ORIGINAL RESEARCH

https://doi.org/10.5005/jp-journals-10005-2627
International Journal of Clinical Pediatric Dentistry
Volume 16 | Issue 4 | Year 2023

Effectiveness of Audiovisual Distraction Technique and Filmed Modeling on Anxiety and Fear in Pediatric Dental Patients

Faiza Jamil¹, Saima Y Khan², Mahendra K Jindal³

^1-3Department of Pediatric and Preventive Dentistry, Dr. Ziauddin Ahmad Dental College, Aligarh Muslim University, Uttar Pradesh, India

Corresponding Author: Faiza Jamil, Department of Pediatric and Preventive Dentistry, Dr. Ziauddin Ahmad Dental College, Aligarh Muslim University, Uttar Pradesh, India, Phone: +91 8171984698, e-mail: jamil.faiza575@gmail.com

ABSTRACT

Aim: To evaluate the effectiveness of the audiovisual distraction (AVD) technique and filmed modeling (FM) on anxiety and fear in pediatric dental patients.

Materials and methods: This experimental in vivo study was conducted on 80 subjects of age-groups 5–8 years coming to the Department of Pediatric and Preventive Dentistry for their first dental visit. Study subjects were subjected to noninvasive restorative treatment under AVD in group I, FM in group II, and a combination of AVD and FM in groups III and IV (control 0). To assess the level of pre and postoperative anxiety and fear, various biological parameters like pulse rate, oxygen saturation, body temperature, respiratory rate, and salivary cortisol estimation along with facial image scale (FIS), and fear assessment picture scale (FAPS) were used.

Results: Group III (a combination of AVD and FM) came out to be better than other experimental groups and control groups in reducing dental anxiety and fear in pediatric dental patients.

Conclusion: A combination of AVD and FM techniques can be recommended to be used as an effective behavior management technique.

Clinical significance: A child’s disruptive behavior due to dental anxiety causes difficulty in delivering effective dental treatment. Thus, a child’s behavior management is of paramount importance in the pediatric dental setup. Nonpharmacological behavior management techniques, that is, a combination of AVD and FM techniques can be recommended to be used as an effective behavior management technique to reduce dental anxiety and fear in pediatric dental patients.

How to cite this article: Jamil F, Khan SY, Jindal MK. Effectiveness of Audiovisual Distraction Technique and Filmed Modeling on Anxiety and Fear in Pediatric Dental Patients. Int J Clin Pediatr Dent 2023;16(4):598–602.

Source of support: Nil

Conflict of interest: None

Keywords: Anxiety assessment scales, Audiovisual distraction technique, Anxiety pediatric dentistry, Dental anxiety assessment, Filmed modeling

INTRODUCTION

Dental fear and anxiety (DFA) have been reported to be a common problem, that affects all age-groups, but the most vulnerable group in particular are children and adolescents.¹ It has been reported that the estimated prevalence of dental anxiety and fear ranges between 6 and 42% among children in different populations.² DFA is a common reason for avoiding dental treatment resulting in poorer oral health with time.³ Children are found to be anxious and fearful during their first dental visit because of exposure to dental equipment and new surroundings. Thus, the first dental visit of children is always important in shaping the child’s behavior and building a positive attitude towards dental treatment.⁴ The nonpharmacological interventions help in effectively reducing DFA.⁵ The basic techniques of nonpharmacological interventions that are commonly used in day-to-day practice in a dental setting include tell-show-do, modeling, contingency management, positive reinforcement, voice control, nonverbal communication, and distraction.⁶ Distraction is a behavioral method useful in helping patients to deal with short-term stress. Patients can be distracted in a delightful way by using audiovisual aids, that involve the use of both senses of vision and hearing and at the same time allow them to partially isolate themselves from the stressful sights of the dental environment.⁷ “Modeling refers to learning by observing and copying other’s behavior.” Several studies have reported the effectiveness of modeling through a film in reducing a child’s dental anxiety.⁸ Guidelines of the American Academy of Pediatric Dentistry on the necessity to study nonpharmacological ways of behavior management led to the inception of the present study.⁹

Hence, the present study aimed to evaluate the effectiveness of the audiovisual distraction (AVD) technique and filmed modeling (FM) on anxiety and fear in pediatric dental patients.

MATERIALS AND METHODS

The study was approved by the Institutional Ethical Committee (D. No. 55/FM/IEC dated: 15/10/20). Informed consent was obtained from all the parents after explaining the detailed treatment. Participants were divided into four groups:

Group I: Audiovisual distraction (AVD).
Group II: Filmed modeling (FM).
Group III: Combination of AVD and FM.
Group IV (control): No specific behavior management technique applied during treatment.

Preoperative assessment of anxiety and fear in the child was done after having the child sit on a dental chair for 1 minute using psychometric scales like the facial image scale (FIS) (Fig. 1), and fear assessment picture scale (FAPS) (Fig. 2). A pulse oximeter was used to monitor pulse rate and oxygen saturation. For measuring skin temperature, a digital thermometer was used. Respiratory rate was measured by counting the number of times the chest had risen up in 1 minute. For collecting saliva samples, the patient was asked to spit out about 1–2 mL of unstimulated saliva in a disposable sterile plastic container while sitting in an upright posture with head bent down. Saliva samples collected from individual patients were transported to the lab of biochemistry on the same day and stored in the refrigerator at −20° C. Cortisol level estimation was done by using enzyme-linked immunosorbent assay method.

Fig. 1: Facial image scale

Fig. 2: Fear assessment picture scale

In group I, children were shown a cartoon video of 10 minutes duration of their own choice on a laptop using earphones (Fig. 3). During this time, the restorative procedure was completed. In group II children received restorative dental treatment while watching a modeling video of 10 minutes duration on a laptop using earphones throughout the restorative procedure (Fig. 4). In group III, the cartoon video and modeling video were clubbed together in such a way as to match the time duration with the rest of the groups of 10 minutes duration. In group IV (control), children received restorative procedures without using any distraction technique. The restorative procedure involved the excavation of carious lesions using a hand instrument and restoration was done with type II glass ionomer restorative cement by the same operator in all four groups. Postoperative assessment of anxiety and fear through FIS, FAPS, and biological parameters was done again at the end of restorative treatment and recorded.

Fig. 3: Audiovisual distraction technique

Fig. 4: Filmed modeling technique

Statistical Analysis

The significance of mean and standard deviation values of all the parameters at pre and postexamination for intragroup comparison was tested by paired sample t-test. The significance of the mean difference between groups for multiple pairwise comparisons was tested by the Tukey honestly significant difference test. The level of significance and confidence interval was 5 and 95%, respectively at a significance p-value of <0.05.

RESULTS

The study was formulated with the following aims and objectives:

Aim: “The aim of the study was to evaluate the effectiveness of the AVD technique and FM on anxiety and fear in pediatric dental patients.”
Objectives: Preassessment of dental anxiety and fear by biological parameters such as; pulse rate, oxygen saturation, respiratory rate, body temperature, salivary cortisol, and by scores of FIS and FAPS in subjects prior to subjecting them to any form of nonpharmacological intervention.
Postassessment of dental anxiety and fear by biological parameters such as; pulse rate, oxygen saturation, respiratory rate, body temperature, salivary cortisol, and by scores of FIS and FAPS in subjects in the following divided study groups—group I (subjected to AVD during the treatment), group II (subjected to FM technique during the treatment), group III (combination of AVD and FM during the treatment), and group IV (control).

The following results were obtained:

At preexamination, the pulse rate of groups I, II, III, and IV were 96.55 ± 9.174, 100.20 ± 11.808, 101.95 ± 10.465, and 87.55 ± 12.492, respectively; oxygen saturation of groups I, II, III, and IV were 97.60 ± 1.392, 98.15 ± 2.059, 92.65 ± 4.356, and 99.00 ± 1.257, respectively; body temperatures of groups I, II, III, and IV were 98.61 ± 0.345, 98.64 ± 0.386, 98.64 ± 0.557, and 98.62 ± 0.916, respectively; respiratory rate of groups I, II, III, and IV were 24.20 ± 2.215, 24.35 ± 2.739, 23.20 ± 2.16, and 19.20 ± 2.337, respectively; salivary cortisol of groups I, II, III, and IV were 6.184 ± 0.192, 5.94 ± 0.249, 5.94 ± 0.276, and 5.93 ± 0.353, respectively (Table 1).
At postexamination, the pulse rate of group I, II, III, and IV were 84.75 ± 8.397, 95.20 ± 12.289, 86.10 ± 8.052, and 103.95 ± 7.323, respectively; oxygen saturation of groups I, II, III, and IV were 99.85 ± 0.366, 98.75 ± 1.713, 99.55 ± 0.605, and 92.25 ± 3.697, respectively; body temperature of groups I, II, III, and IV were 98.30 ± 0.336, 98.59 ± 0.361, 98.03 ± 0.392, and 99.32 ± 0.753, respectively; respiratory rate of groups I, II, III, and IV were 22.85 ± 2.007, 23.95 ± 2.964, 20.65 ± 1.631, and 22.10 ± 1.447, respectively; salivary cortisol of groups I, II, III, and IV were 5.80 ± 0.563, 5.82 ± 0.288, 5.89 ± 0.325, and 6.13 ± 0.375, respectively (Table 1).
The difference between pre and postvalues of the pulse rate of groups I, II, III, and IV were 11.80 ± 5.395 (p = 0.000), 5.00 ± 4.645 (p = 0.000), 15.85 ± 15.941 (p = 0.000), and −16.40 ± 11.198 (p = 0.000), respectively. The difference between pre and postvalues of oxygen saturation of groups I, II, III, and IV were −2.25 ± 1.409 (p = 0.000), −0.600 ± 0.753 (p = 0.002), −6.90 ± 4.411 (p = 0.000), and 6.75 ± 4.140 (p = 0.000), respectively. The difference between pre and postvalues of body temperature of groups I, II, III, and IV were 0.30 ± 0.254 (p = 0.000), 0.04 ± 0.088 (p = 0.028), 0.61 ± 0.433 (p = 0.000), and −0.70 ± 0.760 (p = 0.001), respectively. The difference between pre and postvalues of the respiratory rate of groups I, II, III, and IV were 1.35 ± 0.933 (p = 0.000), 0.40 ± 0.753 (p = 0.035), 2.55 ± 1.316 (p = 0.000), and −3.00 ± 1.863 (p = 0.000), respectively. The difference between pre and postvalues of salivary cortisol levels of groups I, II, III, and IV were 0.3820 ± 0.493 (p = 0.003), 0.12 ± 0.085 (p = 0.000), 0.050 ± 0.365 (p = 0.509), and −0.19 ± 0.433 (p = 0.061), respectively.
At preexamination, the FIS score of groups I, II, III, and IV were 2.95 ± 0.999, 2.05 ± 0.605, 2.55 ± 0.759, and 1.40 ± 0.598, respectively; FAPS scores of groups I, II, III, and IV were 0.55 ± 0.510, 0.20 ± 0.410, 0.20 ± 0.410, and 0.30 ± 0.470, respectively (Table 1).
At postexamination, the FIS scores of groups I, II, III, and IV were 1.15 ± 0.366, 1.75 ± 0.716, 1.85 ± 0.745, and 4.15 ± 0.933, respectively; FAPS scores of groups I, II, III, and IV were 0.00 ± 0.000, 0.05 ± 0.224, 0.00 ± 0.000, and 0.70 ± 0.470, respectively (Table 1).
The difference between pre and postvalues of the FIS scores of groups I, II, III, and IV were 1.80 ± 0.951 (p = 0.000), 0.30 ± 0.571 (p = 0.030), 0.70 ± 0.571 (p = 0.000), and −2.750 ± 1.118 (p = 0.000), respectively. The difference between pre and postvalues of the FAPS scores of groups I, II, III, and IV were 0.55 ± 0.510 (p = 0.000), 0.15 ± 0.366 (p = 0.083), 0.20 ± 0.410 (p = 0.042), and −0.40 ± 0.502 (p = 0.002), respectively.

**Table 1:** Mean and standard deviation values of all parameters at pre and postexamination
Parameters		Groups
		Group I (AVD) (mean ± SD) N = 20	Group II (FM) (mean ± SD) N = 20	Group III (AVD + FM) (mean ± SD) N = 20	Group IV (control) (mean ± SD) N = 20
Respiratory rate	Pre	24.20 ± 2.215	24.35 ± 2.739	23.20 ± 2.167	19.20 ± 2.337
Respiratory rate	Post	22.85 ± 2.007	23.95 ± 2.964	20.65 ± 1.631	22.10 ± 1.447
Body temperature	Pre	98.61 ± 0.345	98.64 ± 0.386	98.64 ± 0.557	98.62 ± 0.916
Body temperature	Post	98.30 ± 0.336	98.59 ± 0.361	98.03 ± 0.392	99.32 ± 0.753
Oxygen saturation	Pre	97.60 ± 1.392	98.15 ± 2.059	92.65 ± 4.356	99.00 ± 1.257
Oxygen saturation	Post	99.85 ± 0.366	98.75 ± 1.713	99.55 ± 0.605	92.25 ± 3.697
Pulse rate	Pre	96.55 ± 9.174	100.20 ± 11.808	101.95 ± 10.465	87.55 ± 12.492
Pulse rate	Post	84.75 ± 8.397	95.20 ± 12.289	86.10 ± 8.052	103.95 ± 7.323
FIS	Pre	2.95 ± 0.999	2.05 ± 0.605	2.55 ± 0.759	1.40 ± 0.598
FIS	Post	1.15 ± 0.366	1.75 ± 0.716	1.85 ± 0.745	4.15 ± 0.933
FAPS	Pre	0.55 ± 0.510	0.20 ± 0.410	0.20 ± 0.410	0.30 ± 0.470
FAPS	Post	0.00 ± 0.000	0.05 ± 0.224	0.00 ± 0.000	0.70 ± 0.470
Cortisol	Pre	6.184 ± 0.192	5.94 ± 0.249	5.94 ± 0.276	5.93 ± 0.353
Cortisol	Post	5.80 ± 0.563	5.82 ± 0.288	5.89 ± 0.325	6.13 ± 0.375

SD stands for standard deviation

DISCUSSION

Dental anxiety is a multifaceted and complex process with reflection on an individual’s behavior, physiology, emotion, and cognitive components.¹⁰ In the present study we have used two different methods to assess fear and anxiety levels—(1) subjective method, which includes self-reporting of DFA level by FIS and FAPS for anxiety and fear respectively and (2) objective method, which assesses physiological parameters that indicate changes in biological markers like pulse rate, oxygen saturation, body temperature, respiratory rate, and salivary cortisol. The combination of the above subjective and objective methods may come up with better results regarding the assessment of patients’ anxiety levels and hence their proper management.²

The present research was conducted on 80 children (20 in each group) of 5–8 years of age. Similar age-groups have also been reported by Khandelwal et al.⁷ and Shetty et al.,¹¹ respectively in their studies. In the present study, we went with an age-group of 5–8 years because, at this age, the child has the cognitive ability to self-report their anxiety along with the ability to understand the behavior-shaping techniques such as FM, distraction, etc.¹²

In the present study, a reduction in postexamination values of FIS score was seen in all the experimental groups, that is, groups I, II, and III. While an increase was seen in the postexamination value of control (group IV). Similar results were reported by Khandelwal et al.⁷ and Raseena et al.¹³ where they found a decrease in mean values of FIS Score in the experimental groups, supporting our study, and the opposite in the control group where no behavior management technique was applied during treatment.

In our study, a reduction in postexamination values of FAPS score was seen in all the experimental groups, that is, groups I, II, and III. While an increase was seen in the postexamination value of the control group, that is, group IV. No study has been conducted using FAPS as a dental anxiety assessment scale. A study conducted by Tiwari et al.¹⁴ suggested that FAPS should be used as a practical anxiety assessment tool in small age-groups of children because this scale gives a quick response, helping in reducing chairside time.

In the present study, a reduction in postexamination values of pulse rate was seen in all the experimental groups, that is, groups I, II, and III. The difference between pre and postvalues was statistically significant in all the above groups. While just the opposite was seen in the postexamination value of control (group IV). Maximum reduction in mean values of pulse rate after treatment was seen in group III followed by groups I and II. Similar results were shown by Khandelwal et al.⁷ where a combination of tell-show-do and AVD technique showed maximum decline in mean values of pulse rate after treatment. The study by Raseena et al.¹³ showed similar results that are in accordance with the present study, where the experimental group showed a significant decrease in mean pulse rate value after treatment and opposite findings were seen in the control group. The reason cited was that anxiety or stress activates the autonomic nervous system, which results in the release of adrenaline from the adrenal medulla. The release of adrenaline acts directly on the cardiovascular system causing peripheral responses such as an increase in heart rate.¹⁵ Another school of thought is the amygdala which is the integrative center for emotions of fear and anxiety and gets activated by these emotions. The central nucleus of the amygdala which regulates many aspects of fear response stimulates autonomic arousal responses to fear or threat signals mainly through output pathways to the hypothalamus and brainstem, which results in activation of the sympathetic nervous system resulting in an increase in heart rate.¹⁶ In contrast to the findings of the present study, Shah et al.¹⁷ showed that the mean value of pulse rate decreased in both the control and experimental group after treatment.

In the present study, an increase in postexamination values of oxygen saturation was seen in all the experimental groups, that is, groups I, II, and III. While reduction was seen in the postexamination value of control (group IV). These results are in concordance with the study done by Raseena et al.¹³ where the control group showed a decrease in oxygen saturation level posttreatment while the intervention group showed an increase in oxygen saturation level after treatment which was statistically significant. A similar kind of pattern was seen in the results of James et al.¹⁸ where the control group showed a decrease in oxygen saturation level posttreatment while the opposite was found in the intervention groups. The reason cited was that anxiety causes an increase in respiratory rate due to hyperventilation resulting in lower oxygen saturation level.¹⁴ On the contrary, studies done by Prabhakar et al.¹⁹ and Khandelwal et al.²⁰ found that there was no significant difference in oxygen saturation levels between the control and experimental group during all the visits of dental treatment.

In the present study, a reduction in postexamination values of body temperature was seen in all the experimental groups, that is, groups I, II, and III. While an increase was seen in the postexamination values of the control group, that is, group IV. To date, to the best of my knowledge, no study has been conducted using body temperature as a dental anxiety assessment tool among children. Thus, in the present study, we have chosen this parameter for assessment of dental anxiety and fear.

In the present study, a reduction in postexamination values of respiratory rate was seen in all the experimental groups, that is, groups I, II, and III. While an increase was seen in the postexamination value of the control group, that is, group IV. Maximum reduction among all the three experimental groups was seen in group III (combination of AVD and FM) followed by groups I and II indicating maximum effectiveness of group III in reduction of dental anxiety level in children in terms of respiratory rate. Similar results were shown by the study of Raseena et al.¹³ where there was a statistically significant reduction in posttreatment mean values of respiratory rate in the experimental group while the control group also showed a reduction in posttreatment respiratory rate values but was not statistically significant. The reason cited was that, negative emotions of fear and anxiety increase the respiratory rate due to hyperventilation as a result of reduced duration of expiration which lowers the partial pressure of carbon dioxide in the bloodstream.¹⁴^,²¹

In the present study, a reduction in postexamination values of salivary cortisol level was seen in all the experimental groups. While an increase was seen in the postexamination value of the control group. These results are in accordance with the study done by Shetty et al.¹¹ where they showed a significant reduction in salivary cortisol levels in the experimental group in which the distraction technique was applied as compared to the control group. The reason cited was that stress or anxiety causes activation of the amygdala, which plays a crucial role in the processing of these negative emotions. Stress-induced amygdala activation further activates the hypothalamic-pituitary axis, which stimulates the release of corticotropin-releasing hormone from the paraventricular nucleus of the hypothalamus causing the pituitary gland to secrete an adrenocorticotropic hormone which in turn stimulates the release of cortisol from adrenal cortex.¹⁵^,²²

In the present study, group III (a combination of AVD and FM) came out to be better than other experimental groups, that is, groups II, III, and control, that is, group IV in reducing dental anxiety and fear. The reason could be that the additive effect of both behavior management methods, that is, AVD and FM played a significant role in controlling the child’s dental anxiety and fear in the best way. Results by Khandelwal et al.⁷ are in support of the present research where they found that the combination of AVD and the tell-show-do technique was more effective in reducing dental anxiety in children.

As per the findings of the present study, group I (AVD technique) showed better results than groups II and IV. Similar to the results of our study, Khandelwal et al.⁷ found the AVD technique to be more effective in controlling a child’s dental anxiety than the control group. The results of the present study are consistent with the findings of Kharouba et al.²³ where they found that the television distraction technique was more effective in reducing anxiety than the control group. The reason cited was that while watching the audiovisual presentation, the child is engaged in using his auditory and visual senses. This helps the child eliminate the unpleasant sound and sight of stressful dental procedures.¹⁹ On the contrary to the findings of the present study, Venham et al.²⁴ showed that the AVD technique was not as effective in reducing the child’s dental anxiety as a control group.

CONCLUSION

From the present study, it can be concluded that group III (combination of AVD and FM) is more effective in reducing anxiety and fear in pediatric dental patients than other experimental groups, that is, group I (AVD), group II (FM) and control group (group IV). Hence, a combination of AVD and FM techniques can be recommended to be used as an effective behavior management technique.

Clinical Significance

A child’s disruptive behavior due to dental anxiety causes difficulty in delivering effective dental treatment. Thus, a child’s behavior management is of paramount importance in the pediatric dental setup. Nonpharmacological behavior management techniques, that is, a combination of AVD and FM techniques can be recommended to be used as an effective behavior management technique to reduce dental anxiety and fear in pediatric dental patients.

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