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Journal of Indian Society of Pedodontics and Preventive Dentistry Official publication of Indian Society of Pedodontics and Preventive Dentistry
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Year : 2020  |  Volume : 38  |  Issue : 4  |  Page : 413-418

Influence of parent-provided distraction and interactive distraction with a handheld video game on the child's responses during local anesthesia administration

1 Department of Pediatric and Preventive Dentistry, Narayana Dental College and Hospital, Nellore, Andhra Pradesh, India
2 Department of Preventive Dental Science, College of Dentistry, Majmaah University, Al-Majmaah, Saudi Arabia
3 Department of Pediatric and Preventive Dentistry, Narayana Dental College and Hospital, Nellore, Andhra Pradesh, India; Department of Preventive Dental Science, College of Dentistry, Majmaah University, Al-Majmaah, Saudi Arabia

Date of Submission09-Nov-2020
Date of Decision07-Dec-2020
Date of Acceptance09-Dec-2020
Date of Web Publication5-Jan-2021

Correspondence Address:
Dr. Sivakumar Nuvvula
Department of Pediatric and Preventive Dentistry, Narayana Dental College and Hospital, Nellore, Andhra Pradesh
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JISPPD.JISPPD_486_20

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Background: To evaluate the influence of parent-provided distraction (PPD) and interactive distraction (ID) with a handheld video game (HVG) on the child's responses to local anesthesia (LA) administration during dental treatment. Methods: Children attending the department of pediatric dentistry were randomly selected and distributed to the two groups (PPD and an ID with HVG). Parents in the operatory and the principles of tell-show-do remained common in both the groups. Behavioral, physiological, and self-report measures of pain were estimated using the Face, Legs, Activity, Cry, and Consolability (FLACC) scale, pulse rate, as well as Iowa pain thermometer-revised (IPT-R) scale and compared for both groups correspondingly. The SPSS (standard statistical package) version 17.0 (SPSS Inc., Chicago, USA) was used for statistical analysis at the significance of P < 0.05. Results: A total of 30 children (15 in each group) aged 7–11 years participated in the study. There were no significant differences observed among boys and girls (P > 0.05). The independent t-test for the pulse rate showed no significant difference between the two groups (P > 0.05). Paired t-test for pulse rate in the PPD group showed a significant difference compared to ID with the HVG group (P < 0.05). The scores for FLACC and ID with HVG, showed a statistically significant decrease in scores recorded for ID with HVG, whereas the scores recorded for FLACC did not show any statistically significant difference. Conclusion: Based on the study results, PPD would be the least distressful option, compared to the ID with HVG in children while administering LA.

Keywords: Handheld video game, interactive distraction, local anesthesia, parent-provided distraction

How to cite this article:
Ega S, Nuvvula S, Mallineni SK. Influence of parent-provided distraction and interactive distraction with a handheld video game on the child's responses during local anesthesia administration. J Indian Soc Pedod Prev Dent 2020;38:413-8

How to cite this URL:
Ega S, Nuvvula S, Mallineni SK. Influence of parent-provided distraction and interactive distraction with a handheld video game on the child's responses during local anesthesia administration. J Indian Soc Pedod Prev Dent [serial online] 2020 [cited 2023 Jan 29];38:413-8. Available from: http://www.jisppd.com/text.asp?2020/38/4/413/306227

   Introduction Top

One of the most stressful events in pediatric dentistry is the administration of local anesthesia (LA). Effective behavior guidance is essential for the successful delivery of dental treatment to the children.[1] Fear and anxiety are elicited when performing procedures in pediatric dentistry and might lead to difficulty for children to accept certain procedures that induce pain, and hence, pain control is key when treating children.[2] Unfortunately, LA administration during a dental procedure is associated with some level of pain stimulus. Painless injections and relevant behavior guidance techniques (BGTs) are essential to create a positive dental experience when treating child patients. A pediatric dentist's role in guiding a child with dental anxiety to cooperativeness is two-fold: primarily, treating the child's chief complaint and secondarily, to instill a positive attitude with effective management of fear and anxiety. Dentists have a wide variety of BGTs to deal with anxiety in children.[3]

The distraction of child appears to be the most common nonpharmacological technique used for behavior guidance during dental procedures. Distraction is the technique that diverts the child's attention from perceiving a dental procedure as unpleasant.[2] A controversy exists on the effect of parental presence in the operatory during their child's dental treatment. Parental presence in the dental situation varies due to the child's disruptive behavior during treatment and projection of parent anxiety on the child.[4] A pediatric dentist decides whether a parent's presence during treatment would positively or negatively impact, and accordingly, the parent might be asked to leave the operatory when needed. Parent-provided distraction (PPD) is considered one of the BGTs. Several studies reported that most parents prefer to accompany their children in the dental operatory.[5] Concomitantly, many parents would like to play an active role in their children's care. Parents' influence is observed by manipulating their presence or absence during children's dental treatment.[4],[5]

The involvement of parents in distraction intervention may be impressive for various reasons. First, the parents are usually unoccupied during their children's dental appointments and are ready to focus on gaining their attention. Second, the parents often know what will hold the child's diligence and are best to capture their child's imaginativeness. Third, once the parents know how to use distraction, it can be performed in any setting and at the time the child gets distressed. Thus, the PPD technique becomes a versatile, inexpensive method for parents to help their children during stressful events.[6] The parent's role as a “distraction coach” has not been explored much.[7] Video games have received a widespread application in health care, primarily as distraction and behavior modification therapy on the child's responses to LA administration.[8] The purpose of this study was to evaluate the influence of PPD and interactive distraction (ID) with handheld video game (HVG) on their child's responses to LA administration. This study hypothesized that the children with the PPD would be least distressed compared to those with ID with HVG is provided.

   Methods Top

The study was carried out in the department of pediatric and preventive dentistry, by a single operator after obtaining the ethical clearance for the study from the institutional ethical committee. All participants and their parents gave their informed assent and written consent before the study, respectively. Healthy children aged 7–11 years, children without previous dental experience involving LA administration, anxious children who had no prior exposure to LA administration, and children with ratings positive and negative, according to Frankl's behavior rating scale,[9] were included in the study. Children with any significant systemic diseases, hearing impairments, and the children or parents of children declined their informed consent were excluded study.

This prospective randomized controlled parallel-arm, participant blinded trial was performed with children aged 7–11 years. A total of 30 participants were randomly allocated equally to the two groups. In Group 1, the children (n = 15) received PPD, and Group 2 children (n = 15) received ID with HVG. The randomization was accomplished by a dental assistant not participating in the study by allocating the first participant to either group by the manual lottery method. After that, the next participant allotted to the other group. The participants received dental treatment by the same dental specialist in pediatric dentistry and the same dental assistant to eliminate the risk of bias. Face, Legs, Activity, Cry, and Consolability (FLACC) scale, Iowa pain thermometer-revised (IPT-R), and pulse oximeter, used for the analysis, whereas the intensity of the pain[10] (objective measurement), pain (subjective measurement), and pulse rate (physiological measurement) were used for comparison. The children's anxiety levels at three clinical situations, before, during, and after LA administration, were recorded. In both the groups, anxiety levels were recorded 15 min before LA administration with a pulse oximeter (pulse rate). The mothers in the PPD group told stories most preferred by the children in the local language during the LA administration, whereas children in the other group played with interactive HVG [Figure 1]. The FLACC scale measured the children's response to the intensity of the pain (objective measure), and the pulse oximeter measured the pulse rate (anxiety level) as physiological measure. After LA administration, the subjective measure of pain perception was recorded using the IPT-R pain assessment tool. IPT-R is a verbal descriptor scale having a vertical thermometer with five pain descriptors ranging from 0 (no pain), 1–3 (mild pain), 4–6 (moderate pain), 7–9 (severe pain), and 10 (most intense pain imaginable). Every participating child chose one of these numbers that best represented their feeling at the time of LA administration. The presence of parents in the operatory and the tell-show-do (TSD) principles remained common for both groups.
Figure 1: Local anesthesia administration with parent-provided distraction and interactive distraction with a handheld video game

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Statistical analysis

The statistical analysis was accomplished using a standard statistical package (SPSS 17.0 for Windows, SPSS Inc., Chicago, USA). The distribution of participants to the two groups based on age and gender was analyzed using the Chi-square test. The intergroup and intragroup comparisons were performed using the unpaired and paired t- test and Mann–Whitney test, respectively.

   Results Top

A total of 110 children were assessed for eligibilty and 30 children (15 in each group; 1:1 boys and girls) who met the inclusion criteria were participated in the study [Figure 2]. All children were accompanied by one of the parents (22 mothere; 8 fathers). No significant group differences were observed for child gender. The independent t-test for the pulse rate noted before, during, and after intervention showed no significant difference among the groups [Table 1]. In the PPD group, the mean scores for pulse recorded before, during, and after the intervention was 98.46, 106.50, and 100.06, respectively, whereas, for the HVG group, the mean was 96.32, 107.47, and 101.36. Paired sample t-test for pulse rate in the PPD group [Table 2] showed a significant difference between pulse rate before and during LA administration (Pair 1) as well as the pulse rate during and after LA administration (Pair 3); however, there was no significant difference between pulse rate before and after LA administration (Pair 2). Pulse rate in HVG group [Table 3] showed a highly significant difference between pulse rate before and during LA administration (Pair 1), whereas the pulse rate during and after LA administration showed a significant difference (Pair 3). However, there was no significant difference between pulse rate before and after LA administration (Pair 2). In both the groups, scores recorded using FLACC and IPT-R decreased significantly after the intervention [Table 4]. Mann–Whitney U-test was performed to compare the reduction in scores for FLACC and IPT-R. A statistically significant decrease was observed in the scores recorded for IPT-R, whereas the scores recorded for FLACC did not show any statistically significant difference.
Figure 2: CONSORT flow diagram of the study design

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Table 1: Mean changes in the scores for pulse rate before, during, and after interventions

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Table 2: Mean differences in the scores for pulse rate before, during, and after interventions (parental provided distraction)

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Table 3: Mean differences in the scores for pulse rate before, during, and after interventions in interactive distraction with the handed video game

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Table 4: Comparison of pain scales Face, Legs, Activity, Cry, and Consolability scale and Iowa pain thermometer-revised scale means of study groups

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   Discussion Top

The triad formed by the dental team, child, and parents influences pediatric dental care. Hence, each part of the triad interrelates and their relationships are dynamic.[11] Including or excluding a parent is not that easy and remains a contentious topic among the pediatric dentists. Attempts to develop and establish guidelines to build an atmosphere most conducive to obtain a child's attention and compliance are subject to specific limitations.[12] The dental team's competence depends on how they handle and control noncompliant child behaviors, and it was extensively accepted by the parents and society.[13] Consequently, clinicians' authority and methods to shape noncompliant child behaviors have become the area of scrutiny. Hence, pediatric dentists continue to search for a low cost, easy to administer, and comprehensive method for anxiety reduction in the pediatric population. Contemporary parents appear to show increasing interest and involvement in witnessing the clinician's management style and participating in the decision process. Parents generally have the best intentions when visiting the dental office with their children and no parent has the motive to derail a positive experience for their child. However, we encounter some parents whose attitudes, biases, personal experiences, and anxieties preclude them from responding favorably to the advice and counseling. Focusing on parental attitudes, Peretz and Zadik[14] reported that over 70% of parents expressed interest in being present. Looking at both dentist and parent preferences, Crossley and Joshi[15] reported similar findings. Therefore, it became necessary for the pediatric dentist to treat children with the presence of parents in the operatory. Standard immunization is the medical procedure studied most frequently along with distraction by the parent. Some researchers have reported a decrease in observed child behavioral distress with the PPD. However, few others reported no difference between the groups. An American study[16] reported that PPD is a valuable intervention for children experiencing painful procedures. In the present study, PPD showed fewer mean values compared to HVG when the IPT-R scale was used, with significant results. However, the American study used Oucher Scale in their study; hence, we cannot compare both the findings. Moreover, both the studies reported pain during needle insertion. Abdelmoniem et al.[17] reported the efficacy of different distraction techniques (passive, active, and passive–active) on children's pain perception during LA administration and showed comparable results in reducing pain perception. The present study showed similar findings with the PPD technique as a distraction method compared to HVG. Allani et al.[18] reported that distraction with a mobile phone video game compared with video viewing reduces pre and postoperative anxiety levels of children receiving LA injection during dental extraction. Similarly, the PPD technique also reduces anxiety in the preoperative area and during the injection of LA. An Indian study[18] suggested that the PPD technique was low cost, easy to administer, and comprehensive method for anxiety reduction in the children. Fakhruddin et al.[19] reported that a wide range of cooperation levels was observed during invasive dental treatment using audiovisual distraction and computerized anesthesia delivery for stainless-steel crowns placement in children. Nonetheless, the PPD technique could be used as a distraction method to maximize these children's cooperation levels. In the present study, for both the groups, the intensity of pain scores using the FLACC scale and IPT-R decreased significantly after the intervention. To our information, this is the first study using IPT-R as a pain intensity measure in pediatric dentistry. Herr et al.[20] evaluated the sensitivity and utility of the IPT and other chosen pain intensity scales for younger and older adults utilizing a controlled clinical pain condition. The IPT was judged to be the best choice for assessing pain intensity for both age groups.[20] Further, Ware et al.[21] evaluated the psychometric properties of the IPT-R and determined patient preference for a self-report pain assessment tool.

Research shows that parents with a negative attitude toward dentistry are most likely to convey the same to their children.[2],[12],[13] A recent study by Nunna et al.[22] reported virtual reality distraction being useful to decrease dental anxiety and fear in children during LA administration compared to counter stimulation. The relation between parental anxiety and child negative behavior was documented in several studies.[2],[13],[19] However, Frankl et al.[9] and several other authors reported an increase in the child's cooperation relative to parental presence during a dental examination and treatment in the operatory. Lewis and Law[23] reported no differences in child behavior, whether the parent was present or absent in the operatory. Riba et al.[24] postulated that parental presence in the dental operatory achieves emotional support and avoids the consequence of stressful separation, especially in preschool children and those with special health-care needs. Barreiros et al.[25] in their systematic review and meta-analysis on audiovisual distraction methods noted that storytelling is a method of audio distraction. The present study used the storytelling by parent as PPD during the painful dental procedures.

The outcome of this study shows that child's anxiety after using both the techniques when delivering LA was significantly lower than the preoperative anxiety. However, PPD reduced the child's anxiety better than playing a video game, and the results were statistically significant. This study indicates that when parents provide the distraction, children have lower distress responses, supporting PPD as a valuable intervention for children experiencing painful dental procedures. The considerably small sample size is the limitation, and further research with large sample size is required to evaluate the parental presence while treating the children. Nonetheless, the current research was performed to maximize the benefits of parental presence in the operatory while managing anxious children.

   Conclusion Top

This study had illustrated the benefits of the presence of parent on child behavior, especially during stressful dental procedures such as administration of LA. Involving parents as a distraction medium is a potential strategy to decrease dental anxiety and enhances the success of treatment, at the same time instilling a positive dental experience to the child.

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.

Presentation at any conference

The abstract was presented as a poster at IAPD2020 Virtual.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Allen KD, Stanley RT, McPherson K. Evaluation of behavior management technology dissemination in pediatric dentistry. Pediatr Dent 1990;12:79-82.  Back to cited text no. 1
American Academy of Pediatric Dentistry. Reference manual guideline on behavior guidance for the pediatric dental patient. Pediatr Dent 2015;37:182-93.  Back to cited text no. 2
McCaul KD, Malott JM. Distraction and coping with pain. Psychol Bull 1984;95:516-33.  Back to cited text no. 3
Cavender K, Goff MD, Hollon EC, Guzzetta CE. Parents' positioning and distracting children during venipuncture: Effects on children's pain, fear, and distress. J Holist Nurs 2004;22:32-56.  Back to cited text no. 4
Cohen LL, Blount RL, Cohen RJ, Ball CM, McClellan CB, Bernard RS, et al. Children's expectations and memories of acute distress: Short- and long-term efficacy of pain management interventions. J Pediatr Psychol 2001;26:367-74.  Back to cited text no. 5
Kleiber C, Craft-Rosenberg M, Harper DC. Parents as distraction coaches during i.v. Insertion: A randomized study. J Pain Symptom Manage 2001;22:851-61.  Back to cited text no. 6
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Frankl SN, Shiere FR, Fogels HR. Should the parent remain with the child in the dental operatory. J Dent Child 1962;29:150-63.  Back to cited text no. 9
Merkel SI, Voepel-Lewis T, Shayevitz JR, Malviya S. The FLACC: A behavioral scale for scoring postoperative pain in young children. Pediatr Nurs 1997;23:293-7.  Back to cited text no. 10
Wright GZ, Starkey PE, Gardner DE. Parent-child separation. In: Managing Children's Behavior in the Dental Office. Ch. 6. Mosby: St. Louis; 1983. p. 57-74.  Back to cited text no. 11
Nathan JE, Rayman MS, Golden BE, Vargas KG. Discretionary parental presence in the dental operatory: A survey of pediatric dentists and parents. Pediatr Neonatal Nurs Open J 2015;2:50-61.  Back to cited text no. 12
Lenchner V, Wright GZ. Non-pharmacotherapeutic approaches to behavior management. In: Wright GZ, editor. Behavior Management in Dentistry for Children. Ch. 5. Philadelphia, USA: WB Saunders; 1975. p. 91-114.  Back to cited text no. 13
Peretz B, Zadik D. Attitudes of parents towards their presence in the operatory during dental treatments to their children. J Clin Pediatr Dent 1998;23:27-30.  Back to cited text no. 14
Crossley ML, Joshi G. An investigation of paediatric dentists' attitudes toward parental accompaniment and behavioral management techniques in the UK. Br Dent J 2002;192:517-21.  Back to cited text no. 15
McCarthy AM, Kleiber C, Hanrahan K, Zimmerman MB, Westhus N, Allen S, et al. Impact of parent-provided distraction on child responses to an IV insertion. Child Health Care 2010;39:125-41.  Back to cited text no. 16
Abdelmoniem SA, Mahmoud SA. Comparative evaluation of passive, active, and passive-active distraction techniques on pain perception during local anesthesia administration in children. J Adv Res 2016;7:551-6.  Back to cited text no. 17
Allani S, Setty JV. Effectiveness of distraction techniques in the management of anxious children in the dental operatory. IOSR J Dent Med Sci 2016;10:69-73.  Back to cited text no. 18
Fakhruddin KS, El Batawi H, Gorduysus MO. Effectiveness of audiovisual distraction with computerized delivery of anesthesia during the placement of stainless steel crowns in children with down syndrome. Eur J Dent 2017;11:1-5.  Back to cited text no. 19
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Herr K, Spratt KF, Garand L, Li L. Evaluation of the iowa pain thermometer and other selected pain intensity scales in younger and older adult cohorts using controlled clinical pain: A preliminary study. Pain Med 2007;8:585-600.  Back to cited text no. 20
Ware LJ, Herr KA, Booker SS, Dotson K, Key J, Poindexter N, et al. Psychometric evaluation of the revised Iowa pain thermometer (IPT-R) in a sample of diverse cognitively intact and impaired older adults: A Pilot study. Pain Manag Nurs 2015;16:475-82.  Back to cited text no. 21
Nunna M, Dasaraju RK, Kamatham R, Mallineni SK, Nuvvula S. Comparative evaluation of virtual reality distraction and counter-stimulation on dental anxiety and pain perception in children. J Dent Anesth Pain Med 2019;19:277-88.  Back to cited text no. 22
Riba H, Al-Shahrani A, Al-Ghutaimel H, Al-Otaibi A, Al-Kahtani S. Parental presence/absence in the dental operatory as a behavior management technique: A review and modified view. J Contemp Dent Pract 2018;19:237-41.  Back to cited text no. 23
Lewis TM, Law DB. Investigation of certain autonomic responses of children to specific dental stress. J Am Dent Assoc 1958;57:769-77.  Back to cited text no. 24
Barreiros D, de Oliveira DS, de Queiroz AM, da Silva RA, de Paula-Silva FW, Küchler EC. Audiovisual distraction methods for anxiety in children during dental treatment: A systematic review and meta-analysis. J Indian Soc Pedod Prev Dent 2018;36:2-8.  Back to cited text no. 25
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