ANXIETY MANAGEMENT STRATEGIES IN REDUCING ANXIETY LEVEL AMONG PEDIATRIC DENTAL PATIENTS

Transcription

1 ANXIETY MANAGEMENT STRATEGIES IN REDUCING ANXIETY LEVEL AMONG PEDIATRIC DENTAL PATIENTS 1 CRIS ANNE M. DAVID, 2 SHIRLEY S. WONG Student of Centro Escolar University Graduate School, Faculty Centro Escolar University Graduate School 1 anne_daviddmd@yahoo.com, 2 sswong@ceu.edu.ph Abstract - Dental anxiety is the main reason why patient avoids and cancels dental appointments. There are different anxiety management strategies that can be performed to reduce dental anxiety especially in pediatric patients. This study compared the different anxiety management strategies in reducing anxiety level of pediatric patients. Dental clinicians employed non-pharmacological strategies namely guided imagery, distraction, tell-show-do, modeling and positive reinforcement when they have manage their anxious pediatric patients. Pulse oximeter was the tool used as indicator of anxiety levels that were recorded from the start of the dental appointment, during the treatment (after the anxiety management strategy), and after the treatment. Subjects of this study belonged to the pediatric dental category. Pediatric patients were chosen through stratified sampling technique. Subjects were grouped into five according to anxiety management strategies done by the dental clinicians to their respective pediatric patients. Another group of sample subjects were assigned as control group by which no anxiety management strategy was done prior to dental treatment. Comparison of the data were statistically computed and represented by t-test and ANOVA. Although the results of some studies concluded that Tell-Show-Do is the most effective non-pharmacological anxiety management strategy, it is also reflected in this study with a p-value of which is less than 0.05 indicates significant difference among other anxiety management strategies. However, other anxiety management strategies were also effective at different extent. This study recommends the dental clinicians should practice proper anxiety management strategies when dealing with anxious dental patients, not only to rely on pharmacologic techniques that can compromise the health of the patients. Index Terms - Anxiety management, pulse oximeter, dental phobia, pediatric I. INTRODUCTION In dentistry, anxiety is categorized into two: Dental phobia and dental anxiety. A person with dental phobia tends to avoid treatment maybe because of unpleasant experience in the past. Dental anxiety, by contrast, relates to the psychological and physiological variations of a non-pathological fear response to a dentist s appointment or treatment. Individuals who cancels, avoids, or postpones dental visits are the anxious patients [1]. It is a major dilemma in pediatric dental practice and it exists in a considerable proportion of children and adolescents. About 6-15% of the world's adult population avoids dental care due to dental anxiety and dental phobia [2]. The catastrophic result of dental anxiety is severe deterioration of the patient's oral health and it is considered as an epidemiologic challenge to the dental professionals. Younger people are more anxious than older ones, as well as females are more anxious than males [3]. Dental students especially those in clinical years are less anxious compared to non-dental students [4]. Dental clinicians confidently performs dental procedures especially those without the use of drills and needles but they are weak in patient management [5]. Children normally are anxious during their first dental visits and anxiety management strategies plays an important role in the success of the dental treatment. Dental clinicians can try performing the different anxiety management strategies to overcome their patient management skills. On the part of the anxious dental patient, how the dentist will handle them during the treatment will make or break their positive thoughts about dental health. The experience of the patient on the first dental visit will shape their behavior on the subsequent visits. II. METHODS The researcher utilized experimental method of research and participants were placed into six groups. The five groups were assigned as experimental group and they conducted an intervention particularly a specific Anxiety Management Strategy. The 6 th group was assigned as the control group wherein no intervention or no Anxiety Management Strategy was used. The study was conducted in CEU Malolos Dental Infirmary located at CEU Malolos South Wing, Dentistry Building. Centro Escolar University-Malolos. It is exactly located at Km 44, Longos, City of Malolos, Bulacan, about 34 kilometers away from Manila, Philippines. The subjects of the study are the preschool children ages 5 to 7 years old, male and female, who had their first dental visit. They were physically healthy during the time when they sought dental treatment at CEU Malolos Dental Infirmary. Their guardians were with them but only stayed at Patient s Waiting Area during the course of treatment. 13

2 The subjects of the study were selected using Stratified Sampling Technique. The subjects were divided into six groups where 5 groups are according to the specific Anxiety Management Strategy and one group is the experimental or control group. The six groups were formed out of the strata which were divided from the population. The groups were involved in this study is composed of same numbers of male in female in each groups and same number of subjects in an age group with the corresponding similarity in gender with the other groups. The only difference of the experimental group is that no anxiety management strategy was done on the subjects. After the initial anxiety level was measured through pulse oximeter, the treatment procedure was done immediately. The researcher determined the sample size using the power analysis. Power analysis for a one-way ANOVA with 6 groups was conducted in G*Power to determine a sufficient sample size using an alpha of 0.05, a power of 0.80, and a large effect size (f = 0.40). Using this formula, the desired sample size is 96, or 16 subjects per group, equality of gender distribution is achieved at the same time. III. PROCEDURES this strategy, the subject will have the idea about the dental procedure to be done on them. Modeling is usually using another child that will serve as a model on the subject that will encourage the subject to behave like the model child while dental procedures are being done. Positive reinforcement uses words of encouragement such as "You can do it!", "You're a brave boy!", "Very Good!", etc. By encouraging the child, he can easily follow instructions during dental procedures. Only 6 dental clinicians have done the experimental study. The lead researcher made sure that proper protocol and all criteria were followed properly and carefully. After doing the assigned anxiety management strategy, a reading of the pulse oximeter was recorded. This was the reading noted during treatment. After the treatment, the pulse oximeter reading was also recorded. The lead researcher was the one responsible for the monitoring and recording of actual pulse oximeter reading. Before the start of the dental treatment, a letter to the respondents as well as the written informed consent were given to the parents or guardians of the subject. Everything about the procedure were explained to them. The initial level of anxiety is determined by the use of the pulse oximeter prior to the application of anxiety management strategy. Anxiety level was measured when the subject has entered the dental infirmary. The anxiety management strategy done depends upon to what strategy was assigned to the dental clinician. Only one dental clinician has done specific anxiety management strategy on one group of pediatric dental patients. There were 6 groups of pediatric dental patients in this study. One group was assigned as the control, by which no anxiety management were done to decrease the subject s dental anxiety. The other 5 groups has done one of the following anxiety management strategies: 1. Guided imagery, 2. Distraction, 3. Tell-show-do, 4. Modeling, and 5. Positive Reinforcement. Guided imagery is done by setting the mind of the subject on the place where they enjoyed being there such as the playground, carnival, beach, etc. The goal is to make the subject imagine that being on a dental treatment is also being in the place where they want. Distraction, nowadays, is done by using gadgets to play with while doing dental procedures. The focus of attention of the subject was on their activities on the gadgets rather than their feeling towards the dental procedures. Tell-show-do was done when the dental clinician will tell what to do on the subject, then showing how it will be done, then the subject also did the same. Through Figure 1 - Diagram of the Experiment IV. RESULTS AND DISCUSSION 1. Anxiety level of the patients before, during, and after the dental procedure Initial Anxiety Level Table 1 shows the mean and standard deviation of the initial anxiety level of the subjects. The highest mean computed under Positive Reinforcement is , followed by Distraction with , Modeling with , Guided imagery with , Tell-Show-Do with , and lowest mean obtained by the control group. Since all the subjects had their first dental visits, it is evident that stimulus 14

3 of fear triggered their anxiety towards dental treatment. In the study among 6-12 years old children found out that the most anxiety provoking situation for them is the time of the clinical oral examination itself rather than when they are in the waiting room, before and after the examination [8]. Moreover, it is suggested that anxiety management strategies should be done prior to dental procedures so that the degree of dental anxiety will reduce and it will be easy for the child to accept the treatment and will become cooperative during the treatment. According to the Stimulus-Response Theory, the stimulus applied in a given situation is directly the same as the response [6]. Dental anxiety ranks fifth among the most commonly feared situations for individuals [7] and it is manifested by the increased in heart rate [8]. According to National Institute of Health in 2013, a normal pulse rate is in between beats per minute, beyond the normal range indicates anxiety [9]. The data showed a mean heart rate of more than 100 beats per minute among all the groups by which it can be concluded that the subjects are really anxious. Although no dental management strategy was employed during the recordings of initial anxiety level, the group where the subjects belonged does not have an effect on the results of the initial anxiety level. It was just happened that the mean heart rate of the subjects under Positive Reinforcement showed the highest among the other groups. Anxiety Level During Dental Treatment Table 2 shows the mean and standard deviation of the anxiety level of the subjects during dental treatment. In this stage of the experiment, anxiety management strategies were employed on the five groups depending on what strategy was assigned on each group. Among all the groups, Tell-Show-Do showed the least heart rate among the other groups with the mean score of and the Positive Reinforcement group showed the most heart rate which is , followed by the control group which is It is showed in the data that after doing the Positive Reinforcement strategy, the mean heart rate of the subjects from that group are still beyond the normal and considered to be still anxious. The mean heart rate of the subjects in control group is somehow still at the border of a normal heart rate. Since there is no anxiety management done among the subjects of the control group, it is not expected that the heart rate of the subjects will changed remarkably. Tell-show-do and material reinforcement are the two most effective non-pharmacologic anxiety management strategies among pediatric patients in Israel [10]. Although aside from Tell-Show-Do and Positive Reinforcement, there are still other anxiety management strategies that are universally acceptable such as the desensitization, non-verbal communication, modeling and distraction [11]. Anxiety Level After the Treatment Table 3 shows the mean and standard deviation of the anxiety level of the subject after the dental treatment. The group with a least heart rate still belongs to the Tell-Show-Do with a mean of Positive Reinforcement ranks the meanest heart rate, followed by the control group. Even without anxiety management strategy, the degree of anxiety reduces considerably after facing the stressful factor which is during the dental procedure itself [8]. Anxiety level after the dental procedure reflects how the child thought about having dental procedure and how the clinician has instill positive attitude towards dental health among pediatric patients. Those children who were not manage properly during dental procedure would still be anxious after the dental treatment and will have number of negative thought about dental treatment [12]. 2. Comparison of dental anxiety of patients who underwent anxiety management compared to those who did not. During Dental Treatment Table 4 shows comparison of anxiety level of patients who underwent anxiety management compared to those who did not during dental procedures. Control group obtained a p-value equal to which is 15

4 greater than 0.05 which indicates no significant difference when initial anxiety level of the group was computed with the anxiety level of the subjects during dental procedure. The five groups representing the different anxiety management strategies obtained a p-value less than 0.01 which indicates very significant difference. Data recorded during dental procedures reflects significant effect of the anxiety management strategy. A significant effect shows the effectivity of the anxiety management strategy in reducing anxiety levels rather than those group which did not employ any strategy. of less than 0.01, those groups with anxiety management strategies done are not comparable with the control group which has a p-value of greater than 0.05 indicates no significant difference. The perception of pain or being hurt by the drill or injection provoked the highest anxiety during dental setting [13]. The assessment of dental anxiety before dental treatment will help the clinician to facilitate proper strategy for anxiety management [14]. So therefore, managing dental anxiety plays a major role in the success of dental treatment. After Dental Treatment Table 5 shows comparison of comparison of anxiety level of patients who underwent anxiety management compared to those who did not after the dental procedures. It also shows a very significant difference to those groups with anxiety management strategies done on anxious pediatric dental patient. Computing the difference of the initial anxiety level and the anxiety level after the dental treatment, with a p-value Depending on clinical situations, dental anxiety can be managed by pharmacological and non-pharmacological strategies [15]. In this study, clinical situation involves pediatric patient who will undergo dental treatment for the first time. Since dental clinicians are the one who will do the dental procedures on the subjects, the strategies that they can only do are the non-pharmacological ones which are based on behavior shaping. Pharmacologic techniques in dental anxiety management can also result in positive response of the patient towards dental treatment but can only be done by those with proper license and training. 3. Most effective anxiety management strategies in reducing anxiety level of pediatric patient. Guided imagery Table 6 shows the anxiety levels of the subjects before, during, and after treatment under Guided Imagery group. The mean initial anxiety level is , mean anxiety level during dental treatment is 97.63, and the mean anxiety level after dental treatment is Data shows that the initial anxiety level of this group is beyond normal ( beats per minute) which 16

5 indicates that the subjects were anxious from the time they were seated in the dental chair. During and after dental treatment, the anxiety levels remarkably reduced because of conditioning the mind of the subjects that they were in the place they want to be like the carnival, playground, beach, etc. That is how guided imagery strategy was employed on the subjects. Table 9 shows the comparison of the initial anxiety level to the anxiety level during dental treatment and it is also compared with anxiety level after dental treatment. The data obtained a p-value of less than 0.01 which indicates very significant difference. The subjects were effectively distracted using gadgets such the ipads and tablets as their mean heart rate remarkably changes into a level when they were not anxious anymore. Distraction is an anxiety management strategy of diverting the patient s attention from what may be perceived as an unpleasant procedure (Appukuttan, 2016). Table 7 shows comparison of the initial anxiety level with the anxiety level during dental treatment and also with anxiety level after dental treatment. The computation obtained a p-value less than 0.01 which indicates significant difference of the heart rate on the different stage of the experiment. Guided imagery strategy on anxious children significantly reduced the pain associated with invasive dental procedures [16]. By conditioning their mind on the places and situations where they want to will deviates their mind from thinking about painful dental procedures. Distraction Table 8 shows the mean anxiety levels of the subjects before, during, and after dental treatment as this group was managed using distraction strategy. The mean initial anxiety level is , still beyond normal, indicates that the subjects were anxious. After doing the anxiety management, it is evidently shows decrease in anxiousness during the dental treatment with a mean anxiety level of The anxiety level further decrease after dental treatment with a mean of Distraction strategy can effectively relief anxiety through cognitive and motor absorption [17]. The active distraction provided by playing a video game can be effective anxiety-reducing treatments. Moreover, distraction were consistently successful in reducing stress in moderately anxious patients [18]. Another study found out that music distraction is also effective in decreasing anxiety level of pediatric patients [19]. Modeling The anxiety levels of the subjects under Modeling group are shown on table 10. The mean initial anxiety level is which indicates that the subjects were anxious before the treatment because of the mean heart rate beyond normal. The mean anxiety level during and after treatment are and respectively. It shows the effect of modeling anxiety management strategy that can change the heart rate of the children from anxious level to normal. The comparison of the anxiety levels before, during, and after treatment of the subjects belonged to modeling group are shown in table 11. With a p-value 17

6 of less than 0.01 for both initial anxiety level compared to anxiety level during dental treatment as well as initial anxiety level compared to anxiety level after dental treatment indicates very significant difference. It means that the modeling strategy is effective in reducing anxiety level of pediatric dental patients. Initial anxiety levels compared with anxiety levels during dental treatment and after dental treatment under Positive Reinforcement group were shown in table 13. Even though the data from table 12 showed that the mean heart rates in all stages of the experiment were beyond normal, meaning that the subjects were still anxious, statistically, this group obtained a p-value of less than 0.01 which indicates that there is a very significant difference in the anxiety level during and after the dental treatment in reference to the initial anxiety level. Positive reinforcement is also an effective anxiety management strategy in reducing anxiety level among pediatric dental patients. Modeling is an anxiety management strategy that can be achieved through observation of a dental procedure, either by viewing a videotaped model who is demonstrating appropriate cooperative behavior in the dental setting or through observation of an actual successful dental procedure [15]. In this experiment, it is done through observation of other child on the other dental chair that was very cooperative while the clinician is doing dental treatment on him. Modeling is one of the universally applied anxiety management strategies [11]. Modeling strategy offers dentists a means of reducing fear in child patients of all ages [20]. Children who received modeling techniques had lower anxiety levels reflected by their lower heart rates [21]. Positive Reinforcement Table 12 shows the initial anxiety levels as well as anxiety levels during and after treatment of the subjects belonged to Positive Reinforcement group. The mean initial heart rate is , and the mean anxiety levels during and after dental treatment are and respectively. Data showed that in all stages of the experiment, majority of the subjects were still anxious considering the mean heart rates are still beyond the normal but it does not mean that Positive Reinforcement strategy is not effective in reducing anxiety level of the pediatric dental patients. Positive Reinforcement is also one of the universally applied anxiety management strategies [11]. It is an anxiety management strategy that is done by offering desirable effects or consequences for a behavior with the intention of increasing the chance of that behavior being repeated in the future [15]. Tell-Show-Do Table 14 shows the mean heart rates of the subjects who were managed using Tell-Show-Do. The mean initial heart rate is , the mean heart rates during and after dental treatment are and respectively. The mean initial heart still at the border line of a normal range. The mean heart rates during treatment and after treatment are within the range of normal heart rate which is 60 to 100 beats per minute. Table 15 shows the comparison of initial anxiety levels with anxiety levels during dental treatment as well as anxiety levels after dental treatment for those subjects who underwent Tell-Show-Do anxiety management strategy. Two pairs of comparison both obtained a p-value of less than 0.01 which 18

7 indicates very significant difference of both anxiety level during and after dental treatment in reference to initial anxiety level. p-value of less than 0.05 which indicates significant difference in the anxiety level during dental treatment and a p-value of less than 0.05 which also indicates significant difference in the anxiety level after dental treatment. Tell-Show-Do is an anxiety management strategy when the dentist uses euphemisms to explain all dental procedures at a child s level of understanding [6]. It is also one of the universally applied anxiety management strategies [11]. In 2003, a study in Israel has proven that Tell-Show-Do together with material reinforcement are the two most effective non-pharmacologic anxiety management strategies [10]. The clinician in-charged for this group did the step-by-step procedure in doing the anxiety management strategy. The child must be familiar first of what the dental treatment is all about by demonstrating how to do it and let the child do it on how she understands the concept of such dental treatment. Comparison of Different Anxiety Management Strategies In the previous tables, it was showed that there is a difference in anxiety levels on subjects who underwent anxiety management strategies in comparison with those group who did not (control group). It presents the effectiveness of the different anxiety management strategies in reducing anxiety levels among pediatric dental patients. The question now is which among the different anxiety management strategies is most effective than the other? Table 16 shows the comparison of the different anxiety management strategies on their effectivity in reducing the anxiety levels of pediatric dental patients. Statistically, all the anxiety management strategies are comparable since they individually obtained a p-value of less than 0.01 which indicates very significant difference when the initial anxiety level is compared with anxiety level during and after dental treatment. But looking at the data below, Tell-Show-Do strategy has the least mean value, from the anxiety level during dental treatment and after dental treatment among the other anxiety management strategies. It was being compared to Positive Reinforcement which has the meanest value of during treatment and after treatment. Their comparison obtained a Non-pharmacologic techniques or the behavior management techniques are widely acceptable in all dentistry practice. The universally applied anxiety management strategies are: tell-show-do, desensitization, non-verbal communication, positive reinforcement, modeling and distraction [11]. Guided imagery also significantly reduced the pain associated with invasive dental procedures [16]. The different anxiety management strategies are all effective in reducing anxiety among pediatric patients. Each has their own strengths that many factors should be given in consideration. Since the strategies are more about behavioral shaping, the convincing ability of the clinician should also be considered. One person is effective in doing a particular anxiety management. The characteristics of the pediatric patient can also be considered. How the child reacts on a particular situation, and even how the dentistry is being introduced to the child also will become a factor in the effectiveness of the anxiety management strategy. Among the different anxiety management strategy, the Tell-Show-Do strategy will let the pediatric patient to touch and simulate the dental treatment that will be done to him that is why it the most effective anxiety management strategy as reflected on different studies as well as in this research. CONCLUSIONS This study concludes that the different anxiety management strategies have a very significant difference in reducing anxiety level among pediatric dental patient compared to those who were not given such interventions. Moreover, among the different anxiety management strategies, Tell-Show-Do presents a significant difference compared to other strategies such as the guided imagery, distraction, modeling, and positive reinforcement. 19

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