Journal of Indian Society of Pedodontics and Preventive Dentistry
Journal of Indian Society of Pedodontics and Preventive Dentistry
                                                   Official journal of the Indian Society of Pedodontics and Preventive Dentistry                           
Year : 2020  |  Volume : 38  |  Issue : 4  |  Page : 393--399

A comparative study of tell-show-do technique with and without the aid of a virtual tool in the behavior management of 6–9-year-old children: A nonrandomized, clinical trial

KT Raseena, PP Jeeva, Anupam Kumar, Digesh Balachandran, Aswani Anil, Resmi Ramesh 
 Department of Pediatric and Preventive Dentistry, Government Dental College, Kottayam, Kerala, India

Correspondence Address:
Dr. K T Raseena
Department of Pediatric and Preventive Dentistry, Government Dental College, Kottayam, Kerala


Context: Dental fear is a common and imperative emotion that develop as a response to the stressful situation, which raises children's anxiety level and resulting in avoidance behavior. Aims: The aim of this study is to evaluate and compare the tell-show-do technique with and without the aid of a virtual tool in the management of pediatric dental patients. Settings and Design: Department of Pediatric and Preventive Dentistry, nonrandomized clinical trial. Subjects and Methods: A total of 90 children of the age group of 6–9 years who were in the need of restorative treatment without using local anesthesia were assigned into two groups: Control group, where tell-show-do was applied as behavior management technique and intervention group in which tell-show-do with the aid of a virtual tool was applied. Child anxiety level was assessed using a combination of anxiety rating parameters before and after the procedure. Three physiological parameters (heart rate, oxygen saturation, and respiratory rate) and two behavioral parameters (Wright's modification of Frankl' behavior Rating Scale and Facial Image Scale) were recorded. Statistical Analysis Used: Physiological parameters were analyzed using the independent sample t-test and behavioral parameters using the Mann–Whitney U-test (P < 0.05). Results: A significant difference in all five parameters was observed between the control group and intervention group. Conclusions: Virtual tool offers a new concept of virtual distraction aid in pediatric dentistry, and it was found to be very effective in managing anxious pediatric patients. This promising method diminishes the unpleasantness often associated with dental procedures and offers a relaxed state in children.

How to cite this article:
Raseena K T, Jeeva P P, Kumar A, Balachandran D, Anil A, Ramesh R. A comparative study of tell-show-do technique with and without the aid of a virtual tool in the behavior management of 6–9-year-old children: A nonrandomized, clinical trial.J Indian Soc Pedod Prev Dent 2020;38:393-399

How to cite this URL:
Raseena K T, Jeeva P P, Kumar A, Balachandran D, Anil A, Ramesh R. A comparative study of tell-show-do technique with and without the aid of a virtual tool in the behavior management of 6–9-year-old children: A nonrandomized, clinical trial. J Indian Soc Pedod Prev Dent [serial online] 2020 [cited 2021 Feb 25 ];38:393-399
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Child dental fear is a significant factor in the provision of pediatric oral health care. The prevalence of dental fear among children has been reported to range between 5% and 20% with a mean prevalence of 11%.[1] The first dental visit is often crucial in the formation of the child's attitude toward dentistry and in turn the future treatment success. Dental appointment is a stressful situation for the child, which raises their anxiety level and avoidance behavior. The sight, sensation, fear of pain from the needle, and sound/vibration of airotor were found to be the most fear-evoking stimuli for children.

Anxious children demand considerable allegiance and expertise in the child management techniques from both dentist and the dental staff. Disruptive behavior can significantly interfere in providing a quality dental care, which will result in increased delivery time and risk of injury to the child. Hence, the management of children's behavior is an essential part of the pediatric dental practice, and it is paramount to the successful treatment.

Both pharmacological and nonpharmacological techniques have been developed for the management of child's behavior at the dental office. Now a days, nonpharmacological methods are gaining popularity which includes parental presence and reassurance, tell-show-do, distraction, relaxation, systematic audio analgesia, desensitization, modeling, physical contact by light touching or stroking and music, etc.

One of the most commonly used non pharmacologic behavior management technique is tell-show-do. It was introduced by Addleston in 1959. In this technique, dentist tells the child what is going to be done in words the child can understand, then demonstrates exactly how the procedure will be conducted, followed by performing the procedure exactly as it was described and demonstrated.[2]

Present day, children are familiar with touch screen devices and Apps, and its usage is very common in all age groups. This can be utilized in pediatric dentistry for educating the patients about the treatment procedure so that their fear/or anxiety can be reduced. Very few studies have been conducted on the behavior management of pediatric dental patient using Dental Apps. Hence, this study was conducted to evaluate whether a virtual tool like a Dental App could be used as an additional aid along with tell-show-do technique, for the management of children in stressful dental setups. One of the short coming of the mobile applications is that they are mostly available in English, and hence, many of the children are not able to use. Hence, a new App named “smart dental for kids” was developed exclusively for this study in the regional language of Kerala to overcome this problem.

 Subjects and Methods

This nonrandomized clinical trial was approved by the Institutional Ethics Committee with Ethical clearance number-IEC/M/14/2017/DCK, dated November 15, 2017.

Physically and mentally healthy children with carious lesion which needs a cavity preparation using the airotor for restoration were included in the study. The exclusion criteria were children who have experienced the airotor hand piece earlier, those with previous unpleasant dental experiences, those with acute painful oral conditions, children with known systemic diseases, and those with a history of recent prolonged hospitalization. Differently abled children and those who did not provide the required consent were also excluded from the study.

Children in the age group of 6–9 years reported to the outpatient department who had satisfied the inclusion criteria were recruited into either Group 1 (control group) or Group 2 (intervention group) with 45 patients in each group (total 90 patients).

In the control group, tell-show-do was applied [Figure 1]. In the intervention group [Figure 2], patients had provided with a virtual tool which is an in-house designed Dental App in a handheld touch screen device [Figure 3], for educating the child patient about the airotor and planned treatment procedure. The App was developed by COSMOS Computer Co LLC, Abu Dhabi, UAE exclusively for this study in the regional language of Kerala, and it was named as “SmartDental kids”. Patients were “virtually made dentists,” and they made use of the App to perform a virtual dental treatment of restoring a carious tooth, which was immediately followed by the dentist performing the same treatment for them.{Figure 1}{Figure 2}{Figure 3}

Each child in both groups had two dental visits. In the first visit, screening was done, procedure was explained and consent was obtained from the parent. In the second visit, cavity preparation was done using airotor with round bur followed by GIC restoration. [Figure 4] shows the armamentaria used in the study.{Figure 4}

Child anxiety level was assessed by the combination of anxiety rating parameters before and after the procedure. Pulse rate and oxygen saturation were measured using pulse oximeter, and respiratory rate was measured manually by simply counting the number of breaths for 1 min. Each patient's behavioral response was assessed by a second person who was not involved in the treatment procedure or grouping of the patients using Wright's modification of Frankl's Behavior Rating Scale[2] [Table 1] and Facial Image Scale[3] [Figure 5].{Table 1}{Figure 5}

Facial image scale comprises of a row of five faces ranging from very happy to very unhappy. The child was asked to point at which face/emotion they felt most like at that moment before the start of procedure and also after the completion of treatment. The scale is scored by giving a value of 1 to the most positive effect face and 5 to the most negative effect face.

After completing data collection, data were fed in the computer for processing and analysis using the software package of statistical analysis (SPSS-16.02, SPSS Inc., Chicago, IL, USA). Quantitative variables were expressed in mean and standard deviation and compared using the independent sample t-test. The qualitative variables were expressed in proportion and were compared using the Mann–Whitney U-test.


Among 90 children studied, 39 were boys (43.3%) and 51 were girls (56.7%). The mean age of the participants in the control group was 6.56 ± 0.785 years and that of the intervention group was 6.89 ± 1.191 years. The t value obtained was 1.87 at P = 0.121 which means, there was no significant difference in the age between the control group and intervention group, so the patients selected were of same age groups, eliminating the selection bias.

There was a statistically significant reduction in mean pulse rate and respiratory rate for intervention group (both have P = 0.000) after treatment comparing with the control group indicating that a low anxiety level in the intervention group. When oxygen saturation was analyzed between two groups, there was an increase from before treatment to after treatment with the high statistical significance of P = 0.000 [Table 2].{Table 2}

A statistically significant difference between mean FIS score was obtained between two groups after the treatment (P = 0.000) which indicates a greater reduction of anxiety in intervention group. The Frankl's score after the procedure in the intervention group showed that more number of patients exhibited positive/definitely positive behavior comparing to the control group which is also highly significant (P = 0.000) [Table 3].{Table 3}


The cornerstone of success in pediatric dentistry is behavior management and the use of these behavior management techniques (BMTs) which enable children to learn appropriate behavior, coping skills, reduce anxiety, and facilitate the delivery of adequate oral health care. Owing to the limitless burden of expectations from parent, society, and child, there has been a constant evolution in the application of BMTs in dental clinics.[4]

Tell-show-do is the widely used technique to make aware the patient about the new procedure, while reducing the fear of the unknown.

A variety of studies have been conducted, and based on their results, it was found that ideal distraction requires the activation of child's various senses such as hearing, vision, touch, and active involvement of child's emotion to counteract anxiety causing noxious stimuli.[5]

In recent years, there has been immense research in behavioral science pertaining to virtual reality (VR) and virtual world. This VR refers to human interaction with computer generated environment using the sophisticated systems. This VR drains the patient's attention from the real world to virtual world, allowing the child in dental operatory to focus on the virtual world.[5] Sullivan et al. demonstrated that using VR during dental treatment significantly reduced the pulse of the patient.[6] A significant reduction in the stress levels was achieved in the majority of studies using VR distraction.[7],[8],[9]

Mobile phones are used all over the world in most of the fields because of its extreme versatility and function as personal computers, so having an important role in day to day life. Owing to the increasing spread of mobile technologies throughout the world, the World Health Organization (WHO) has coined a new term: mobile Health (mHealth), a component of eHealth, and is defined as “medical and public health practice supported by mobile devices, such as mobile phones, patient monitoring devices, personal digital assistants, and other wireless devices”.[10] One review by Fiordelli et al. concluded that “the potential of smartphones does not seem to have been fully exploited yet” and shows the potential and scope of evolution of smart phones and its use in treatment aspects.[11]

Literature suggests a variety of mobile applications use for the management of diabetes, mental illness, and obesity.[12] However, there is a scarcity of information regarding the use of smartphones for reduction in anxiety levels worldwide and there are no reported studies from Kerala. The present study, to the best of the researcher's knowledge, is the first one reported from Kerala to analyze the connection of smartphone applications and reduction in dental anxiety, if achieved, and to compare the effectiveness of smartphone application with the most widely used tell-show-do for the behavior management of anxious pediatric dental patients.

The age group of the patients selected for the study was 6–9 years. Similar study was conducted by Harsh A Shah et al.[13] where they evaluated the influence of using smartphone applications to reduce dental anxiety and hemodynamic changes produced in pediatric patients aged 5–10 years.

Out of the 90 children studied, 39 were boys and 51 were girls, i.e., study population consisted of 43.3% males and 56.7% females. In the present study, Chi-square value for gender distribution was 0.045, which is not statistically significant (P = 0.832). That means there is no significant dependency of gender between the two groups. This result was in accordance to the study conducted by BS Suprabha et al.[4] in 2011 where they found there is no statistically significant difference in the mean scores of boys and girls. However, generally, girls are expected to display their fear while boys are not. A study conducted by Ann E Gaber et al.[14] concluded that the level of DFA was affected by the gender of child where girls were more dentally anxious than boys.

Looking into the various physiological parameters connected with the study, heart rate, which was used in the study according to Mccarthy, 1957[15] acted as a reliable indicator of stress and anxiety. In this study, heart rate showed a significant difference between the control group and intervention group. This was in conjunction with observations made by Harsh A Shah et al.[13] who had observed a similar kind of pattern. A study done by Buchanan and Niven has been reported as a valid indicator of a child's pain experience precisely.[3] Wright's modification of Frankl' Behavior Rating Scale determines the children's behavior during the dental treatment procedure. This system has been used in previous studies and found to have good validity.

The App developed for the present study is the first one available in the regional language of Kerala and thus eliminating the language barrier when using the already available apps.

In the present study, a statistically significant difference in the respiratory rate was observed between the two groups after the procedure. According to Leivseth et al., the changes in breathing can be both the consequence of an increased level of anxiety as well as the source of threat experienced by the individual, which, in turn, leads to increased anxiety.[16],[17] Thus, assessing breathing might be a useful physiological marker of the level of anxiety.[18] Hence, based on these studies, respiratory rate was used in the present study to indicate the level of anxiety.

The results from this study indicate that although there was a decrease in the oxygen saturation as the pulse rate increased, there was no statistically significant difference which was in conjunction with the earlier studies done by Yelderman and William.[19] A statistically significant difference was observed between the two groups.

Considering various behavioral parameters such as facial image scale, after the procedure, the Z value obtained was 4.18 with a P = 0.000 with a mean rank facial score of 56.30 for the control group and 34.70 for the intervention group. In the case of behavior rating scale, post treatment Z value was 4.65 with a P = 0.000 with a mean rank facial score of 56.30 for the control group and 34.70 for the intervention group.

In contrast to previous studies, the present study indicated a definite negative effectiveness of tell-show-do technique in managing dental anxiety in children except for the respiratory rate which showed a decrease after procedure, which is not significant. Nowadays, children are more attracted to pictures and videos than the oral instructions. Lower anxiety levels in the intervention group are due to the fact that, by virtual tool children became familiar with the whistling airotor (one of the most fearful object for the children), the vibration felt by the airotor and also to the various armamentaria used for the restorative procedures.

The operator bias was also not a consideration in the present study as the same operator performed the restorative procedure in both groups. The readings of both behavior rating scale and the physiologic parameters were recorded by an independent observer who was unaware of the grouping.

There are several studies like study conducted by Mitrakul et al.[20] who evaluated the effectiveness of video eye glasses and Ram et al.[21] who also evaluated the effectiveness of AV eyeglass system. Their results also showed a significant reduction in the anxiety of children during dental procedure. However, some studies showed that children missed the interaction with the clinician while using the AV eyeglasses. For short procedures or treatment of new patients, the use of the AV eyeglasses may not be so much beneficial, since verbal preparation before the procedure and maintaining communication during the treatment would be needed. The use of virtual tool will be a good alternative for this limitation of AV eyeglass system. The same was observed during the course of study where some patients wanted virtual tool in their subsequent visit.

Limitations of the study: More recent studies are showing that increased screen time neglects the circuits in the brain that control more traditional methods for learning and these are typically used for reading, writing, and concentration. Hence, the WHO recommends to limit the screen time. Even though we are exploring the educational aspects of virtual tool, there is a chance of misconception on parents that we are promoting the use of such devices. Furthermore, the sample size could be considered as a limitation. A larger sample size and in a general clinical setting might have elucidated the difference in anxiety levels with various distraction aids. This study excluded children with previous bad experience which might have affected the results and could hence be considered a limitation. However, this was chosen in order to achieve a study group as homogeneous as possible to be able to draw any conclusions.


The virtual tool helps in the activation of child's various senses such as hearing, vision, touch and also helps in the active involvement of child's emotion to counteract anxiety causing noxious stimuli. Taken together with few prior researches conducted, results suggest that the use of virtual tool may be a beneficial option for patients with mild-to-moderate fear and anxiety associated with dental treatment in children. However, still much research need to be done to obtain a clearer picture of its full potential strength and limitations.


We would like to thank all the children participated in the study and Mr. Sujithran, Statistician, Assistant Professor in Education, St.John's Baptist College of Education, Nedukunnum, Kottayam, Kerala, India, for helping us with the statistical analysis. Sincere thanks to COSMOS Computer Co LLC, UAE for developing the required App for the study.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


1Klingberg G, Broberg AG. Dental fear/anxiety and dental behaviour management problems in children and adolescents: A review of prevalence and concomitant psychological factors. Int J Paediatr Dent 2007;17:391-406.
2Wright GZ, Kupietzky A. Behaviour Management in Dentistry for Children. 2nd ed. US: Wiley Blackwell Publishers; 2014. p. 24-5.
3Buchanan H, Niven N. Validation of facial image scale to assess child dental anxiety. Int J Paediatr Dent 2002;12:47-52.
4Suprabha BS, Arathi R, Shwetha C, Ramya S. Child dental fear and behaviour: The role of environmental factors in a hospital cohort. J Indian Soc Pedod Prev Dent 2011;29:95-101.
5Aminabadi NA, Erfanparast L, Sohrabi A, Oskouei SG, 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.
6Sullivan C, Schneider PE, Musselman RJ, Dummett CO Jr., Gardiner D. The effect of virtual reality during dental treatment on child anxiety and behavior. ASDC J Dent Child 2000;67:193-6, 160-1.
7Venham LL, Goldstein M, Gaulin-Kremer E, Peteros K, Cohan J, Fairbanks J, et al. Effectiveness of a distraction technique in managing young dental patients. Pediatr Dent 1981;3:7-11.
8Pfefferle JC, Machen JB, Fields HW, Posnick WR. Child behavior in the dental setting relative to parental presence. Pediatr Dent 1982;4:311-6.
9Melamed BG, Bennett CG, Jerrell G, Ross SL, Bush JP, Hill C, et al. Dentists' behavior management as it affects compliance and fear in pediatric patients. J Am Dent Assoc 1983;106:324-30.
10Seyrek SK, Corah NL, Pace LF. Comparison of three distraction techniques in reducing stress in dental patients. J Am Dent Assoc 1984;108:327-9.
11Allen KD, Stokes TF. Use of escape and reward in the management of young children during dental treatment. J Appl Behav Anal 1987;20:381-90.
12Greenbaum PE, Turner C, Cook EW, Melamed BG. Dentists' voice control: Effects on children's disruptive and affective behavior. J Health Psychol 1990;9:546-58.
13Shah HA, Nanjunda Swamy KV, Kulkarni S, Choubey S. Evaluation of dental anxiety and hemodynamic changes (Sympatho-Adrenal Response) during various dental procedures using smartphone applications v/s traditional behavior management techniques in pediatric patients. Int J Appl Res 2017;3:429-33.
14Gaber AE, Khalil AM, Talaat DM. The impact of gender on child dental anxiety in a sample of Egyptian children (a cross-sectional study). Alex Dent J 2018;43:1-5.
15Mccarthy FM. A clinical study of blood pressure responses to epinephrine-containing local anesthetic solutions. J Dent Res 1957;36:132-41.
16Leivseth L, Nilsen TI, Mai XM, Johnsen R, Langhammer A. Lung function and anxiety in association with dyspnoea: The HUNT study. Respir Med 2012;106:1148-57.
17von Leupoldt A, Chan PY, Bradley MM, Lang PJ, Davenport PW. The impact of anxiety on the neural processing of respiratory sensations. Neuroimage 2011;55:247-52.
18Paulus MP. The breathing conundrum-interoceptive sensitivity and anxiety. J Depress Anxiety 2013;3:315-20.
19Yelderman M, William N. Evaluation of pulse oximetry. J Anesth 1983;59:349-52.
20Mitrakul K, Asvanund Y, Arunakul M, Paka-Akekaphat S. Effect of audiovisual eyeglasses during dental treatment in 5–8 year-old children. Eur J Paediatr Dent 2015;16:239-45.
21Ram D, Shapira J, Holan G, Magora F, Cohen S, Davidovich E, et al. Audiovisual video eyeglass distraction during dental treatment in children. Quintessence Int 2010;41:673-9.