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Nonpharmacologic Intervention on the Prevention of Pain and Anxiety During Pediatric Dental Care: A Systematic Review

      Abstract

      Background

      Nonpharmacologic interventions may be used to reduce fear and anxiety during dental treatment.

      Objectives

      To systematically review trials on the effect of nonpharmacologic interventions in behavior, anxiety, and pain perception in children undergoing dental treatment.

      Data sources

      Medline, Scopus, Web of Science and CINAHL, Google Scholar, and studies' reference lists.

      Participants and Interventions

      Studies performed with children and adolescents that evaluated the effect of interventions on children's behavior, anxiety, and pain perception during dental treatment were included.

      Study Appraisal Methods

      Independent quality assessment of the studies was carried out following the classification categories present on the Cochrane Handbook for Development of Systematic Reviews of Intervention.

      Results

      Twenty-two articles, reporting 21 studies, were selected. Most studies tested distraction techniques. Eight studies presented bias and results were not considered. The remaining 13 studies had control groups with inactive controls, and 4 also included a variation of the intervention. Of the 4 studies assessing behavior, 3 found difference between intervention and control. Anxiety was evaluated by 10 studies: 4 found differences between intervention and control and 2 found differences between interventions. Five studies investigated pain perception: 3 found difference comparing active versus inactive interventions. In 1 of the 3, variations in the intervention decreased pain perception.

      Conclusions

      More research is needed to know whether the techniques are effective for improving behavior and reducing children's pain and distress during dental treatment. However, the majority of the techniques improved child's behavior, anxiety, and pain perception.

      Keywords

      What This Systematic Review Adds
      • Nonpharmacologic approaches can be effective in behavior management.
      • A range of nonpharmacologic techniques may be used to manage children's dental fear and anxiety; most interventions are effective.
      • Future studies are recommended to confirm the effectiveness of some of the techniques.
      How to Use This Systematic Review
      • This systematic review can help primary care providers counsel the family about the possibilities of effective behavior management.
      • Dentists can use nonpharmacologic methods to address anxiety and fear either in place of pharmacologic approaches or, when appropriate, in addition to them.
      According to the latest survey of oral health conducted in Brazil, the oral health status of children and adolescents has improved in many aspects; however, access to health services is still poor, especially in economically disadvantaged populations.
      • Roncalli A.G.
      Projeto SB Brasil 2010: pesquisa nacional de saúde bucal revela importante redução da cárie dentária no país.
      • de Melo Costa S.
      • de Abreu M.H.N.G.
      • Vasconcelos M.
      • et al.
      [Inequalities in the distribution of dental caries in Brazil: a bioethical approach].
      Besides factors associated with access to dental care, psychosocial factors such as fear and anxiety may also compromise dental care, interfering with regular oral health care and contributing to poor oral conditions in children.
      • Karnad M.
      Dental anxiety—how would you manage it?.
      In the United States, a national survey showed that many actions to improve oral health, encouraged by medical policies, are performed by pediatricians. Thus, the management of child's behavior and anxiety is deemed important in the general health context.
      • Gereige R.S.
      • Dhepyasuwan N.
      • Garcia K.L.
      • et al.
      Pediatric residents' knowledge and comfort with oral health Bright Futures concepts: a CORNET study.
      Dental fear and anxiety can have psychologic, cognitive, and behavioral effects in children. The behavior, focused on the degree of cooperation that the child exhibits during dental treatment, appears to be conditioned by many situations such as level of mental development, temperament, and previous experiences, as well as the attitude and anxiety of parents.
      • Salem K.
      • Kousha M.
      • Anissian A.
      • et al.
      Dental fear and concomitant factors in 3–6-year-old children.
      • Crego A.
      • Carrillo-Díaz M.
      • Armfield J.M.
      • et al.
      From public mental health to community oral health: the impact of dental anxiety and fear on dental status.
      It has been shown that positive experiences can reduce dental fear and improve children's oral health–related quality of life.
      • Luoto A.
      • Lahti S.
      • Nevanpera T.
      • et al.
      Oral-health-related quality of life among children with and without dental fear.
      Dental procedures are a common source of pain and distress for children. The identification of behaviors that indicate traces of anxiety during dental treatment and use of management strategies of anxiety and pain perception, allied with the establishment of a trust relationship among the child, the family, and the health care professional, can contribute to positive experiences during the treatment.
      • Assunção C.M.
      • Losso E.M.
      • Andreatini R.
      • et al.
      The relationship between dental anxiety in children, adolescents and their parents at dental environment.
      • Majstorovic M.
      • Morse D.
      • Do D.
      • et al.
      Indicators of dental anxiety in children just prior to treatment.
      A number of psychologic interventions for managing pain and distress in children exist that help individuals develop and use coping skills to manage pain and distress. Systematic reviews examining the effect of nonpharmacologic interventions during injections,
      • Uman L.S.
      • Chambers C.T.
      • McGrath P.J.
      • et al.
      Psychological interventions for needle-related procedural pain and distress in children and adolescents.
      during medical procedures,
      • Klassen J.A.
      • Liang Y.
      • Tjosvold L.
      • et al.
      Music for pain and anxiety in children undergoing medical procedures: a systematic review of randomized controlled trials.
      and in emergency departments
      • Wente S.J.
      Nonpharmacologic pediatric pain management in emergency departments: a systematic review of the literature.
      have shown the efficacy of using these techniques to manage pediatric pain and distress.
      In recent years, studies have been conducted to evaluate the effectiveness of additional resources for behavior management in dental treatment, which use distraction, visualization, and persuasion, combined with traditional techniques.
      American Academy on Pediatric Dentistry Clinical Affairs Committee-Behavior Management Subcommittee; American Academy on Pediatric Dentistry Council on Clinical Affairs
      Guideline on behavior guidance for the pediatric dental patient.
      The use of the techniques such as viewing positive images related to dental care,
      • Fox C.
      • Newton J.
      A controlled trial of the impact of exposure to positive images of dentistry on anticipatory dental fear in children.
      • Ramos-Jorge M.
      • Ramos-Jorge J.
      • de Andrade R.V.
      • et al.
      Impact of exposure to positive images on dental anxiety among children: a controlled trial.
      virtual reality,
      • Aminabadi N.A.
      • Vafaei A.
      • Erfanparast L.
      • et al.
      Impact of pictorial story on pain perception, situational anxiety and behavior in children: a cognitive-behavioral schema.
      • Hoge M.A.
      • Howard M.R.
      • Wallace D.P.
      • et al.
      Use of video eyewear to manage distress in children during restorative dental treatment.
      music,
      • Marwah N.
      • Prabhakar A.
      • Raju O.
      Music distraction-Its efficacy in management of anxious pediatric dental patients.
      and magic tricks
      • Peretz B.
      • Gluck G.
      Magic trick: a behavioural strategy for the management of strong willed children.
      could facilitate compliance, obtain improvement in child behavior, and decrease anxiety and pain perception.
      It is important that such evaluations are conducted using appropriate methodologies, aiming to provide reliable answers about their effectiveness and reinforcing its use in pediatric dentistry. For this, randomized clinical trials are the most appropriate methodology to adequately evaluate the effects of interventions in health, considering that the technique is tested after randomization, which allows the same probability of an individual belonging to the intervention group or control group.
      • Altman D.G.
      • Schulz K.F.
      • Moher D.
      • et al.
      The revised CONSORT statement for reporting randomized trials: explanation and elaboration.
      Thus, our review sought to systematically review the existing literature on randomized clinical trials on the effect of nonpharmacologic interventions on behavior, anxiety, and pain perception in children undergoing dental treatment compared to inactive or active controls.

      Methods

      Search Methods for Identification of Studies

      This systematic review was oriented following the Preferred Reporting Items for Systematic Reviews and Meta-analyses protocol.
      • Moher D.
      • Liberati A.
      • Tetzlaff J.
      • et al.
      PRISMA Group
      Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
      A systematic search of articles published before February 2016 was conducted following the criteria described in the Inclusion/Exclusion Criteria. The electronic databases used were Medline via PubMed (1953–present), Scopus (1823–present), Web of Science (1945–present) and CINAHL (1976–present). Also, Google Scholar was used as a method for searching for literature (limited to the 100 most relevant articles). The syntax used for the search adapted to each database is described in Table 1. The electronic search was supplemented by a manual cross-reference search of identified articles. The references of articles that were read in full were checked to identify potentially relevant studies. Only articles in English were included. No publication status or publication date restrictions were imposed. All references were managed by the reference manager software EndNote Basic (Thomson Reuters, New York, NY), and duplicates were removed.
      Table 1Keywords and Databases Used for Search
      DatabaseKeywords
      Medline(“dental treatment” OR “dentistry” [Mesh] OR “dentistry” [All fields] OR “dental care” [Mesh]) OR “dental care” [All fields]) AND (“dental anxiety” [Mesh] OR “dental anxiety” [All fields] OR “dental fear” OR “dental fears” OR “fears, dental” OR “Odontophobia” OR “Odontophobias” OR “Phobia, Dental” OR “Dental Phobias” OR “Phobias, Dental” OR “Dental Phobia” OR “Anxiety, Dental” OR “Anxieties, Dental” OR “Dental Anxieties” OR “Fear, Dental” OR “behavior”[Mesh] OR “behavior” [All fields] OR “behaviors” OR “pain” OR “dental pain” OR “behavior management” [All fields] OR “behavior guidance” [All fields] OR “Behavior Modification” OR “Behavior Modifications” OR “Modification, Behavior” OR “Modifications, Behavior”)
      Scopus(TITLE-ABS-KEY(“dental treatment” OR “dentistry” OR “dental care”) AND TITLE-ABS-KEY(“dental anxiety” OR “dental fear” OR “dental fears” OR “Odontophobia” OR “Odontophobias” OR “Dental Anxieties” OR “behavior” OR “behaviors” OR “pain” OR “dental pain” OR “behavior management” OR “behavior guidance” OR “Behavior Modification” OR “Behavior modifications”)) AND (“child” OR “preschool children” OR “adolescent”) AND (LIMIT-TO(DOCTYPE,“ar”)) AND (LIMIT-TO(SUBJAREA,“DENT”) AND (“clinical trial” OR “randomized controlled trial” “controlled clinical trial”))
      Web of Science(“dental treatment” OR “dentistry” OR “dental care”) AND (“dental anxiety” OR “dental fear” OR “dental fears” OR “Odontophobia” OR “Odontophobias” OR “Dental Anxieties” OR “behavior” OR “behaviors” OR “pain” OR “dental pain” OR “behavior management” OR “behavior guidance” OR “Behavior Modification” OR “Behavior modifications”)) AND (“child” OR “preschool children” OR “adolescent”) AND (“clinical trial” OR “randomized controlled trial” OR “controlled clinical trial”))
      CINAHL(“dental treatment” OR “dentistry” OR “dental care”) AND (“dental anxiety” OR “dental fear” OR “dental fears” OR “Odontophobia” OR “Odontophobias” OR “Dental Anxieties” OR “behavior” OR “behaviors” OR “pain” OR “dental pain” OR “behavior management” OR “behavior guidance” OR “Behavior Modification” OR “Behavior modifications”))
      Google Scholar“dental treatment” AND “randomized clinical trial” AND “behavior management”

      Inclusion/Exclusion Criteria

      The inclusion criteria for the study were related to: (1) types of studies: randomized clinical trials assessing the use of nonpharmacologic interventions in the management of children's behavior during dental care, comparing with a nonintervention (usual treatment or inactive controls) or comparing with other interventions or variations of the same intervention (active controls); (2) types of participants: children and adolescents up to 18 years for dental treatment, not physically or mentally handicapped, with or without a history of dental care; (3) outcomes: interventions that evaluated behavior, anxiety, and pain perception. The exclusion criteria were: (1) cross-sectional studies, cohort studies, case reports, reviews, letters, and conference abstracts; (2) clinical trials investigating nonpharmacologic interventions that were not cognitive behavioral (for example, acupuncture; heat or cold); (3) clinical trials in which the outcomes were not behavior, pain, or anxiety; (4) clinical trials that used pharmacologic techniques, nitrous oxide, or general anesthesia; and (5) clinical trials conducted in individuals older than 18.

      Study Selection

      The articles were selected by title and abstracts according to the inclusion/exclusion criteria independently by 2 authors to identify eligible papers. To avoid double counting, data from multiple reports of the same study were identified. Thereafter, the reading of full papers that met the inclusion criteria was performed. Two review authors made the collection. Any disagreement of inclusion, exclusion, and quality assessment criteria was discussed to be resolved; if resolution could not be reached, a third reviewer was consulted.

      Quality Assessment

      Independent quality assessment of the included studies was carried out following the classification categories present on the Cochrane Handbook for Development of Systematic Reviews of Intervention, version 5.1.0 (Cochrane Handbook), as follows: random sequence generation and allocation concealment (selection bias), blinding of participants and personal (performance bias), blinding of outcome assessment (detection bias), incomplete outcome data (attrition bias), selective reporting (reporting bias), and other bias. The quality evaluation was performed in Review Manager 5.3 software.

      Data Extraction

      Data extraction was conducted by 2 reviewers by completely reading the articles and analysis of the variables related with behavior control, anxiety, and pain perception, without being blinded to authors, institutions, journal name, or trial results. A specifically designed data sheet in Microsoft Excel (Microsoft, Redmond, WA) was developed and previously piloted. For each trial, the following information was extracted by 2 authors independently: (1) study characteristics (authors, country and year of publication), (2) participants' characteristics (sample size, age at and history of previous treatment), (3) type of intervention tested, including duration and frequency, (4) comparison groups (active or inactive control), (5) criteria used to evaluate outcomes (behavior, pain, and/or anxiety), and (6) main results. All the summary measures reported, and any comparisons in means and frequencies of related outcome measure were collected. Disagreements between authors concerning data extracted were resolved through discussion and consensus. The third author was involved, when required, to make a final decision. Authors were contacted for further details when relevant information was not reported or when doubt remained about duplicate publication.

      Results

      Study Selection

      Figure 1 depicts the results of the search, according to each stage. A search in the databases resulted in 2175 records. After removing duplicate articles, the title and abstract of 1966 records were screened. The full text of 32 articles was evaluated. The references lists were searched to detect any relevant publication. Five articles were then included. The first 100 records in Google Scholar identified one additional study. Of the 38 potentially relevant papers considered, 17 were excluded. Three were excluded by characteristics of the participants (age and patients with disabilities), 4 did not have the study design of interest, 2 did not evaluate the outcome during the appointment, 2 were excluded because they included pharmacologic intervention, 2 were excluded because they used usual techniques for the management of the behavior, and 3 were not in English and/or were not available. Twenty-two articles involving 21 studies met the inclusion criteria and were selected for review. Two of them reported different analyses of the same studies; however, one of the articles was not in English.
      • Farhat-Mchayleh N.
      • Sabbagh J.
      • Souaid P.
      [Multidisciplinary approach to behavior control of children during dental care: clinical study on the effect of learning by imitation].
      • Farhat-McHayleh N.
      • Harfouche A.
      • Souaid P.
      Techniques for managing behaviour in pediatric dentistry: comparative study of live modelling and tell–show–do based on children's heart rates during treatment.

      Description of Included Studies

      Characteristics of studies are shown in Supplementary Table. Most studies tested distraction techniques. The techniques used were music, virtual reality, magic tricks, exposure to positive dental images, modeling, provision of information or preparation, counterstimulation during the procedure, noncontingent stops, camouflage of syringe, and active distraction with movements. Research was conducted in 10 different countries: United States, Iran, Saudi Arabia, Egypt, Lebanon, United Kingdom, India, Thailand, Israel, and Brazil. The studies included in this systematic review were published between 1981 and 2015.

      Quality Assessment

      Figure 2, Figure 3 report the quality of the studies included.
      Figure 2
      Figure 2Risk of bias summary illustrating review authors' judgments about each risk of bias item for each included study.
      Figure 3
      Figure 3Risk of bias graph illustrating review authors' judgments about each risk of bias item presented as percentages across all included studies.

      Random sequence generation and allocation concealment

      Of the clinical trials included in the systematic review, 6 did not report the method of random sequence generation.
      • Aminabadi N.A.
      • Vafaei A.
      • Erfanparast L.
      • et al.
      Impact of pictorial story on pain perception, situational anxiety and behavior in children: a cognitive-behavioral schema.
      • Farhat-McHayleh N.
      • Harfouche A.
      • Souaid P.
      Techniques for managing behaviour in pediatric dentistry: comparative study of live modelling and tell–show–do based on children's heart rates during treatment.
      • Aitken J.C.
      • Wilson S.
      • Coury D.
      • et al.
      The effect of music distraction on pain, anxiety and behavior in pediatric dental patients.
      • Aminabadi N.A.
      • Erfanparast L.
      • Sohrabi A.
      • et al.
      The impact of virtual reality distraction on pain and anxiety during dental treatment in 4–6-year-old children: a randomized controlled clinical trial.
      • Attar R.
      • Baghdadi Z.
      Comparative efficacy of active and passive distraction during restorative treatment in children using an iPad versus audiovisual eyeglasses: a randomised controlled trial.
      • Mitrakul K.
      • Asvanund Y.
      • Arunakul M.
      • et al.
      Effect of audiovisual eyeglasses during dental treatment in 5–8 year-old children.
      Considering allocation concealment, 9 articles did not describe the allocation concealment,
      • Hoge M.A.
      • Howard M.R.
      • Wallace D.P.
      • et al.
      Use of video eyewear to manage distress in children during restorative dental treatment.
      • Marwah N.
      • Prabhakar A.
      • Raju O.
      Music distraction-Its efficacy in management of anxious pediatric dental patients.
      • Peretz B.
      • Gluck G.
      Magic trick: a behavioural strategy for the management of strong willed children.
      • Farhat-McHayleh N.
      • Harfouche A.
      • Souaid P.
      Techniques for managing behaviour in pediatric dentistry: comparative study of live modelling and tell–show–do based on children's heart rates during treatment.
      • Aitken J.C.
      • Wilson S.
      • Coury D.
      • et al.
      The effect of music distraction on pain, anxiety and behavior in pediatric dental patients.
      • Attar R.
      • Baghdadi Z.
      Comparative efficacy of active and passive distraction during restorative treatment in children using an iPad versus audiovisual eyeglasses: a randomised controlled trial.
      • Mitrakul K.
      • Asvanund Y.
      • Arunakul M.
      • et al.
      Effect of audiovisual eyeglasses during dental treatment in 5–8 year-old children.
      • Ujaoney S.
      • Mamtani M.
      • Thakre T.
      • et al.
      Efficacy trial of camouflage syringe to reduce dental fear and anxiety.
      • Venham L.L.
      • Goldstein M.
      • Gaulin-Kremer E.
      • et al.
      Effectiveness of a distraction technique in managing young dental patients.
      and 2 studies used a coin flip, a procedure that does not conceal the allocation.
      • Kamath P.
      A novel distraction technique for pain management during local anesthesia administration in pediatric patients.
      • El-Sharkawi H.F.
      • El-Housseiny A.A.
      • Aly A.M.
      Effectiveness of new distraction technique on pain associated with injection of local anesthesia for children.

      Blinding

      The blinding of studies in this systematic review proved limited. Of the 21 clinical trials included, just 6 reported blinding of the participants, researchers, or both.
      • Fox C.
      • Newton J.
      A controlled trial of the impact of exposure to positive images of dentistry on anticipatory dental fear in children.
      • Ramos-Jorge M.
      • Ramos-Jorge J.
      • de Andrade R.V.
      • et al.
      Impact of exposure to positive images on dental anxiety among children: a controlled trial.
      • Aminabadi N.A.
      • Vafaei A.
      • Erfanparast L.
      • et al.
      Impact of pictorial story on pain perception, situational anxiety and behavior in children: a cognitive-behavioral schema.
      • Aitken J.C.
      • Wilson S.
      • Coury D.
      • et al.
      The effect of music distraction on pain, anxiety and behavior in pediatric dental patients.
      • Olumide F.
      • Newton J.T.
      • Dunne S.
      • et al.
      Anticipatory anxiety in children visiting the dentist: lack of effect of preparatory information.
      • Srai J.P.
      • Petrie A.
      • Ryan F.S.
      • et al.
      Assessment of the effect of combined multimedia and verbal information vs verbal information alone on anxiety levels before bond-up in adolescent orthodontic patients: a single-center randomized controlled trial.
      In some studies it was not possible to blind the children in view of the nature of the intervention.
      • Farhat-McHayleh N.
      • Harfouche A.
      • Souaid P.
      Techniques for managing behaviour in pediatric dentistry: comparative study of live modelling and tell–show–do based on children's heart rates during treatment.
      • Attar R.
      • Baghdadi Z.
      Comparative efficacy of active and passive distraction during restorative treatment in children using an iPad versus audiovisual eyeglasses: a randomised controlled trial.
      • Mitrakul K.
      • Asvanund Y.
      • Arunakul M.
      • et al.
      Effect of audiovisual eyeglasses during dental treatment in 5–8 year-old children.
      • Ujaoney S.
      • Mamtani M.
      • Thakre T.
      • et al.
      Efficacy trial of camouflage syringe to reduce dental fear and anxiety.
      • El-Sharkawi H.F.
      • El-Housseiny A.A.
      • Aly A.M.
      Effectiveness of new distraction technique on pain associated with injection of local anesthesia for children.

      Outcome data and selective reporting

      Only one study reported losses during the intervention.
      • Wright N.S.
      • Fleming P.S.
      • Sharma P.K.
      • et al.
      Influence of supplemental written information on adolescent anxiety, motivation and compliance in early orthodontic treatment.
      Besides, the reporting of some outcomes proved unclear in 5 studies.
      • Aminabadi N.A.
      • Vafaei A.
      • Erfanparast L.
      • et al.
      Impact of pictorial story on pain perception, situational anxiety and behavior in children: a cognitive-behavioral schema.
      • Hoge M.A.
      • Howard M.R.
      • Wallace D.P.
      • et al.
      Use of video eyewear to manage distress in children during restorative dental treatment.
      • Aminabadi N.A.
      • Erfanparast L.
      • Sohrabi A.
      • et al.
      The impact of virtual reality distraction on pain and anxiety during dental treatment in 4–6-year-old children: a randomized controlled clinical trial.
      • Venham L.L.
      • Goldstein M.
      • Gaulin-Kremer E.
      • et al.
      Effectiveness of a distraction technique in managing young dental patients.
      • Aminabadi N.A.
      • Farahani R.
      • Balayi Gajan E.
      The efficacy of distraction and counterstimulation in the reduction of pain reaction to intraoral injection by pediatric patients.

      Effect of Interventions

      A meta-analysis was not performed because the intervention and groups tested in studies were too different and the outcomes measured were not sufficiently similar. Thus, we report a qualitative synthesis of the results. To easily interpret the results, the studies were clustered according to the type of intervention tested.
      Eight studies presented bias according to the items assessed, and thus their results are not presented. The main results of the 13 studies are detailed in Table 2. All of the studies had control groups with inactive controls. In 4 of the studies, a variation in the intervention was also tested.
      • Marwah N.
      • Prabhakar A.
      • Raju O.
      Music distraction-Its efficacy in management of anxious pediatric dental patients.
      • Farhat-McHayleh N.
      • Harfouche A.
      • Souaid P.
      Techniques for managing behaviour in pediatric dentistry: comparative study of live modelling and tell–show–do based on children's heart rates during treatment.
      • Aitken J.C.
      • Wilson S.
      • Coury D.
      • et al.
      The effect of music distraction on pain, anxiety and behavior in pediatric dental patients.
      • Aminabadi N.A.
      • Farahani R.
      • Balayi Gajan E.
      The efficacy of distraction and counterstimulation in the reduction of pain reaction to intraoral injection by pediatric patients.
      Of the 4 studies assessing the effect of techniques on children's behavior, 3 studies found statistically significant differences between intervention and inactive control groups. The anxiety was evaluated by 10 studies, and 4 found a statistically significant difference between intervention and control groups, while 2 found differences between interventions. In addition, 5 studies investigated the influence of nonpharmacologic techniques on pain perception, and 3 found statistically significant results comparing active versus inactive interventions. In 1 of those 3 studies, variations in the intervention also decreased pain perception.
      Table 2Main Results of Studies Included
      StudyMain Results
      BehaviorPain PerceptionAnxiety
      Aitken
      • Aitken J.C.
      • Wilson S.
      • Coury D.
      • et al.
      The effect of music distraction on pain, anxiety and behavior in pediatric dental patients.
      Percentage of time spent quiet or demonstrating disruptive behavior among 3 groups was compared by ANOVA. No significant difference was found in any type of disruptive behavior among 3 groups during visits 1 or 2Using scale from 1 to 100 to measure pain, ANOVA found no significant difference in pain reported among groups 1 (29.4), 2 (28.8) and 3 (40.0) (P = .649)ANOVA was used to compare pre- and posttreatment anxiety measurements. No difference was found between preoperative (P = .632) and postoperative (P = .897) scores
      Aminabadi
      • Aminabadi N.A.
      • Farahani R.
      • Balayi Gajan E.
      The efficacy of distraction and counterstimulation in the reduction of pain reaction to intraoral injection by pediatric patients.
      ANOVA was used to compare mean SEM values: group 1 (control), SEM 8.25; group 2, SEM 5.07; group 3, SEM 3.41. All 3 modules of SEM in group 2 were consistently lower than in group 1. Group 3 surpassed 1 (P < .05). Results of post hoc demonstrated pain reaction in group 2 was significantly more than group 3 (P < .05)
      Aminabadi
      • Aminabadi N.A.
      • Vafaei A.
      • Erfanparast L.
      • et al.
      Impact of pictorial story on pain perception, situational anxiety and behavior in children: a cognitive-behavioral schema.
      ANCOVA was used for comparisons. mean SEM scores were 3.58 (SD 0.74) and 6.03 (SD 1.95) in test and control groups, respectively (P < .001, F = 57.002)Intensity of pain perceived by subjects in test group was significant less than in control group (P = .02, F = 5.595)Subjects in test group exhibited statistically significant lower situational anxiety compared to subjects in control group (P < .001, F = 271.024)
      Aminabadi
      • Aminabadi N.A.
      • Erfanparast L.
      • Sohrabi A.
      • et al.
      The impact of virtual reality distraction on pain and anxiety during dental treatment in 4–6-year-old children: a randomized controlled clinical trial.
      Paired samples and independent sample t tests were used. In group 1, mean FACES Pain Scale pain scores in first (with virtual reality distraction) and second (without virtual reality distraction) treatment sessions were 1.89 ± 0.65 and 3.00 ± 0.81, showing statistically significant increase in pain score. In group 2, mean of FACES Pain Scale score was 3.05 ± 0.60 in first treatment session (without virtual reality distraction), which decreased to 2.05 ± 0.60 in second session (with virtual reality distraction). In both groups, difference was detected between 2 treatment sessions (P < .001)In group 1, anxiety scores in first (with virtual reality distraction) and second (without virtual reality distraction) treatment sessions were 12.58 ± 1.01 and 17.68 ± 1.25, respectively. These values represent statistically significant increase in anxiety score. In group 2, anxiety score was 18.25 ± 1.02 in first treatment session (without virtual reality distraction), which decreased to 13.20 ± 1.00 in second treatment session (with virtual reality distraction). In both groups, statistically significant difference was detected between 2 treatment sessions
      Farhat-McHayleh
      • Farhat-McHayleh N.
      • Harfouche A.
      • Souaid P.
      Techniques for managing behaviour in pediatric dentistry: comparative study of live modelling and tell–show–do based on children's heart rates during treatment.
      Difference between group mean heart rates were compared by Bonferroni test. Average heart rate over entire treatment period was significantly lower among children in group A (live modeling by mother) than group B (live modeling by father; P = .034) and group C (control) (P = .005)
      Fox
      • Fox C.
      • Newton J.
      A controlled trial of the impact of exposure to positive images of dentistry on anticipatory dental fear in children.
      Difference in anticipatory anxiety between experimental and control groups was significant (Mann-Whitney U = 29.0, P < .001). Median-positive images was 0 and median-neutral images was 3
      Hoge
      • Hoge M.A.
      • Howard M.R.
      • Wallace D.P.
      • et al.
      Use of video eyewear to manage distress in children during restorative dental treatment.
      Percentage of any type of disruptive behavior was compared by ANCOVA. Children wearing video eyewear demonstrated significantly less disruptive behavior than those in control group (F[1.123] = 7.74; P = .006). Those in control group were disruptive 22% of time and those in experimental group 14% of timeNo effect on self-reported pain because children in both groups reported relatively low levels of pain (2–3 out of 10 on FPS-R).
      Marwah
      • Marwah N.
      • Prabhakar A.
      • Raju O.
      Music distraction-Its efficacy in management of anxious pediatric dental patients.
      Measures of child's anxiety level by VPT. Heart rate and oxygen saturation analyzed by one ANOVA and Mann-Whitney test. Only significant difference was observed between anxiety ratings among instrumental music group and nursery rhyme group, with lower anxiety rates in instrumental music group (P < .05) when measured by VPT and heart rates
      Olumide
      • Olumide F.
      • Newton J.T.
      • Dunne S.
      • et al.
      Anticipatory anxiety in children visiting the dentist: lack of effect of preparatory information.
      After reading leaflets, mean anxiety levels had dropped slightly from 2.12 to 1.56 and from 2.04 to 1.80 in experimental and control groups, respectively, but these drops were not statistically significant (Mann-Whitney U = 257.5, NS).
      Peretz
      • Peretz B.
      • Gluck G.
      Magic trick: a behavioural strategy for the management of strong willed children.
      • 1.
        Children shown magic trick sat significantly faster on dental chair than children not shown magic trick (141.2 ± 71.5 and 221.7 ± 110.7, respectively).
      • 2.
        Radiographs could be taken in significantly more children in magic-trick group (91% and 54%, respectively)
      • 3.
        Children in magic-trick group demonstrated more cooperative behavior (Frankl Behavior Scale categories 3 and 4)
      Ramos-Jorge
      • Ramos-Jorge M.
      • Ramos-Jorge J.
      • de Andrade R.V.
      • et al.
      Impact of exposure to positive images on dental anxiety among children: a controlled trial.
      No significant difference was detected between scores of VPT in 2 groups at any evaluation time
      Srai
      • Srai J.P.
      • Petrie A.
      • Ryan F.S.
      • et al.
      Assessment of the effect of combined multimedia and verbal information vs verbal information alone on anxiety levels before bond-up in adolescent orthodontic patients: a single-center randomized controlled trial.
      Statistically significant difference of 2 points (95% confidence interval for difference, 0.15–3.85) was found in median state anxiety scores between groups, with participants in intervention group showing lower state anxiety scores (P = .012)
      Venham
      • Venham L.L.
      • Goldstein M.
      • Gaulin-Kremer E.
      • et al.
      Effectiveness of a distraction technique in managing young dental patients.
      ANOVA showed no evidence that distraction procedure affected children's response during dental visits
      ANCOVA indicates analysis of covariance; ANOVA, analysis of variance; FPS-R, Faces Pain Scale—Revised; SD, standard deviation; SEM, self-expandable metal stent; and VPT, Venham Picture Test.

      Virtual reality

      Distraction through videos was evaluated by Srai et al
      • Srai J.P.
      • Petrie A.
      • Ryan F.S.
      • et al.
      Assessment of the effect of combined multimedia and verbal information vs verbal information alone on anxiety levels before bond-up in adolescent orthodontic patients: a single-center randomized controlled trial.
      and Venham et al.
      • Venham L.L.
      • Goldstein M.
      • Gaulin-Kremer E.
      • et al.
      Effectiveness of a distraction technique in managing young dental patients.
      Both studies found no statistically significant association between total score of anxiety and use of videos as distraction during treatment.
      Aminabadi et al
      • Aminabadi N.A.
      • Erfanparast L.
      • Sohrabi A.
      • et al.
      The impact of virtual reality distraction on pain and anxiety during dental treatment in 4–6-year-old children: a randomized controlled clinical trial.
      evaluated children using virtual reality eyeglasses at one visit and no device at the next visit compared to the opposite, and observed that the scores of FACES Pain Scale and anxiety level decreased with distraction with audiovisual glasses.
      Distraction with audiovisual glasses was evaluated by Hoge et al.
      • Hoge M.A.
      • Howard M.R.
      • Wallace D.P.
      • et al.
      Use of video eyewear to manage distress in children during restorative dental treatment.
      Authors found significantly less disruptive behavior in the group of children using audiovisual eyeglasses, but the intervention did not influence self-reported pain.

      Music distraction

      Aitken et al
      • Aitken J.C.
      • Wilson S.
      • Coury D.
      • et al.
      The effect of music distraction on pain, anxiety and behavior in pediatric dental patients.
      compared upbeat music distraction and relaxing music distraction with a control group (without music) during restorative treatment; their study did not reveal significant differences in behavior, pain perception, or anxiety. Marwah et al
      • Marwah N.
      • Prabhakar A.
      • Raju O.
      Music distraction-Its efficacy in management of anxious pediatric dental patients.
      investigated if listening to instrumental music or nursery-rhyme music through headphones influenced dental anxiety. The authors did not find significant differences between the control and intervention groups. A difference was detected between instrumental and nursery-rhyme music, with the former producing anxiety reduction.

      Magic tricks

      Peretz and Gluck
      • Peretz B.
      • Gluck G.
      Magic trick: a behavioural strategy for the management of strong willed children.
      evaluated the influence of magic tricks on behavior and observed that children in the intervention group showed more cooperative behavior.

      Modeling

      Farhat-McHayleh et al
      • Farhat-McHayleh N.
      • Harfouche A.
      • Souaid P.
      Techniques for managing behaviour in pediatric dentistry: comparative study of live modelling and tell–show–do based on children's heart rates during treatment.
      studied the influence of the live modeling technique with the mother and father as models. Average heart rate over the entire treatment period was significantly lower among children in the group live-modeled by the mother than among those live-modeled by the father or an inactive control group.

      Exposure to dentally positive images

      Ramos-Jorge et al
      • Ramos-Jorge M.
      • Ramos-Jorge J.
      • de Andrade R.V.
      • et al.
      Impact of exposure to positive images on dental anxiety among children: a controlled trial.
      and Fox and Newton
      • Fox C.
      • Newton J.
      A controlled trial of the impact of exposure to positive images of dentistry on anticipatory dental fear in children.
      tested exposure to positive images of dentistry before treatment compared to exposure to dentally neutral images; only the latter study resulted in an anxiety score significantly lower in the intervention group.

      Providing information or preparation

      The study conducted by Olumide et al
      • Olumide F.
      • Newton J.T.
      • Dunne S.
      • et al.
      Anticipatory anxiety in children visiting the dentist: lack of effect of preparatory information.
      failed to find a statistically significant difference in the outcomes measured between the group that underwent use of a preparatory pamphlet on dental care and the group that did not. Aminabadi et al
      • Aminabadi N.A.
      • Vafaei A.
      • Erfanparast L.
      • et al.
      Impact of pictorial story on pain perception, situational anxiety and behavior in children: a cognitive-behavioral schema.
      investigated if a story about going to the dentist influenced pain perception and anxiety, and observed that scores of pain and anxiety were lower in the test group compared to the control group.

      Distraction with counterstimulation

      In the study of Aminabadi et al,
      • Aminabadi N.A.
      • Farahani R.
      • Balayi Gajan E.
      The efficacy of distraction and counterstimulation in the reduction of pain reaction to intraoral injection by pediatric patients.
      children who received simple anesthesia (inactive control) presented severe pain reaction, whereas children in the 2 experimental groups did not.

      Discussion

      Our review found that there are many behavior guidance techniques used in contemporary pediatric dentistry. Results are mixed, with most studies suggesting that nonpharmacologic interventions produce a positive effect in behavior, anxiety, and pain perception in children undergoing dental treatment. These findings reinforce the idea that although the innate ability of the dentist in dealing with children is important during a pediatric dental consultation, knowledge of child management techniques results in a better relationship between the dentist and his or her patient and the success of dental treatment. This review highlights the importance of using child management techniques supported by randomized clinical trials, which, if well designed, have a high level of evidence. This review also presents to the clinician some of the techniques that may be used in the dental office.
      Systematically reviewed nonpharmacologic interventions to manage pediatric needle pain concluded that there is strong evidence supporting the efficacy of interventions using distraction techniques for needle-related pain and distress in children and adolescents.
      • Uman L.S.
      • Chambers C.T.
      • McGrath P.J.
      • et al.
      Psychological interventions for needle-related procedural pain and distress in children and adolescents.
      Also, a meta-analysis of 19 randomized clinical trials found that distraction with music reduces pain and anxiety for children undergoing medical procedures.
      • Klassen J.A.
      • Liang Y.
      • Tjosvold L.
      • et al.
      Music for pain and anxiety in children undergoing medical procedures: a systematic review of randomized controlled trials.
      Another systematic literature search conducted to examine nonpharmacologic interventions used for pain management of children in emergency departments showed the benefits of using nonpharmacologic methods to decrease pain, distress, and anxiety as reported by the parent, child, and/or observer.
      • Wente S.J.
      Nonpharmacologic pediatric pain management in emergency departments: a systematic review of the literature.
      Studies in this review included children and adolescents up to 18 years. Because children exhibit a broad range of physical, intellectual, emotional, and social development and a diversity of attitudes and temperament, it is important that dentists have a wide range of behavior-guidance techniques to meet the needs of the individual child and be tolerant and flexible in their implementation. With a basic understanding of the cognitive development of children, dentists can use appropriate techniques consistent with the receiver's intellectual development.
      American Academy on Pediatric Dentistry Clinical Affairs Committee-Behavior Management Subcommittee; American Academy on Pediatric Dentistry Council on Clinical Affairs
      Guideline on behavior guidance for the pediatric dental patient.
      The use of conscious sedation has been widely described in the literature as effective in younger children undergoing dental treatment; it may also provide a basis for later behavior management.
      • Shavlokhova E.A.
      • Ostreikov I.F.
      • Korolenkova M.V.
      [Sedation with midazolam for ambulatory pediatric dentistry].
      • Lourenco-Matharu L.
      • Ashley P.F.
      • Furness S.
      Sedation of children undergoing dental treatment.
      However, nonpharmacologic interventions in dentistry have been shown to be effective and should be used in pediatric dentistry.
      • Nuvvula S.
      • Alahari S.
      • Kamatham R.
      • et al.
      Effect of audiovisual distraction with 3D video glasses on dental anxiety of children experiencing administration of local analgesia: a randomised clinical trial.
      They may be an alternative in some cases, as when pharmacologic technique cannot be used, when parents refuse to permit the use of analgesia, or if equipment is unavailable, as in some countries. In addition, nonpharmacologic techniques allow a link to be established between the child and the dentist.
      • Ram D.
      • Shapira J.
      • Holan G.
      • et al.
      Audiovisual video eyeglass distraction during dental treatment in children.
      In a study performed by Boka et al,
      • Boka V.
      • Arapostathis K.
      • Vretos N.
      • et al.
      Parental acceptance of behaviour-management techniques used in paediatric dentistry and its relation to parental dental anxiety and experience.
      it was observed that the best accepted technique to behavior management was tell–show–do, followed by parental presence/absence technique and nitrous oxide inhalation sedation, respectively.
      As noted in this review, randomized clinical trials testing the effectiveness of certain behavior, anxiety, and pain control techniques showed statistically significant results when comparing the control and intervention groups or when comparing different interventions, but attention should be paid to the ways outcomes are measured. Behavior was evaluated in most of the studies using the Frankl Behavior Scale, a traditionally used scale in pediatric dentistry, but other measures were also adopted to assess this outcome, and this should be considered when comparing studies. The perception of pain was measured in most studies by the Wong-Baker FACES pain rating scale and by the FPS-R. Both scales combine pictures and numbers to enable the user to rate pain and can be used for children over the age of 3. Anxiety evaluation varied in the studies. Most of the studies used the Venham Picture Test, which is traditionally used in dentistry and consists of a projective self-report measure of anxiety. Other instruments used to assess anxiety were the Modified Child Dental Anxiety Scale (MCDAS),
      • Howard K.E.
      • Freeman R.
      Reliability and validity of a faces version of the Modified Child Dental Anxiety Scale.
      the visual analog scale (VAS),
      • Barretto Ede P.
      • Ferreira e Ferreira E.
      • Pordeus I.A.
      Evaluation of toothache severity in children using a visual analogue scale of faces.
      the measurement of heart rate, and the Facial Image Scale (FIS).
      • Buchanan H.
      • Niven N.
      Validation of a Facial Image Scale to assess child dental anxiety.
      An important question regarding the management techniques is the clinical situation in which it will be applied. It is known that more invasive procedures tend to produce situations of increased stress for the child. Thus, levels of anxiety tend to be larger and the child's response tends to be worse, requiring more professional and management technique. Thus, studies that evaluate the effectiveness of techniques from less invasive procedures may not be effective in higher-stress situations. Some studies in this review presented the effectiveness of nonpharmacologic techniques during anesthesia,
      • Aminabadi N.A.
      • Erfanparast L.
      • Sohrabi A.
      • et al.
      The impact of virtual reality distraction on pain and anxiety during dental treatment in 4–6-year-old children: a randomized controlled clinical trial.
      • Kamath P.
      A novel distraction technique for pain management during local anesthesia administration in pediatric patients.
      • Aminabadi N.A.
      • Farahani R.
      • Balayi Gajan E.
      The efficacy of distraction and counterstimulation in the reduction of pain reaction to intraoral injection by pediatric patients.
      • Peretz B.
      • Gluck G.M.
      Assessing an active distracting technique for local anesthetic injection in pediatric dental patients: repeated deep breathing and blowing out air.
      but other studies evaluated the techniques in noninvasive procedures.
      Another characteristic of the included studies is that routine behavior-guidance techniques (eg, tell–show–do, praise, redirection, reprimands) were adopted for all children, even in control groups. Tell–show–do is the most popular technique for managing children's behavior in dentists' offices. It consists of explaining to the child what is to be done and describing the sensations that the child could possibly experience. However, it should be noted that differences in routine behavior-guidance approach for a child might vary among practitioners in each clinician's training, experience, and personality. Thus, this may represent a problem in interpreting the effectiveness of the tested interventions.
      Another limitation of our systematic review is our inability to conduct a meta-analysis, the result of disparity in the measurement of the outcomes included. Interventions varied widely regarding the degree of passive or active involvement of the child, parent, or health professional. The variance in age ranges between and within studies, as well as the variability in the type of procedures, limits our ability to make age- or procedure-specific conclusions or recommendations, similar to results observed in a systematic review of nonpharmacologic interventions to manage pediatric needle pain. On the other hand, ours is the first systematic literature review to address the effectiveness of nonpharmacologic techniques in managing behavior, anxiety, and pain perception during dental treatment.
      Knowledge of available techniques to help children cope with dental treatment may be useful for dentists and for other health care professionals involved with child care
      • Gereige R.S.
      • Dhepyasuwan N.
      • Garcia K.L.
      • et al.
      Pediatric residents' knowledge and comfort with oral health Bright Futures concepts: a CORNET study.
      because dental care is medically necessary for the purpose of preventing and eliminating orofacial disease, infection, and pain. Also, despite the mixed evidence existing for some techniques, given the ease of introducing music distraction, for instance, into the clinic, and the absence of any known deleterious effects, the potential for positive outcomes and stated patient preference recommends it for more systematic and widespread use.
      • Armfield J.
      • Heaton L.
      Management of fear and anxiety in the dental clinic: a review.
      • Allen K.D.
      • Wallace D.P.
      Effectiveness of using noncontingent escape for general behavior management in a pediatric dental clinic.
      It is important that further studies be conducted comparing usual techniques to the interventions we describe here. Also, future trials should investigate potential age and developmental differences. Limited evidence was found for most of the interventions tested. More research is needed to know whether the techniques are effective in improving behavior and reducing children's pain and distress during dental treatment. However, in the studies available to date, the majority of the techniques improved behavior, anxiety, and pain perception in children. Thus, results emphasize the importance of professional knowledge and the use of nonpharmacologic interventions to improve the child's perception of the dental treatment and to reduce the fear and anxiety during treatment.

      Supplementary Data

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