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Year : 2020  |  Volume : 38  |  Issue : 4  |  Page : 407-412

Effectiveness of distraction techniques in the management of anxious children – A randomized controlled pilot trial

Department of Pedodontics and Preventive Dentistry, KSR Institute of Dental Science and Research, Tiruchengode, Tamil Nadu, India

Date of Submission06-Oct-2020
Date of Decision08-Nov-2020
Date of Acceptance30-Nov-2020
Date of Web Publication5-Jan-2021

Correspondence Address:
Dr. Sharath Asokan
Department of Pedodontics and Preventive Dentistry, KSR Institute of Dental Science and Research, Tiruchengode - 637 215, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JISPPD.JISPPD_435_20

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Aim: The aim was to evaluate and compare the effectiveness of two distraction techniques, magic trick and mobile dental game with tell-show-do (TSD) in the management of anxious children. Methodology: Two hundred and thirty children aged 4–5 years were screened for their baseline anxiety using the Chotta Bheem-Chutki scale. A double-blinded randomized control trial was conducted among 60 children with high anxiety scores. They were randomly divided into three groups. Group 1 received a magic trick distraction technique. Group 2 received a mobile dental game distraction technique. Group 3, the control group received TSD. Readiness to accept the dental treatment and postoperative anxiety scores were recorded. Results: Statistically significant reduction in the anxiety level was seen in children who received magic (P = 0.001), mobile dental game (P < 0.001), and TSD technique (P < 0.001). Based on the readiness to accept dental treatment, there was a statistically significant difference between the three groups (P = 0.025). The children in the mobile group were found to accept the treatment faster compared to the magic and TSD groups. Conclusion: All three techniques were equally effective in reducing the anxiety of children. The mobile dental game was superior to magic trick and TSD in terms of children's readiness to accept dental treatment.

Keywords: Acceptance of treatment, anxiety, distraction technique

How to cite this article:
Asokan S, Geetha Priya P R, Natchiyar S N, Elamathe M. Effectiveness of distraction techniques in the management of anxious children – A randomized controlled pilot trial. J Indian Soc Pedod Prev Dent 2020;38:407-12

How to cite this URL:
Asokan S, Geetha Priya P R, Natchiyar S N, Elamathe M. Effectiveness of distraction techniques in the management of anxious children – A randomized controlled pilot trial. J Indian Soc Pedod Prev Dent [serial online] 2020 [cited 2022 Jun 29];38:407-12. Available from: https://www.jisppd.com/text.asp?2020/38/4/407/306224

   Introduction Top

Anxiety is defined as the fear of the unknown. The first dental visit for children is mostly associated with dental fear, anxiety, and apprehension.[1] This might be due to the exposure of the child to a new dental environment. The child's fearful or uncooperative behavior may impede the effective and efficient delivery of dental care, thereby compromising the quality of treatment to be provided.[2] A persistently negative response pattern may act as a barrier to routine dental care. Hence, it is important to mold the child's attitude toward dentistry in its first dental experience.

Successful pediatric dentistry not only depends on the dentist's technical skills but also on his/her ability to acquire and maintain a child's cooperation which is the key to render treatment.[3] To instill a positive dental attitude and to treat anxious children, many behavior guidance techniques have been used. The American Academy of Pediatric Dentistry has enlisted strategies such as communication, tell-show-do (TSD), voice control, nonverbal communication, positive reinforcement, distraction, parental absence/presence, and advanced behavior guidance such as protective stabilization, sedation, and general anesthesia.[4] The primary objective of any behavior guidance technique is to make the patient happy and comfortable. TSD is a simple technique that dictates that, before anything is done, the child is told what will be done and then shown by some sort of simulation exactly what will happen before the dental procedure is started.[5] TSD is the basic, most commonly used behavior guidance technique that helps the child to cope with dental situations. The child gets familiarized with the dental setting and thereby, its anxiety is reduced.[6] Distraction is the technique of diverting the patient's attention from what may be perceived as an unpleasant procedure.[4] The distraction technique can be active or passive. An active technique involves a child's participation in activities such as virtual reality, interactive toys, guided imagery, controlled breathing, and relaxation. Niharika et al.[7] and Pande et al.[8] found that the virtual reality was effective in reducing dental anxiety in children. Passive techniques rely on a child's observation of an activity rather than making the child directly participate in the activity. It involves activities such as watching television and listening to music.[9] These anxiety-reducing strategies divert the child's attention and help the child sit through dental procedures. Magic is also one of the passive techniques. Magic is “the art of producing illusions as entertainment by the use of sleight of hand, or deceptive devices”. The distraction of the mind may be just as necessary as the distraction of the eye. Magic can be shown to the anxious children before they are seated on the dental chair.[10] An active technique that involves the kinesthetic sensation is playing a mobile game and children like to play with it.[6] Pediatric dentists are always in search of attractive, child-friendly modes of distractions to make the dental visit more pleasant for the child. Hence, the present study was undertaken to evaluate and compare the effectiveness of two distraction techniques, namely magic trick and mobile dental game with TSD, in the management of anxious pediatric dental patients.

   Methodology Top

The reporting of the study has been done according to CONSORT (CONsolidated Standards of Reporting Trials) 2010 guidelines. After obtaining clearance from the Ethical Committee and Institutional Review Board, a double-blinded randomized control trial was conducted to compare the effectiveness of three techniques in the management of anxious children. The sample size estimation for the present pilot study was done using G * Power version software with the significance level set at 5% and the power of the test as 80%. The estimated sample size was 60 children.

A total of 230 children aged 4–5 years from two private kindergarten schools in Tiruchengode, Namakkal district, Tamil Nadu, were screened in their school premises. Children were individually asked the question “How would you feel when you visit the dental clinic for the first time?” They were shown the Chotta Bheem-Chutki scale which has two cards, one for boys with pictures of Chotta Bheem cartoon character and the other for girls with Chutki cartoon character. Each cartoon character expressed six different emotions ranging from happiness to running away in fear. A score of one was assigned to the happy face and six to the unhappy running face.[19] The question was explained to the child in their native language appropriate to the developmental level of the child. Children were asked to choose the cartoon character that mirrored their emotions at that moment. This was recorded as the baseline anxiety score by the secondary investigator. Children with high anxiety scores (score 4–6), with no history of a previous dental visit, with definite indications for oral prophylaxis and consent for participation from parents, were included in this study. From the 110 eligible children, 60 children were randomly selected and divided into three equal groups. The sequence generation and allocation were done using the table of random numbers and closed opaque white envelopes, respectively, by two postgraduate students who were not involved in this study. In the second visit, all the children received their respective behavior guidance from the principal investigator on the school premises, before they had their oral prophylaxis done in the mobile dental van.

Group 1: In this group, children were distracted using an “Acrylic Thumb Light” developed by Ebest Magic Light Up Finger Trick Company. This “Acrylic Thumb Lights” produces the light which could appear and disappear magically.

Group 2: For this group, a mobile dental application “Little Lovely Dentist” developed by Tenlogix Games available on the Google Play Store on the android platform of the smartphones was used. This application gives an idea about the nature of various dental treatments.

Group 3: Conventional TSD technique was performed for the control group. Diagnostic instruments and the scaler unit were shown to the children in this group. They were allowed to touch, feel, and hold the dental instruments. The procedure was explained using euphemisms appropriate to their cognitive capabilities.

All the techniques were performed on the child individually limited to a period of 3–5 min. After receiving the designated behavior guidance strategies, children were asked if they were ready to get into the dental van for dental treatment. Time taken by each child from the end of the behavior guidance technique to the moment he/she was ready to get into the mobile dental van for the treatment was noted using a stopwatch by a trained intern. Ultrasonic scaling was done for all the children and postoperative dental anxiety was assessed using the Chotta Bheem-Chutki scale by the secondary investigator, who was blinded to the randomization process and the intervention received by the children. The analysis of outcomes was carried out using SPSS version 21.0 (IBM SPSS Statistics 21, SPSS South Asia, Bangalore, India) by the statistician who was also blinded. Wilcoxon signed-rank test was used for intragroup comparison and the Kruskal–Wallis test was used for intergroup comparison. To compare the difference between independent groups, post hoc analysis was used. P <0.05 was considered statistically significant.

   Results Top

The recruitment, randomization, and allocation of children in different groups are represented in the CONSORT flow diagram [Figure 1]. There was a statistically significant reduction in the anxiety score from baseline to the postoperative levels in all the three groups, magic (P = 0.001), mobile dental game (P < 0.001), and TSD technique (P < 0.001) as shown in [Table 1]. A maximum reduction in anxiety was seen in the mobile dental game group. However, the intergroup comparison showed no statistically significant difference between the three groups (P = 0.11). The readiness of the child to accept dental treatment is shown in [Table 2]. Children in the mobile dental game group accepted the treatment in a median time of 3 s, whereas the other two groups accepted the treatment in 5 s. The children in the mobile dental game group were ready to accept the dental treatment significantly faster than the other two groups (P = 0.025). Post hoc analysis revealed a significant difference between the magic and mobile dental game group (0.042) and mobile dental game group and TSD group (0.01). However, there was no significant difference between TSD and the magic group (0.64).
Figure 1: CONSORT flow diagram

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Table 1: Intragroup and intergroup comparison of dental anxiety scores

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Table 2: Intragroup and intergroup comparison of readiness to accept the dental treatment

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   Discussion Top

Dental anxiety is the most common reason for not seeking dental care, especially by pediatric patients. It is the emotional condition anteceding a dental appointment that is common in the child's first dental visit.[11] Unpleasant dental experiences occur frequently in anxious and recalcitrant children in opposition to nonanxious children.[12] Hence, anxiety should be addressed from the first dental visit itself as it is very crucial in the development of a positive attitude toward dentistry and the success of the treatment.[1] The first unpleasant experience can lead to irregular dental visits which affect patients' oral health and may increase the cost of dental treatments which could have been well avoided through early preventive care.[12] An anxious child in a dental clinic constitutes a problem not only for the child himself/herself but also for his/her family. An attempt should be made to cope with the anxious behavior depending on their age and cognitive ability.[13] The children in the present study belonged to the 4–5 years category which can show disruptive behavior and are difficult to manage.[14],[15] Apart from the gold standard behavior guidance technique TSD, it is possible to distract and shift the attention of these children from the dental environment by a magic trick or a mobile dental game. The distraction techniques influence children's brain waves, leading to deep relaxation and alleviating pain and anxiety.[1] Hence, this study attempted to compare the effectiveness of magic tricks and mobile dental game distraction techniques with the conventional TSD technique.

Various methods have been used to assess dental anxiety. Physiological measures include pulse rate, muscle tension, and blood pressure.[16] Projective measures like Corah's dental anxiety survey[17] and questionnaire surveys like Children's Fear Survey Schedule-Dental Subscale[18] have been used. The ideal scale to record anxiety should require less skill and should be easy to record.[19] The picture test is the most appropriate choice for young patients.[20] Venham's pictorial test and facial index scale (FIS) have been used in numerous studies.[12],[21],[22] The ambiguous and unfamiliar nature of the figures on the scale may confuse the child in making the right choice. Hence, the Chotta Bheem-Chutki scale developed by Sadana et al. with cartoon characters from a famous ongoing cartoon series was used in this study.[19] The cartoon characters attracted the child's attention and this enhanced the interaction between the child and the dentist.

Magic trick redirects the spectator away from the one that causes the effect.[28] It expands the variety of behavioral options when treating uncooperative children.[29] Magic tricks directly influence the right hemisphere of the brain which is involved in understanding the way magic works. The right side of the brain which is more developed in children aged 3–6 years attracts them toward the magic trick and drags them into the world of imagination. In some children, magic can kindle their curiosity and intellectual thinking and thereby activates the left hemisphere of the brain also.[10] Studies on magic tricks as a distraction technique in the recent past are limited in number. Hence, the present study was conducted to compare this technique with TSD and mobile dental games. In the present study, there was a reduction in the anxiety level in the magic group and the findings were consistent with the results of Peretz et al. 2005. Their study compared the efficiency of magic tricks and TSD in the management of strong-willed children in whom distraction by the magic trick was found to be superior.[10] This result was not consistent with the findings of the present study where distraction by a magic trick and TSD was equally effective. Children of this era are too smart to be beguiled by the magic tricks or the tricks performed in this study might have been too simple to cater to the curiosity of these children.

The smartphone is a double-edged sword. On one hand, it grants us the ability to use applications at our convenience and they are easily accessible. But on the other hand, it can be a spiraling pit of distraction, actually making children less productive.[30] Today, we have an application for anything and everything. Children in all age groups get attracted to mobile games. This can be beneficially utilized in the dental operatory. A maximum reduction of anxiety was seen in the mobile dental game group. These findings were consistent with the results of Attar et al. 2015,[31] Patil et al. 2017,[32] and Elicherla 2019.[33] Passive distraction techniques were not as effective as active distraction techniques like playing a video game in reducing patient anxiety.[31] Seyrek et al. found that video games were more effective than the audio program. They reported that successful distraction was accompanied by an increase in physiological arousal which possibly increased the engagement of the child in the video.[34] A systematic review and meta-analysis concluded that distraction techniques combining audio and video were more effective in reducing dental anxiety in children.[35] The children in the mobile dental game group were ready to accept the dental treatment significantly faster than the other two groups. As the children used the mobile applications willingly, a happy child-friendly atmosphere was created and the dentist was no longer a stranger to be scared of. Children were made to virtually behave like a dentist and were made to do treatments such as scaling, restoration, and extraction in the mobile application. This provided preprocedure information to children in a manner that is appropriate for their developmental stages.[6],[32] Thus, the reduction in the anxiety and faster acceptance of treatment could have been due to the familiarization of the child to the treatment procedures and the real experience with them. Half the battle in pediatric dentistry is won, when good communication is established and this target was easily achieved by the use of mobile dental games.

TSD is the most commonly used behavior guidance technique.[3],[4],[23],[24],[25] Dictating and demonstrating the procedure to the child exactly the way things will happen before the actual procedure develops a sense of trust in children.[24] There was a reduction in the anxiety level in the TSD group and the findings were consistent with the results of Adair et al. 2004,[23] Eaton et al. 2005,[26] Sharma and Tyagi 2011,[27] and Vishwakarma et al. 2017.[24]

Among the three distraction techniques used, all the three techniques were equally effective in reducing the anxiety of young children by desensitizing and detraumatizing them. In terms of readiness to accept the treatment, the mobile dental game was superior to magic and TSD. A lot of creativity is needed on the part of the dentist in both TSD and magic to avoid boredom from monotonous repetition. However, mobile dental games provide ample chances for children to actively participate in a realistic situation. The child's activity and involvement were more in mobile game techniques rather than in TSD or magic. In this digital era, mobile dental games which are appealing and attractive can be used as an adjunct in reducing the anxiety of children.

The limitation of the present study was the assessment of anxiety based on the subjective response given by very young children. All behavioral studies on children aged 3–5 years do have this drawback. However, the information on situation anxiety can be best collected from the child directly and not from other sources like parents or caregivers.

   Conclusion Top

All three distraction techniques were equally effective in reducing anxiety, with maximum anxiety reduction seen in the mobile dental game group. In terms of readiness to accept the treatment, children in the mobile dental group accepted the treatment faster than those in the magic and TSD groups.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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