ORIGINAL RESEARCH |
https://doi.org/10.5005/jp-journals-10005-2655 |
Management of Dentally Anxious Adolescents with Retraining Technique: A Double-blind Randomized Controlled Clinical Study
1,3-6Department of Pedodontics, Kamineni Institute of Dental Sciences, Nalgonda, Telangana, India
2Department of Pedodontics and Preventive Dentistry, Kamineni Institute of Dental Sciences, Nalgonda, Telangana, India
Corresponding Author: Kiranmayi Merum, Department of Pedodontics, Kamineni Institute of Dental Sciences, Nalgonda, Telangana, India, Phone: +91 8919425949, e-mail: kiranmayee30dec@gmail.com
ABSTRACT
Background: Anxiety toward dental treatment may be the reason for not only young children but also secondary school children to postpone dental treatment despite having severe pain. Hence this study was undertaken to recognize such anxious secondary school children prior to the treatment and tried to manage them with the retraining technique.
Materials and methodology: The present interventional study comprised 100 participants with highly anxious about dental treatment and were selected randomly within the secondary school age group of 11–16 years visiting the dental hospital. These selected participants were randomly allocated into two groups with 50 members in each group. Group I participants were managed with the retraining behavior management technique and in group II subjects retraining behavior management technique was not employed. Preinterventional and postinterventional dental anxiety (DA) scores were assessed using a Modified Dental Anxiety Scale (MDAS). The data obtained was statistically analyzed with Statistical Package for the Social Sciences (SPSS) version 22 using the Wilcoxon sign ranked test.
Results: There was a significant difference in preinterventional and postinterventional mean DA scores in group I treated with the retraining technique with no significant difference in group II.
Conclusion: The retraining technique can be used in managing highly anxious secondary school children during dental procedures.
How to cite this article: Saraswati S, Saraswati SD, Mudusu SP, et al. Management of Dentally Anxious Adolescents with Retraining Technique: A Double-blind Randomized Controlled Clinical Study. Int J Clin Pediatr Dent 2023;16(S-2):S118–S121.
Source of support: Nil
Conflict of interest: None
Keywords: Dental Anxiety, Retraining technique, Secondary school children
INTRODUCTION
Odontophobia means “marked and persistent fear that is excessive or unreasonable cued by the presence or anticipation of a specific object or situation.”1 Dental anxiety (DA) is a known factor that plays a significant factor in dental care.2-5 Despite the advancements in dentistry, that is, techniques and dental materials, there is still a considerable section of people who are apprehensive toward dental treatment. The DA prevalence among people from different developed countries shows that these patients seek emergency dental care and postpone their further appointments, which could lead to poor oral health.6,7 It has been attributed to factors such as vicarious learning from dentally anxious family members or peers, perception of body image, blood injury fears, and pain reactivity.8,9 The anxiety toward dental care is seen in every age group, that is, children, adolescents and adults. As age advances adults try to cope with stress and anxiety during dental procedures, but young adults tend to postpone them. Many anxious secondary school children accept dental treatment if treated by loving and caring staff with the assistance of behavioral therapies like retraining techniques apart from pharmacological methods. Prior to the treatment, the dentist should identify such anxious children undergoing dental care which makes them execute certain behavioral therapies which reduce anxiety toward dentistry. In this study, such anxious adolescent patients were identified prior to the treatment and tried to manage them with retraining management techniques.
MATERIALS AND METHODOLOGY
Ethical Approval
The present study was accepted by the Ethical Committee of Kamineni Institute of Dental Sciences, Nalgonda, Telangana, India.
Sample Collection
Study participants were recruited from the walk-in patients of the Department of Pedodontics over a period of 6 months. To evaluate anxiety in children, the Modified Dental Anxiety Scale (MDAS) was considered. In the reception area, the patient was requested to answer the questionnaire of the MDAS. In this scale, anxiety scores will range from 5 to 25. An anxiety score in the range of 19 to 25 was considered to be highly anxious toward the dental treatment and these children were opted for the study group. A sample of 100 secondary school children within the age group of 11–16 years with the following inclusion criteria was selected and informed consent was obtained.
Inclusion Criteria
-
Adolescents willing to take part in the study.
-
Adolescents who are highly anxious about dental treatment.
-
Adolescent with comprehensive treatment needs such as oral prophylaxis, tooth restorations, and procedures requiring local anesthesia (LA).
Exclusion Criteria
-
Those who are not willing to participate.
-
Those who are not anxious about dental procedures.
-
Special children who are not able to cooperate.
The selected 100 adolescents were randomly allocated into two groups based on the management technique employed. Group I participants were managed with a retraining technique. These two groups were further divided into two subgroups with 25 participants in each based on gender.
Group I (study group)—group IA—boys; group IB—girls.
Group II (control group)—group IIA—boys; group IIB—girls.
Intraoral examination and oral prophylaxis procedures in both groups were done on the first visit. Cavity preparation followed by restoration and procedures requiring LA were planned in the second visit.
Group I
The retraining technique includes distraction, avoidance, and substitution.
Distraction
Dental sounds such as airotor and suction apparatus during the treatment procedure will provoke anxiety. To avoid these dental sounds, patients were asked to wear headphones to listen to songs (audio distraction) or watch their favorite show on television (audiovisual distraction). This will distract the patient from unpleasant dental sounds which in turn reduces their anxiety levels (Fig. 1).
Fig. 1: Management of dentally anxious secondary school child with retraining technique
Avoidance and Substitution
If the patient was afraid of any dental sounds or chemicals which provoke anxiety then they were avoided and replaced with another. If the patient had discomfort with the sound of the suction apparatus, then they were asked to spit in the spittoon avoiding the suction apparatus. Cotton isolation with intermittent suction was done to avoid the sound of a high-volume suction apparatus. If the patient had discomfort with the usage of zinc oxide eugenol cement, it was replaced with other restorative material. If the patient had discomfort with airotor, it was substituted with a spoon excavator or chemomechanical caries removal agents. If the patient had discomfort with ultrasonic scalers, they were substituted with hand scalers. In the case of extraction or pulpal therapy, as many of the patients were afraid of injection prick, a local anesthetic topical spray was applied followed by administration of LA using an insulin syringe or electronic dental anesthesia.
During the treatment procedure, the patient was asked to raise their hand if there was any history of pain/anxiety if so the procedure was immediately stopped and the patient was reassured. If the patient had severe anxiety, then a short break was given in between the procedure, and the patient was asked to do breathing and muscle relaxation exercises. The operating pediatric dentist had shown utmost patience throughout the procedure and reassured the adolescent to complete the treatment.
Group II
In this group the dental procedure was done with general instructions. If the patient was apprehensive, then the procedure was stopped and another appointment was given.
In the last appointment of the treatment plan, each patient was again given MDAS questionnaire and postintervention DA scores were measured. If the patient didn’t turn up, then the anxiety score was taken as 25 which is the highest score. The respective operating pediatric dentist was blind to the postoperative DA scores. One blinded observer calibrated the preintervention and postintervention DA scale values. The obtained data was statistically analyzed with Statistical Package for the Social Sciences (SPSS) version 22 using the Wilcoxon sign ranked test.
RESULTS
The preinterventional mean DA in group IA is 17.86 ± 1.98. The preinterventional mean DA in group IIA is 17.72 ± 1.99. The preinterventional mean DA scores show no statistical significant differences between group IA and group IIA.
The postinterventional mean DA in group IA is 9.72 ± 1.42. The postinterventional mean DA in group IIA is 18.04 ± 1.64. Postinterventional mean DA scores show statistical significant differences between group IA and group IIA.
The preinterventional mean DA in group IB is 19.32 ± 1.90. The preinterventional mean DA in group IIB is 18.88 ± 2.04. The preinterventional mean DA scores show no statistical significant difference.
The postinterventional mean DA in group IB is 9.84 ± 1.06. The postinterventional mean DA in group IIB is 19.56 ± 1.58. Postinterventional mean DA scores show significant differences between the two groups.
A statistical significant difference (p < 0.05) between preinterventional mean DA and postinterventional mean DA in group IA was seen. Group IB also shows a statistical significant difference (p < 0.05) between preinterventional mean DA and postinterventional mean DA scores (Table 1). No statistical significant difference was seen between preinterventional mean DA and postinterventional mean DA scores in group IIA (p > 0.05). Preinterventional mean DA and postinterventional mean DA scores show no statistical significant difference in group IIB (p > 0.05) (Table 2).
| Group | Preintervention mean DA score | Postintervention mean DA score | p-value (<0.05) |
|---|---|---|---|
| Group IA | 17.86 ± 1.98 | 9.72 ± 1.42 | 0.000 (significant) |
| Group IB | 19.32 ± 1.90 | 9.84 ± 1.06 | 0.000 (significant) |
| Group | Preintervention mean DA score | Postintervention mean DA score | p-value (<0.05)—significance |
|---|---|---|---|
| Group IIA | 17.72 ± 1.99 | 18.04 ± 1.64 | 0.039(no significance) |
| Group IIB | 18.88 ± 2.04 | 19.56 ± 1.58 | 0.011 (no significance) |
DISCUSSION
Dental anxiety (DA) is a major issue which is prevalent worldwide. The quality of dental care and ultimately the quality of life can be improved by reducing the anxiety of the patient when a dental issue arises.10 Dentally anxious individuals, because of their avoidant behavior, often have poorer dental health.11,12 Those people who delay dental visits for a prolonged time might have extensive problems that require more complex and complicated treatment.13 Bad dental experiences in the past might be a key factor in the initiation of anxiety toward dental treatment. Fotedar et al.14 in their study concluded that a correlation was seen between negative dental experience in the past and MDAS score. Identifying these anxious individuals can enable the dentist to retrain them which reduces DA and instill a positive dental attitude.
The Modified Dental Anxiety Scale (MDAS) (modified version of Corah Dental Anxiety Scale) is considered to assess anxiety for community-based research and is easy to compare responses. This MDAS comprises five different questions related to a dental situation that was given to the study population. They rate the anxiety level score according to their perception of a particular dental situation. Considering its advantages, in the present study this scale was considered to know the anxiety levels of the study population.
Anxiety reduces as age advances,15 hence adults try to cooperate during the procedure, but children and adolescents tend to postpone them. This study was planned on secondary school children who were highly anxious to dental treatment. In our study Female patients have more anxiety than male patients and these results were similar to studies done earlier.16,17 Social factors such as phobia, panic, depression, stress, and fear are more common in females.18 This might be the reason in our study female patients have high DA than male patients.
There are many behavior management techniques in pediatric dentistry but the technique that is commonly used for adults shouldn’t be childish as secondary school children have enough maturity to understand the situation. The only criterion is to reduce the DA. Conscious sedation is a pharmacological behavior management technique that reduces anxiety but this conscious sedation unit is expensive and it is not readily available in all dental clinics, hence behavior management technique called retraining technique is used in the present study. By following these simple procedures such as distraction, avoidance, and substitution anxiety can be reduced in secondary school children.
In the present study as the retraining management technique reduced anxiety levels, there was no postponement of appointments in group I whereas in group II because of apprehension, there was the postponement of appointments and some patients even didn’t turn up to the clinic. Deogade et al. also concluded that adult patients who are highly anxious about dental treatment tend to postpone their visit.19 Participants of group II who didn’t turn up to the clinic were recalled after the study and completed the treatment procedures using retraining techniques to instill a positive dental attitude in them. During the treatment procedure, the clinician asked the patients to raise their hands if they had any complaint of anxiety/pain, which made them feel that treatment, was in their hands which in turn reduced anxiety levels.20
Patients visiting the hospital with tooth pain tend to be highly anxious compared to the patients visiting for cosmetic reasons.10 Tooth cavity preparation and restoration is the most common procedure preferred in dental clinics for the management of tooth pain associated with reversible pulpitis. Retraining management technique is the most effective technique to reduce anxiety toward dental procedures ranging from minimally invasive procedures such as cavity preparations, and oral prophylaxis to highly invasive procedures such as extraction and pulpectomies.
Since the majority of adolescent patients were anxious and scared of injection pricks, in this study adolescents were distracted with audio or audiovisual methods, and an insulin syringe was used for LA administration. Thinner gauge needles cause less pain during tissue penetration which results in a decrease in anxiety during LA administration.21 Similarly, Khandelwal et al.22 and Prabhakar et al.23 in their study concluded that a decrease in anxiety was seen in children distracted with audio-visual methods.
CONCLUSION
Secondary school children who were highly anxious tend to avoid dental procedures and it is a barrier to render quality oral health services. Identifying these anxious children prior to the treatment and managing them with the retraining technique was found to reduce their anxiety and thereby instill a positive dental attitude toward dental procedures.
ORCID
Srikanth Saraswati https://orcid.org/0000-0001-7442-3821
Kiranmayi Merum https://orcid.org/0000-0003-4266-5847
REFERENCES
1. American pPsychiatric a-Association. Diagnostic and statistical Manual of Mental Disorders DSM- IV. Washington, DC: American Psychiatric Association; 1994.
2. Locker D, Liddell AM. Correlates of dental anxiety among older adults. J Dent Res 1991;70(3):198–203. DOI: 10.1177/00220345910700030801
3. Teo CS, Foong W, Lui HH, et al. Prevalence of dental fear in young adult Singaporeans. Int Dent J 1990;40(1):37–42.
4. Hakeberg M, Berggren U, Carlsson SG. Prevalence of dental anxiety in an adult population in a major urban area in Sweden. Community Dent Oral Epidemiol 1992;20(2):97–101. DOI: 10.1111/j.1600-0528.1992.tb00686.x
5. Kvale G, Berg E, Raadal M. The ability of Corah’s Dental Anxiety Scale and Spielberger’s State Anxiety Inventory to distinguish between fearful and regular Norwegian dental patients. Acta Odontol Scand 1998;56(2):105–109. DOI: 10.1080/00016359850136076
6. Gift HC, Atchison KA. Oral health, health, and health-related quality of life. Med Care 1995;33(11 Suppl):NS57–NS77. DOI: 10.1097/00005650-199511001-00008
7. Thomson WM, Stewart JF, Carter KD, et al. Dental anxiety among Australians. Int Dent J 1996;46(4):320–324.
8. Locker D, Shapiro D, Liddell A. Overlap between dental anxiety and blood-injury fears: psychological characteristics and response to dental treatment. Behav Res Ther 1997;35(7):583–590. DOI: 10.1016/s0005-7967(97)00016-8
9. Seeman K, Molin C. Psychopathology, feelings of confinement and helplessness in the dental chair, and relationship to the dentist in patients with disproportionate dental anxiety (DDA). Acta Psychiatr Scand 1976;54(2):81–91. DOI: 10.1111/j.1600-0447.1976.tb00099.x
10. Jeddy N, Nithya S, Radhika T, et al. Dental anxiety and influencing factors: a cross-sectional questionnaire-based survey. Indian J Dent Res 2018;29(1):10–15. DOI: 10.4103/ijdr.IJDR_33_17
11. Eitner S, Wichmann M, Paulsen A, et al. Dental anxiety–an epidemiological study on its clinical correlation and effects on oral health. J Oral Rehabil 2006;33(8):588–593. DOI: 10.1111/j.1365-2842.2005.01589.x
12. Armfield JM, Slade GD, Spencer AJ. Dental fear and adult oral health in Australia. Community Dent Oral Epidemiol 2009;37(3):220–230. DOI: 10.1111/j.1600-0528.2009.00468.x
13. Sinha E, Rekha R, Nagashree SR. Anxiety of dental treatment among patients visiting primary health centers. J Indian Assoc Public Health Dent 2019;17(3):235–240. DOI: 10.4103/jiaphd.jiaphd_178_18
14. Fotedar S, Bhardwaj V, Fotedar V. Dental anxiety levels and factors associated with it among patients attending a dental teaching institute in Himachal Pradesh. SRM J Res Dent Sci 2016;7(3):153–157. DOI: 10.4103/0976-433X.188799
15. Folayan MO, Idehen EE, Ojo OO. The modulating effect of culture on the expression of dental anxiety in children: a literature review. Int J Paediatr Dent 2004;14(4):241–245. DOI: 10.1111/j.1365-263X.2004.00563.x
16. Reddy ER, Raju SS, Merum K, et al. Postgraduates’ perspective of pediatric dental chair: a questionnaire study. Int J Clin Pediatr Dent 2020;13(3):251–254. DOI: 10.5005/jp-journals-10005-1758
17. Udoye CI, Oginni AO, Oginni FO. Dental anxiety among patients undergoing various dental treatments in a Nigerian teaching hospital. J Contemp Dent Pract 2005;6(2):91–98.
18. Arslan S, Ertas E, Ülker M. The relationship between dental fear and sociodemographic variables. Erciyes Med J 2011;33(4):295–300.
19. Deogade SC, Suresan V. Psychometric assessment of anxiety with the Modified Dental Anxiety Scale among central Indian adults seeking oral health care to a dental school. Ind Psychiatry J 2016;25(2):202–209. DOI: 10.4103/ipj.ipj_16_16
20. American Academy of Pediatric Dentistry. Behavior guidance for the pediatric dental patient. The Reference Manual of Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry 2020;292–310.
21. Asokan A, Rao AP, Mohan G, et al. A pain perception comparison of intraoral dental anesthesia with 26 and 30 gauge needles in 6-12-year-old children.. J Pediatr Dent 2014;2(2):56–60.
22. Khandelwal M, Shetty RM, Rath S. Effectiveness of distraction techniques in managing pediatric dental patients. Int J Clin Pediatr Dent 2019;12(1):18–24. DOI: 10.5005/jp-journals-10005-1582
23. Prabhakar AR, Marwah N, Raju OS. A comparison between audio and audiovisual distraction techniques in managing anxious pediatric dental patients. J Indian Soc Pedod Prev Dent 2007;25(4):177–182. DOI: 10.4103/0970-4388.37014
________________________
© The Author(s). 2023 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and non-commercial reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.