free to withdraw from the study at anytime without affecting the dental treatment. The patient information sheet was shared with parents/guardians with verbal explanation to them.

Study procedures: sample power calculation and randomization

The sample size was calculated using the SPSS Statistics 21 statistical software (SPSS Inc., Chicago, ILL., USA). Three hundred and thirty-six sample size was determined using total population (N) which was considered as 7300 with margin error (e) of 0.05% for a confidence level of 95%. An additional 20% were comprised in the research to compensate for potential refusals, absenteeism, and dropouts (d). The sample size of 380 was further randomly divided by the lottery method into two groups, namely Group A (behavior modification with storybook) and Group B (behavior modification without storybook) having 190 children in each group. It was a double-blinded study where co-principal investigator was blinded and performed operative procedure followed by data recording, statistician was given the coded data to preserve the blinding and storybook intervention was provided by the principal investigator.

Study procedures

Data were collected by trained pediatric dentist, whereas each patient was treated by other pediatric resident who was unaware about the allocation of the participant. Parents were not present in the counseling and/or operating room during the entire study.

The research was conducted in two dental visits for the entire subjects. The duration of dental treatment in both the groups was standardized to 20 min. The operator performed oral prophylaxis for children in the first visit and occlusal cavity was prepared for restoration of the teeth on the second visit in both the groups. Conventional behavior management techniques, namely: verbal communication and tell-show-do were used in operatory for all the participating children (Group A and B). The children allocated in intervention group (Group A) were directed to the counseling room where co-investigator had provided a self-designed storybook to children before receiving dental treatment. Self-designed dental storybook addressed following areas: oral conditions; diagnostic; and restorative and preventive dental procedures.

Pulse rate (using Dr Trust [USA] finger oximeter), FIS, and Venham Scale (VS)[7] were noted for all the participating children before starting the study as baseline data. Children allocated to intervention group (A) were taken to the counseling room to receive intervention by dental storybook, whereas Group B (behavior modification without storybook) children were seated comfortably in the waiting area for the same duration which was 15 min. Pulse rate (using Dr Trust [USA] finger oximeter), FIS, and VS[7] were again recorded for all the participants. Readings were also noted at both dental visits which was; before initiating dental procedure (oral prophylaxis/pit and fissure sealants/preventive resin restoration) and during dental procedure.

Statistical analysis

Data were analyzed using SPSS 23.0 (Version 23, IBM SPSS Inc., Chicago, ILL., USA) software for statistical analysis. Descriptive statistical analyses followed by the unpaired t-test, Friedman rank test and Wilcoxon signed rank test were carried out in the present study, wherein results with P ≤ 0.05 were considered statistically significant.

   Results Top

The research was initiated with 380 children; however, 35 children were excluded. Twenty-seven children were excluded as they did not report for second dental visit and eight required additional behavior management techniques. Hence, the final sample size was 345 children.

The pulse rate values of children in both the groups at different time intervals are depicted in [Table 1]. It was observed that there was a gradual reduction in pulse rate from the 1st visit before intervention to the 2nd visit after intervention in both the groups with P < 0.05. However, in the control group there was rise in the pulse rate observed in children while they were waiting in the counseling room (104.07/min) [Table 1].
Table 1: Inter-group comparison of pulse rate at different time intervals during the first and second dental visit among both the groups using the unpaired t-test

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Intergroup comparison of anxiety scores between both the groups on the first visit at different time interval was recorded using Facial Image Scale and Venham picture test. There was highly significant difference observed in both Group A and Group B in both the visits, i.e. P < 0.001 [Table 2]
Table 2: Inter-group comparison of anxiety score at different time intervals during the first visit among both the groups using Friedman rank test

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The pretest and posttest anxiety scores of both the groups in the second visit, respectively, were compared using the Wilcoxon signed-rank test. Wherein, negative rank indicates anxiety score of posttest < pretest, positive rank indicates anxiety score of posttest > pretest and Ties indicate anxiety score of posttest = pretest. On intra-group comparison, both the groups showed statistically significant difference in reduction of the anxiety score after dental procedure [Table 3].
Table 3: Inter-group comparison of anxiety score at different time intervals during the second visit among both the groups using Wilcoxon signed-rank test

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   Discussion Top

Anxiety is an emotional state commonly referred as fear of unknown. It is often expressed as an unpleasant feeling that precedes the actual interaction with the threatening stimuli. According to Agras et al., anxiety associated with dental appointments and procedures is the fifth most common cause of anxiety, with a substantially higher frequency among children.[9] According to literature reported by Chhabra N, Chhabra A, and Walia G, the prevalence of dental anxiety was 7.9%, 7.1%, and 6.6% in children aged 5, 6, and 7, respectively, and decreased as age increased.[11] Children with no previous dental experience commonly express anxiety due to the uncertainty they feel, about what awaits them. Alleviating a child's anxiety about dental treatment is important not only in mitigating the immediate fear but also in preventing apprehension continuing into adulthood. According to Filewich, extremely fearful patients required approximately 20% more chairside time compared to that of less fearful patients, highlighting the importance for dentists to learn and employ various management techniques to alleviate patient's fear and anxiety.[12]

Behavior management needs to be flexible and individualized for each child. Most behavior management techniques require an understanding of the cognitive, emotional, and social development of the child. It is of vital importance that any approach of behavioral management must be implanted in empathy and concern for well-being of the child. Nonpharmacological behavior management techniques such as tell-show-do, distraction, modeling, desensitization, verbal communications are commonly used behavior modification techniques implied by pediatric dentist for the management of children's anxiety at a pretreatment visit. Among various approaches available, this research aimed to explore a psychological approach employing a self-designed dental storybook as a behavior management technique to alleviate dental anxiety in 57-year-old children. It is difficult for a 57-year-old child to perceive an idea, for which he has no conceptual framework and to understand dentist's frame of reference. The storybook was designed to explain various oral conditions and their associated treatment modalities, assisting child in becoming more comfortable with the dental procedure and provide introductory information before dental procedure.

Various studies on the usefulness of previsit information have revealed convincing findings. Fox and Newton reported that British children's dental anxiety decreased after being exposed to the positive images of dental-related items.[13] Similar to this, Moura et al.[14] measured children's anxiety levels before and after presenting them with an audio-visual book before their dental sessions and Deshpande et al.[15] used self-designed pictorial flashcard in the form of dental pictionary which was based on substitute words. Children's anxiety levels significantly decreased in both the studies. In contrast, having prior knowledge about dental care had no discernible impact on dental anxiety in Nigerian youngsters,[16] while a study done with the viewing of leaflets with positive dental information had the same results.[17] The current study assessed the efficiency of a specially designed dental storybook in lowering dental anxiety and enhancing behavior in children during examination and treatment planning visits, followed by a restorative dental visit. In a study by Alsaadoon et al., where behavior changes were examined after several dental appointments as well, similar conclusions were obtained.[18]

To assess dental anxiety, physiological and behavior measuring scales/parameters were assessed in the current research. Sympathetic stimulation is observed when the child is anxious or fearful leading to increase in the pulse rate.[19] As a result, pulse rate was used to assess dental anxiety, determined using a pulse oximeter.[20] In the present study, it was observed that there was significant difference in the pulse rate of children in both intervention and control groups. This was in conjunction with the research conducted by Aminabadi et al., wherein it was concluded that story telling can effectively ensure children's cognitive development and progress indicating significant decrease in situational anxiety and perception of pain during dental procedure.[21] In earlier studies done by Prabhakar et al.,[7] Yelderman and New,[19] and Tailor et al.,[22] a similar kind of pattern was observed while using audio-visual distraction as the behavior modification technique. De Menezes Abreau et al. reported decrease in anxiety after visiting dental clinic in children aged 6–7 years, emphasizing the key role of behavior management in reducing dental anxiety in children.[23]

For behavioral parameters, Facial Image Scale (FIS) and Venham picture test were used to quantify and evaluate anxiety. According to a study by Buchanan and Niven,[24] FIS is a valid means of assessing child dental anxiety status whereas, Krishnappa et al.[25] concluded that both the scales are valid means of assessing child dental anxiety in a clinical context. In the present study, there was significant reduction in anxiety observed in children of both the groups. It was observed that the score of FIS showed highly significant changes in anxiety, whereas Venham picture test showed significant difference. This may be because it was simpler for children to make their decision from FIS when compared to Venham picture test. Whereas, the Venham picture test was complicated and challenging for the child to choose the response.

It can be thus accomplished from the results of the present study that dental storybook illustrates a positive impact on children and can be used as an effective behavior management technique to reduce dental anxiety.


The sample size was small and can be conducted on the larger population. Only restorative dental procedures were included. To make the process uniform for all subjects, pulp treatment and extraction were eliminated. The self-designed story book was only printed in the English language; this can be converted to several other languages for better understanding.

Strength of the study

Despite the aforementioned drawbacks, there are some positive aspects of this study, such as the use of a specially designed dental storybook in a blinded, randomized clinical study to modify children's behavior. This method made the study groups more comparable and reduced bias and confounding. A further attempt was made to create more precise and trustworthy results by integrating the physiological parameters with a number of different scales to measure anxiety levels.[25],[26]

   Conclusion Top

Based on the results, it can be concluded that:

  • Self-designed storybook can serve as a relatively simple and effective tool when used before dental procedures
  • It also aided in facilitating patient awareness and motivation to begin care for their dental health, ensuring a better, cavity-free future
  • Patients and their parents expressed positive opinions regarding the use of self-designed storybook in the dental environment.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Vandermeer J, Beamish W, Milford T, Lang W. IPad-presented social stories for young children with autism. Dev Neurorehabil 2015;18:75-81.  Back to cited text no. 1
Jain SD, Jain M, Khan K, Pandey A, Bagban A. Evaluating the use of audio-visual aids in health education of patients visiting a dental college in Greater Noida. Int Healthcare Res J 2017;1:278-83.  Back to cited text no. 2
Grisolia BM, Dos Santos AP, Dhyppolito IM, Buchanan H, Hill K, Oliveira BH. Prevalence of dental anxiety in children and adolescents globally: A systematic review with meta-analyses. Int J Paediatr Dent 2021;31:168-83.  Back to cited text no. 3
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.  Back to cited text no. 4
Marion IW, Nelson TM, Sheller B, McKinney CM, Scott JM. Dental stories for children with autism. Spec Care Dentist 2016;36:181-6.  Back to cited text no. 5
Murshid EZ. Effectiveness of a preparatory aid in facilitating oral assessment in a group of Saudi children with autism spectrum disorders in Central Saudi Arabia. Saudi Med J 2017;38:533-40.  Back to cited text no. 6
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. 7
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Deshpande AN, Shah YS, Jain A. Effectiveness of euphemism with and without self-designed pictorial flashcard in the form of dental pictionary as behavior modification technique in 4-6-year-old Children: A randomized controlled study. J South Asian Assoc Pediatr Dent 2022;5:59-63.  Back to cited text no. 15
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de Menezes Abreu DM, Leal SC, Mulder J, Frencken JE. Patterns of dental anxiety in children after sequential dental visits. Eur Arch Paediatr Dent 2011;12:298-302.  Back to cited text no. 23
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  [Table 1], [Table 2], [Table 3]


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