|Year : 2018 | Volume
| Issue : 1 | Page : 76-81
RMS tactile scale: An innovative tactile anxiety scale for visually impaired children
Raghavendra M Shetty1, Trisha R Gadekar2
1 Department of Preventive and Pediatric Dentistry, College of Dentistry, Gulf Medical University, Ajman, United Arab Emirates
2 Department of Pedodontics and Preventive Dentistry, Chhattisgarh Dental College and Research Institute, Rajnandgaon, Chhattisgarh, India
|Date of Web Publication||28-Mar-2018|
Dr. Raghavendra M Shetty
College of Dentistry, Gulf Medical University, P. O. Box: 4184, Ajman
United Arab Emirates
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Introduction: Behavior guidance is considered to be the backbone of pediatric dentistry which differentiates us from the other fields in dental sciences. Anxiety and fear being the primary concern in pediatric patients, has to be taken into consideration for the visually impaired children too. In the present study, an innovative anxiety scale RMS tactile scale (RMS-TS) was designed for the visually impaired children. Introducing newer concept other than Braille in the dental clinic for such patients can help in coping up and bringing out positive behavior in the special children. Aims and Objective: The study aimed to validate and assess the efficacy of RMS-TS for visually impaired child and compare it with modified dental anxiety scale (MDAS) and Braille scale. Materials and Methods: A total of hundred children of age 12–15 years from the special school were selected for the study. MDAS, RMS-TS, and Braille scale were used to determine the pretreatment anxiety scores in the visually impaired children. Results: The validity of the RMS-TS in the pretreatment anxiety in the assessment of child's dental anxiety is supported by its strong correlation with both the scales. Conclusions: The RMS-TS can be reliable anxiety assessment scale for measuring child's dental anxiety in visually impaired children. It can be used alone or in combination with other methods to improve assessment of dental anxiety.
Keywords: Anxiety scale, braille, modified dental anxiety scale, RMS-tactile scale, tactile scale, visually impaired child
|How to cite this article:|
Shetty RM, Gadekar TR. RMS tactile scale: An innovative tactile anxiety scale for visually impaired children. J Indian Soc Pedod Prev Dent 2018;36:76-81
|How to cite this URL:|
Shetty RM, Gadekar TR. RMS tactile scale: An innovative tactile anxiety scale for visually impaired children. J Indian Soc Pedod Prev Dent [serial online] 2018 [cited 2022 Aug 14];36:76-81. Available from: http://www.jisppd.com/text.asp?2018/36/1/76/228749
| Introduction|| |
Dental anxiety can be defined as the patient's response specific to the dental situation. The era of modern science has witnessed tremendous advancements in the field of pain control and patient management. Despite the advances in the child management, anxiety related to dental treatment and the fear of pain associated with the treatment remain widespread among the population. The uncooperative behavior is attributed to the child's behavioral manifestation of anxiety which by in turn will delay the treatment or affect the quality of care. Studies have found that uncooperative and anxious children tend to avoid dental care and they show worse oral health condition as compared to the less anxious and more cooperative peers. Globally, total visual impairment affects more than 15 million people in the world. With 7.8 million blind people in India, the country accounts for 20.5% of the 39 million blind population across the globe. The prevalence of childhood blindness is stated to be 0.17%, and the major causes of the blindness seen apart from nutritive deficiencies included congenital eye anomalies (16.7%) and retinal degeneration (16.7%) in southern parts of Andhra Pradesh. Menacker and Batshaw reported that the overall incidence of blindness in children is about 1 in 3000, 46% of these children being born blind, and an additional 38% lost their sight before the age of 1 year. Visually impaired children face problems with learning and behaviors; in such cases, dentists have a challenging responsibility to gain their cooperation and reach the best treatment. To ensure the acceptance of dental care in visually impaired children, appropriate behavior management strategy should be applied. Blind people particularly excel remarkably in complex tactile tasks.
In past, dental anxiety in normal children has been evaluated by various techniques such as physiological measures (pulse rate, blood pressure, muscle tension), projective techniques (children's dental fear picture test), psychological test such as Corah's dental anxiety scale, modified child dental anxiety scale (MDAS), and RMS pictorial scale (RMS-PS). Although Braille is a common tool used to educate the visually impaired children, there is no evidence of anxiety scale designed using braille; also, there is no existence of anxiety scale for visually impaired children reported in the literature. An innovative scale keeping in mind the needs of visually impaired children was designed and named RMS-tactile scale (RMS Tactile Scale Patented – Ref: No. 201741038533/CHE/2017) which is a modified version of RMS-PS  using tactile sense.
Hence, the aims of this paper were in 3-folds – first, to assess the anxiety levels of visually impaired children by three different scales; second, to compare the relationship between these three scales, and finally, to confirm the validity and reliability of RMS-TS.
| Materials and Methods|| |
A total of hundred visually impaired children with no past dental experience between 10 and 15 years of age were selected from special schools for visually impaired of Chhattisgarh state. The study was approved by the institutional ethical committee. Information regarding the study was provided to the children and caretakers, and the consents were obtained. Children belonging to Category 5 (completely blind) as per World Health Organization classification  and with no previous dental visit were included in the study.
The selected children were asked about their feelings during different dental situations using a set of five questions. The same set of questions were asked for all the scales, and similar scoring pattern was used in the study [Table 1].
Child's anxiety levels were measured using three different scales.
Modified dental anxiety scale
The MDAS is a brief, five-item questionnaire consisting of questions regarding dental situation with a consistent answering scheme for each item ranging from “not anxious” to “extremely anxious” (1-Not anxious, 2-Slightly anxious, 3-Fairly anxious, 4-Very anxious, 5-Extremely anxious). It is summed together to construct a Likert scale with a minimum score of 5 and a maximum of 25. The cutoff if 19 or above indicates a highly dentally anxious patient, possibly dentally phobic.
RMS tactile scale
It is a new anxiety rating scale designed in the Department of Pedodontics and Preventive Dentistry, where the study was conducted. The RMS-TS consists of a row of five expression carved faces with commonly seen expressions ranging from not anxious to extremely anxious (1-Not anxious, 2-Slightly anxious, 3-Fairly anxious, 4-Very anxious, 5-Extremely anxious) [Figure 1].
Initially, a pilot study was conducted using moulded clay material which gave us the positive results. The children were able to differentiate between a smiling and a crying face. So the final scale was fabricated using a fiber material and minute details of each expression such as teeth while smiling, tears while crying, elevations and depressions of cheeks were taken into consideration. After fabrication, the faces were painted. Test-retest reliability was examined by re-administering RMS-TS after 2 h on the initially interviewed half of the sample. Test-retest reliability was assessed using intraclass correlation coefficients (ICC). The reliability for RMS-TS in visually impaired children was found to 0.83.
The faces were circulated among the children 10 min before the start of the particular session to get familiarized with the various faces. The children were asked to choose the face by using their tactile sense as a guide for determining the expressions they feel at that moment when the questions were asked [Figure 2]. The expressions were rated from 1 to 5 (1-Not anxious, 2-Slightly anxious, 3-Fairly anxious, 4-Very anxious, 5-Extremely anxious). It was summed together to construct a Likert scale with a minimum score of 5 and a maximum of 25. Cutoff if 19 or above indicates a highly dentally anxious patient, possibly dentally phobic.
The last scale which was used as an anxiety measure tool was designed in the Braille press. The questions regarding dental situation with a consistent answering scheme for each item ranging from “not anxious” to “extremely anxious” was exactly the same as MDAS with only difference being that it was typed on a Braille sheet. The sentences were typed in English as well as in Hindi. Reliability of Braille scale in visually impaired children was assessed using test-retest reliability analysis. Test-retest reliability was examined by readministering Braille scale after 2 h on the initially interviewed half of the sample. Test-retest reliability was assessed using ICC. The reliability for Braille scale in visually impaired children for both English and Hindi was found to 0.85, where an ICC of more than 0.6 is considered satisfactory.
All the children included in the study were asked to read the Braille sheets and choose one answer to the question asked (1-Not anxious, 2-Slightly anxious, 3-Fairly anxious, 4-Very anxious, 5-Extremely anxious). Each of the answers was summed together to construct a Likert scale with a minimum score of 5 and a maximum of 25. The cutoff if 19 or above indicates a highly dentally anxious patient, possibly dentally phobic.
The anxiety level was measured using all the three scales one after the other in a sequential manner with a break of 15 min in between the scales used. The first scale to be used was MDAS followed by RMS-TS. The Braille scale was given to the children after RMS-TS so as to prevent the bias of knowing the answers already. Six children were excluded from the study, as they were not able to read Braille or had some difficulty in reading. The final sample consisted of ninety-four children.
| Results|| |
Among 94 children, 49 were boys and 45 were girls. Among 28 children in the age group of 10–12 years, the mean age of boys and girls was found to be 11.07 ± 0.83 and 11.64 ± 0.63, respectively, and in 66 children of age group of 13–15 years, the mean age was found to be 14.0 ± 0.8 and 14.03 ± 0.75 and the difference was found to be nonsignificant [Table 2].
The mean anxiety scores of males and females in RMS-TS, MDAS, and Braille anxiety rating scales were tabulated. However, no statistical difference of mean anxiety scores between samples was seen in any of the anxiety rating scales [Table 3].
Correlation of the RMS-tactile scale with modified dental anxiety scale and braille scale
A measure of the applicability of a psychometric instrument may be evaluated by its degree of correlation with another psychometric instrument designed to measure basically the same phenomenon. It is reported that validity, whether the instrument measures what it intends to, can be assessed by correlating the instrument with another instrument designed to measure the same phenomenon. Spearman's correlation test was performed as a measure of similarity of anxiousness on two scales at different stages. A strong correlation was found between RMS-TS and MDAS (Spearman's correlation value = 0.97, P < 0.0001) which indicates that RMS-TS can measure the anxiety in the similar manner as MDAS. On similar lines, a strong correlation was observed between RMS-TS and Braille scale (Spearman's correlation value = 0.89, P < 0.0001). A strong correlation was observed between Braille scale and MDAS (Spearman's correlation value = 0.88, P < 0.0001) [Table 4]. The cut off value of 19 has nearly same percentile value (95th) indicating that the dental anxiety by three methods was very much similar [Figure 3].
Choice of scale by children
All the children included in the study were asked to choose the most preferable anxiety rating scales which they found easy to understand and liked the most. About 63.83% of children found RMS-TS as the preferable one, whereas 27.66% children found Braille Scale as their choice with only 8.51% of children selected MDAS as the preferred scale [Figure 4].
| Discussion|| |
Pediatric dentistry has been identified for decades as the specialty which is responsible for the development, research and expertise in the area of behavior guidance associated with the dental care of children in dental settings. Visiting the dentist remains stressful to many children which affect their behavior during treatment. Behavior guidance is considered to be the backbone of pediatric dentistry which differentiates us from the other fields. Managing medically compromised children, especially the visually impaired children proves to be a challenge for the pediatric dentist. Visually impaired population forms a significant proportion of this underprivileged one. Visual impairment has an impact on oral health through physical, social, or informational barriers related to impairment, attendant medical condition (and associated medical disorders), or a lack of customized information. Furthermore, the anxiety levels of the adolescents with visual impairment are significantly higher than those of the sighted ones. Although the dental anxiety in visually impaired children has not been tested, knowing their anxiety levels will help the pediatric dentist to follow the proper behavior guidance techniques. Hence, the focus of the present study was to specially design an anxiety scale for visually impaired children and to check its reliability.
MDAS is the most frequently used dental anxiety questionnaire in the United Kingdom  and does not increase patient fears when completed. Existing data suggest that completion of the questionnaire can significantly reduce state anxiety in the practice setting. It has good psychometric properties, it is relatively quick to complete, and scoring is easy., A cutoff value of 19 and above has been determined empirically  to indicate high dental anxiety that may require special attention by dental personnel hence was used as a standard scale in the present study.
The present study has shown high levels of agreement between the scores of RMS-TS and MDAS' as well as between RMS-TS and Braille Scale in the assessment of child's anxiety. The validity of the RMS-TS in the pretreatment anxiety in the assessment of child's dental anxiety is supported by its strong correlation with both the scales.
People who are blind from birth are able to detect tactile information faster than people with normal vision; the ability to quickly process nonvisual information probably enhances the quality of life of blind individuals who rely to an extraordinary degree on the nonvisual senses. The brain adapts to the absence of vision by accelerating the sense of touch. This might be the reason behind children choosing RMS-TS as the preferred scale. Normally, we assume that verbal scales seem to be the simplest and easiest one for the children, but in our study, the involvement of visually impaired children was more in RMS-TS as when compared to the verbal scale.
RMS-TS may be helpful to visually impaired children as it can improve their cognitive skills by their active involvement as it includes expressions which are most relevant to the child's dental experience. It also can be used for all age groups. The RMS-TS can be captivating not only for the visually impaired but also for the normal healthy kids. In the present study, it was observed that RMS-TS also fulfills the ideal requisites of an anxiety scale suggested by Buchanan.
Very young children lack the cognitive ability to complete difficult questionnaires, and it was observed in our study that 6 children who were excluded from the study as they had difficulty in reading Braille responded well to RMS-TS scale. Therefore, with young visually impaired children, employing RMS-TS can be very beneficial. However, further studies on a larger sample and in different dental anxiety situation have to be carried out.
| Conclusions|| |
The RMS-ts can be reliable anxiety assessment scale for measuring child's dental anxiety in visually impaired children. It can be used alone or in combination with other methods to improve assessment of dental anxiety. It will not only pave the road to satisfactory clinical outcome but also build confidence in visually impaired pediatric patients making the dental visit more cooperative.
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.
| References|| |
Corah NL, Gale EN, Illig SJ. Assessment of a dental anxiety scale. J Am Dent Assoc 1978;97:816-9.
Allen KD, Stark LJ, Rigney BA, Nash DA, Stokes TF. Reinforced practice of children's cooperative behavior during restorative dental treatment. ASDC J Dent Child 1988;55:273-7.
Klingberg G, Berggren U, Carlsson SG, Noren JG. Child dental fear: Cause-related factors and clinical effects. Eur J Oral Sci 1995;103:405-12.
Thylefors B, Négrel AD, Pararajasegaram R, Dadzie KY. Available data on blindness (update 1994) Ophthalmic Epidemiol 1995;2:5-39.
Mariot SP. Global Data on Visual Impairments 2010. WHO/NMH/PBD/12.01. Geneva, Switzerland: WHO; 2012. p. 1-14.
Dandona R, Dandona L. Childhood blindness in India: A population based perspective. Br J Ophthalmol 2003;87:263-5.
Menacker S, Batshaw M. Vision: Our window to the world. In: Batshaw ML, editor. Children with Disabilities. 4th
ed. USA: Paul Brooke's Publishing Company; 2000. p. 211-39.
Law CS, Blain S. Approaching the pediatric dental patient: A review of nonpharmacologic behavior management strategies. J Calif Dent Assoc 2003;31:703-13.
Stevens JC, Foulke E, Patterson MQ. Tactile acuity, aging, and braille reading in long-term blindness. J Exp Psychol Appl 1996;2:91-106.
Sullivan 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.
Klingberg G, Löfqvist LV, Hwang CP. Validity of the children's dental fear picture test (CDFP). Eur J Oral Sci 1995;103:55-60.
Corah NL. Development of a dental anxiety scale. J Dent Res 1969;48:596.
Humphris GM, Morrison T, Lindsay SJ. The modified dental anxiety scale: Validation and United Kingdom norms. Community Dent Health 1995;12:143-50.
Shetty RM, Khandelwal M, Rath S. RMS Pictorial Scale (RMS-PS): An innovative scale for the assessment of child's dental anxiety. J Indian Soc Pedod Prev Dent 2015;33:48-52.
] [Full text]
Buchanan H, Niven N. Validation of a facial image scale to assess child dental anxiety. Int J Paediatr Dent 2002;12:47-52.
Wilson S, Cody WE. An analysis of behavior management papers published in the pediatric dental literature. Pediatr Dent 2005;27:331-8.
Baier K, Milgrom P, Russell S, Mancl L, Yoshida T. Children's fear and behavior in private pediatric dentistry practices. Pediatr Dent 2004;26:316-21.
Jain A, Gupta J, Aggarwal V, Goyal C. To evaluate the comparative status of oral health practices, oral hygiene and periodontal status amongst visually impaired and sighted students. Spec Care Dentist 2013;33:78-84.
Bolat N, Doǧangün B, Yavuz M, Demir T, Kayaalp L. Depression and anxiety levels and self-concept characteristics of adolescents with congenital complete visual impairment. Turk Psikiyatri Derg 2011;22:77-82.
Dailey YM, Humphris GM, Lennon MA. The use of dental anxiety questionnaires: A survey of a group of UK dental practitioners. Br Dent J 2001;190:450-3.
Dailey YM, Humphris GM, Lennon MA. Reducing patients' state anxiety in general dental practice: A randomized controlled trial. J Dent Res 2002;81:319-22.
Newton JT, Edwards JC. Psychometric properties of the modified dental anxiety scale: An independent replication. Community Dent Health 2005;22:40-2.
Humphris GM, Freeman R, Campbell J, Tuutti H, D'Souza V. Further evidence for the reliability and validity of the Modified Dental Anxiety Scale. Int Dent J 2000;50:367-70.
Bhattacharjee A, Ye AJ, Lisak JA, Vargas MG, Goldreich D. Vibrotactile masking experiments reveal accelerated somatosensory processing in congenitally blind braille readers. J Neurosci 2010;30:14288-98.
Buchanan H. Development of a computerised dental anxiety scale for children: Validation and reliability. Br Dent J 2005;199:359-62.
Aartman IH, Van Everdingen TA, Hoogstraten J, Schuurs AH. Appraisal of behavioural measurement techniques for assessing dental anxiety and fear in children: A review. J Psychopathol Behav Assess 1996;18:153-71.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4]