A comparison between audio and audiovisual distraction techniques in managing anxious pediatric dental patients

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1 A comparison between audio and audiovisual distraction techniques in managing anxious pediatric dental patients PRABHAKAR A. R. a, MARWAH N. b, RAJU O. S. c Abstract ISSN Pain is not the sole reason for fear of dentistry. Anxiety or the fear of unknown during dental treatment is a major factor and it has been the major concern for dentists for a long time. Therefore, the main aim of this study was to evaluate and compare the two distraction techniques, viz, audio distraction and audiovisual distraction, in management of anxious pediatric dental patients. Sixty children aged between 4-8 years were divided into three groups. Each child had four dental visits - screening visit, prophylaxis visit, cavity preparation and restoration visit, and extraction visit. Child s anxiety level in each visit was assessed using a combination of four measures: Venham s picture test, Venham s rating of clinical anxiety, pulse rate, and oxygen saturation. The values obtained were tabulated and subjected to statistical analysis. It was concluded that audiovisual distraction technique was more effective in managing anxious pediatric dental patient as compared to audio distraction technique. Keywords: Anxiety, audiovisual distraction, pediatric dental patients Introduction All dentists who treat children occasionally find themselves faced with a fearful child in his/her first visit to the dentist. Considering the awesomeness of dental equipment and the newness of the experience, it is not surprising that the child may be apprehensive. The role of a dentist in managing a child with anxiety, so that a child can become a co-operative patient is twofold - firstly, to control and treat the problem with which the child reports and secondly, to teach the child appropriate ways of managing the anxiety. Dentists have a wide variety of techniques available to them to assist in management of child with anxiety [1] such as tell-show-do, relaxation, distraction, systematic desensitization, modeling, audio analgesia, hypnosis, and behavior rehearsal. Among all these techniques, traditional behavior management techniques such as papoose board and hand over mouth technique can be successful, but the attitude of parents and dental professional towards these techniques is changing, [2] and now nonaversive techniques like distraction are becoming more popular. The success of distraction technique in medical settings and in adult patients is well documented, but there are very few studies done to evaluate the efficacy of distraction technique in pediatric dental patient. a Professor and Head, Department of Pedodontics and Preventive Dentistry, Bapuji Dental College and Hospital, Davangere, Karnataka, b Senior Lecturer, Department of Pedodontics and Preventive Dentistry, Government Dental College, Rohtak, Haryana, c Professor, Department of Pedodontics and Preventive Dentistry, Bapuji Dental College and Hospital, Davangere, Karnataka, India This paper was presented at the 27th ISPPD Conference, Dharwad, December 2006 Therefore, the aim and objective of this study was to evaluate and compare audio distraction and audiovisual distraction in management of anxious pediatric dental patient. Materials and Methods Sixty children aged between 4 and 8 years, with no previous dental experience were selected from patients who came for their first dental visit. Consent was taken from patient s parents on the first visit along with brief medical and dental history of patient. The children were divided into three groups of 20 each. First group was the control group (group A) on whom the treatment was performed under normal dental setup [Figure 1]. The second group (group B) listened to audio presentation through headphones throughout the course of the treatment [Figure 2]. The third group (group C) was shown audiovisual presentation through television during the entire treatment [Figure 3]. Each child had four dental visits - first was the screening visit and the next three were treatment visits during which various treatments were performed on patients such as oral prophylaxis in the second visit, cavity preparation and restoration in the third visit, and extraction after the administration of local anesthesia in the fourth or the last visit. Child s anxiety level in each visit was assessed using a combination of four measures: Venham s picture test, [3] Venham s rating of clinical anxiety, [3] pulse rate and oxygen saturation, [4] which were measured using pulse oximeter (Biosys BPM 200). The values obtained were tabulated and subjected to statistical analysis. 177 J Indian Soc Pedod Prevent Dent - December CMYK

2 Results Tables 1-3 show the mean scores and S.D. of Venham s anxiety scale, pulse rate, and oxygen saturation during the four visits in control group, audio distraction group, and audiovisual distraction groups, respectively. In the control group, there was statistically no significant difference between Venham s anxiety scale ratings during all the four visits. Figure 1: Photograph of a child in normal dental setup prior to treatment (Group A) Figure 2: Photograph of a child in audio distraction setup prior to treatment (Group B) In the audio distraction group, there was a statistically significant difference (P < 0.05) in the Venham s anxiety rating between second and fourth visits i.e., between the prophylaxis and extraction visits, but there was no significant difference between other visits. In the audiovisual distraction group, there was statistically no significant difference between Venham s anxiety scale ratings during all the four visits. In the inter-group comparisons between the control group, audio distraction group, and the audiovisual distraction group, there was statistically no significant difference in Venham s anxiety scale ratings during the four visits. The observations from Table 4 show that although Venham s anxiety scale ratings were lower in audiovisual distraction group, they were not statistically significant and that these ratings were mostly constant during all the visits for a particular group [Table 4]. In the control group, there was a statistically significant difference (P < 0.05) in pulse rate between first and third visits, first and fourth visits, second and third visits, second and fourth visits, and third and fourth visits. In the audio distraction group, a statistically significant difference (P < 0.05) was observed between first and third visits as well as in first and fourth visits. Significant difference (P < 0.01) was also observed between second and fourth visits. There was no statistically significant difference between first and second, and third and fourth visits. In the audiovisual distraction group, a highly significant (P < 0.01) difference in the pulse rate was observed between the following visits i.e. first and third visits, first and fourth visits, second and third visits as well as in second and fourth visits. But there was no difference between first and second or third and fourth visits. In the inter-group comparisons, during the first visit, a statistically significant difference (P < 0.05) was observed between the control group and the audiovisual distraction group. No significant difference was reported between control group and audio distraction group, and between audiovisual distraction group and audio distraction group. Figure 3: Photograph of a child in audiovisual distraction setup prior to treatment (Group C) In the second visit, no statistically significant difference was seen between any of the groups. In the third visit, statistically J Indian Soc Pedod Prevent Dent - December CMYK

3 Table 1: Control group (Group A) Visits Venham s anxiety scale Pulse rate Oxygen saturation (mean score ± S.D.) (mean score ± S.D.) (mean score ± S.D.) 1 (Screening) 1.3 ± ± ± (Prophylaxis) 0.9 ± ± ± (Restoration) 0.9 ± ± ± (Extraction) 1.3 ± ± ± 1.1 Table 2: Audio distraction group (Group B) Visits Venham s anxiety scale Pulse rate Oxygen saturation (mean score ± S.D.) (mean score ± S.D.) (mean score ± S.D.) 1 (Screening) 1.3 ± ± ± (Prophylaxis) 0.9 ± ± ± (Restoration) 1.1 ± ± ± (Extraction) 1.7 ± ± ± 1.2 Table 3: Audiovisual distraction group (Group C) Visits Venham s anxiety scale Pulse rate Oxygen saturation (mean score ± S.D.) (mean score ± S.D.) (mean score ± S.D.) 1 (Screening) 1.0 ± ± ± (Prophylaxis) 0.7 ± ± ± (Restoration) 0.9 ± ± ± (Extraction) 1.1 ± ± ± 0.7 Table 4: Intra- and inter-group comparisons of Venham s anxiety scale Visits Group A Group B Group C Comparison (mean score ± S.D.) (mean score ± S.D.) (mean score ± S.D.) between groups F-value P-value 1 (Screening) 1.3 ± ± ± , NS 2 (Oral prophylaxis) 0.9 ± ± ± , NS 3 (Restoration) 0.9 ± ± ± , NS 4 (Extraction) 1.3 ± ± ± , NS Between visits comparison F = 1.39; P = 0.25, NS F = 2.84; P < 0.05, S F = 1.41; P = 0.30, NS - - 2nd vs 4th; P < 0.05, S One-factor ANOVA; Studentized range test, S - Signifi cant, NS - Not Signifi cant, P < 0.05, Signifi cant; P > 0.05, Not Signifi cant significant difference (P < 0.01) was seen between the control group and the audiovisual distraction group. No significant difference was reported between control group and audio distraction group or between audiovisual distraction group and audio distraction group. In the fourth visit, there was a statistically significant difference (P < 0.01) in pulse rate between the control group and the audiovisual distraction group and also between audio distraction and audiovisual distraction groups. There was no significant difference between control group and audio distraction group. The observations from Table 5 show that the pulse rate increased progressively during all the four visits and was maximum in the last visit. The results also showed that the pulse rate was constantly increasing in all the three groups, but there was relatively less increase in pulse rate in the audiovisual distraction group. A statistical difference (P < 0.05) was seen in the control group between second and fourth visits, but there was no statistically significant difference in oxygen saturation levels between any other groups and also between different visits. The observations from Table 6 show that there was not much change in oxygen saturation in any of the group during any type of treatment visits. Results show that there is statistically no difference between the ratings of Venham s anxiety scale and the levels of oxygen saturation in any of the groups [Graphs 1 and 2]. There was a statistically significant difference (P < 0.01) in the pulse rate between the control group and audiovisual distraction group [Graph 3]. Significant difference (P < 0.05) was also reported between audio distraction and audiovisual distraction groups, but there was no significant difference between control groups and audio distraction groups. The observations from Table J Indian Soc Pedod Prevent Dent - December CMYK

4 Table 5: Intra- and inter-group comparisons of pulse rate Visits Group A Group B Group C Comparison between group (mean PR ± S.D.) (mean PR ± S.D.) (mean PR ± S.D.) F-value A - B A - C B - C (P-value) 1 (Screening) ± ± ± (<0.05, S) NS P < 0.05 NS 2 (Oral prophylaxis) 99.2 ± ± ± (0.36, NS) NS NS NS 3 (Restoration) ± ± ± (<0.01, S) NS P < 0.01 NS 4 (Extraction) ± ± ± (<0.01, S) NS P < 0.01 P < 0.01 F-value F = 18.4; F = 29.0; F = 12.6; (between visits) P < 0.001, HS P < 0.001, HS P < 0.001, HS 1 vs 3,4; 2 vs 3,4; 1 vs 3,4 (P < 0.05); 1 vs 3,4 (P < 0.01); 3 vs 4 (P < 0.05,S) 2 vs 4 (P < 0.01) 2 vs 3,4 (P < 0.01) S - Signifi cant; NS - Not Signifi cant; HS - Highly Signifi cant Table 6: Intra- and inter-group comparisons of oxygen saturation Visits Group A Group B Group C Comparison (mean so 2 ± S.D.) (mean so 2 ± S.D.) (mean so 2 ± S.D.) between groups F-value P-value 1 (Screening) 97.8 ± ± ± , NS 2 (Oral prophylaxis) 98.0 ± ± ± , NS 3 (Restoration) 97.9 ± ± ± , NS 4 (Extraction) 97.2 ± ± ± , NS Comparison between visits F = 2.82; P < 0.05, S F = 2.30; P = 0.08, NS F = 1.31; P = 0.28, NS vs 4; P < S - Signifi cant, NS - Not Signifi cant Graph 1: Intergroup comparison of oxygen saturation Graph 3: Intergroup comparison of pulse rate audiovisual distraction group as compared to control groups and audio distraction groups, but these were not statistically significant. Discussion Graph 2: Intergroup comparison of Venham s anxiety scale ratings reveal that there was significantly less increase in pulse rate in the audiovisual distraction group. The observations also show that ratings of Venham s anxiety scale were also less in The age group of the patients selected for the study was 4-8 years as this is the age group, which shows most disruptive or negative behavior and is most difficult to manage. Venham s picture test, [3] which was used in the study, is among one of the reliable measures of self-reported anxiety in children. [5] Venham s anxiety rating scale [3] is also an effective and reliable means of assessing anxiety in children. [5] Pulse oximeter, which measures the pulse rate and oxygen saturation, is one of the most acceptable methods for measuring the physiological changes [4,6] as it gives continuous J Indian Soc Pedod Prevent Dent - December CMYK

5 Table 7: Combined visits Variable Groups Difference between groups A (control) B (audio) C (audiovisual) F-value P-value A - B A - C B - C Venham s anxiety scale 1.0 ± ± ± , NS Pulse rate ± ± ± <0.001, HS NS P < 0.01 P < 0.05 Oxygen saturation 97.7 ± ± ± , NS NS - Not Signifi cant; HS - Highly Signifi cant percentage measurements of the patient s arterial hemoglobin oxygenation as well as the pulse rate. The observations from this study indicated that Venham s picture test gave statistically inconclusive results, but the choice of the picture by the children was consistent during all the four visits. Despite the inconclusive results, the picture test was an effective measure of the emotional state of the child at that particular instance. This observation was similar to the earlier observations made by Venham et al. [3] and Alwin et al. [7] 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. This was in conjunction with the earlier studies done by Yelderman et al. [4] who had observed a similar kind of pattern. The reason for increased anxiety in the cavity preparation and restoration visits is because of the sound and the sight of the hand piece. This was also observed by Kleinknecht et al. [8] The peak of anxiety in the last visit is due to the highly stressful event of extraction. This finding was also observed by Baldwin. [9] The increase in anxiety in the last visit can also be due to the sight of the injection. The fact that the pulse rate was maximum during the injection phase indicates that increase is psychosomatic in origin. Possibly, the anticipation of injection provides sympathetic stimulation and catecholamine release, which accounts for greater increase in pulse rate. Observations from the results showed that audio distraction did not have a significant effect on reduction of anxiety. This was also observed by Aitken et al. [10] It was also noted that the anxiety ratings in this group were lower as compared to the control group. This may be attributed firstly to the relaxation effect of music, and secondly, because the sound of music will eliminate unpleasant dental sounds such as the sound of handpiece. [11] The results from this study showed that audiovisual distraction was the most effective means of managing the anxiety in children. Although not many studies have shown the effectiveness of audiovisual distraction in managing anxious pediatric dental patients, some studies have shown its effectiveness in managing anxious adult dental patients. [12] It is possible that our results differ because of the different methods and techniques that we have used. Reduction in anxiety in the audiovisual distraction technique may be attributed to a variety of reasons. Firstly, in our study, the patient chose the choice of distraction. According to Klein and Winklestein, [13] this will help the children to gain control over the unpleasant stimulus and give them a feeling of being in a familiar environment. Secondly, the child seeing the audiovisual presentation will have multi-sensory distraction as he/she will tend to concentrate on the TV screen, thereby screening out the sight of dental treatment, [12,14] and the sound of the program will help the child to eliminate the unpleasant dental sounds such as the sound of handpiece. [11] Summary and Conclusion Following conclusions were drawn from the study: 1. Audiovisual distraction technique was more effective in managing anxious pediatric dental patient as compared to audio distraction technique and normal dental setup. 2. Dental anxiety is seen commonly during routine dental procedures and is maximum during the extraction procedure. 3. The patients had an overwhelming response to music presentation and wanted to hear it at their subsequent visits. References 1. Allen KD, Stanley RT, McPherson K. Evaluation of behavior management technology dissemination in pediatric dentistry. Pediatr Dent 1990;12: Lawrence SM, McTigue DJ, Wilson S, Odan JG, Waggener WF, Fields HW Jr. Parental attitude towards behaviour management techniques used in pediatric dentistry. Pediatr Dent 1991;13: Venham L, Bengston D, Cipes M. Children s response to sequential dental visits. J Dent Res 1977;56: Yelderman M, William N. Evaluation of pulse oximetry. J Anesth 1983;59: Newton JT, Buck JD. Anxiety and pain measures in dentistry. J Am Dent Assoc 2000;131: Aka W, Jedrychowski JR. Intra operative and post operative physiologic monitoring practices by pediatric dentists. J Clin Pediatr Dent 1995;19: Alwin NP, Murray JJ, Britton PG. An assessment of dental anxiety in children. Br Dent J 1991;171: Kleinknecht RA, Klepac RK, Alexander LD. Origins and characteristics of fear of dentistry. J Am Dent Assoc 1973;86: Baldwin DC Jr. An investigation of psychologic and behavioral 181 J Indian Soc Pedod Prevent Dent - December CMYK

6 response of dental extractions in children. J Dent Res 1966;45: Aitken JC, Wilson S, Coury D, Moursi AM. The effect of music distraction on pain, anxiety and behaviour in pediatric dental patients. Pediatr Dent 2002;24: Baghdadi ZD. Evaluation of audio analgesia for restorative care in children treated using electronic dental anaesthesia. J Clin Pediatr Dent 2000;25: Seyrek SK, Corah NL, Pace LF. Comparison of three distraction techniques in reducing stress in dental patients. J Am Dent Assoc 1984;108: Klein SA, Winklestein ML. Enhancing pediatric health care with music. J Pediatr Health Care 1996;10: Satoh Y, Nigai E, Kitambura K, Sakamura M, Oleki K, Yokota S, et al. Relaxation effect of an audio visual system on dental patients, Part 2: Palus-amplitude. J Nihon Univ Sch Dent 1995;37: Reprint requests to: Dr. Nikhil Marwah, Department of Pedodontics and Preventive Dentistry, Government Dental College, Rohtak , Haryana, India. dr_nikhilmarwah@rediffmail.com J Indian Soc Pedod Prevent Dent - December CMYK