NIHR DC Discover

NIHR Signal Cartoons are promising for reducing dental anxiety in children

Published on 3 July 2018

doi: 10.3310/signal-000609

Cartoons delivered on laptops, projectors or 3D goggles with sound can help distract anxious children who fear dental procedures. Dental anxiety can prevent children from attending the dentist for care, and this type of distraction could offer a useful tool to help them.

This review looked at a range of audiovisual approaches tested in trials of healthy children receiving dental treatment under local anaesthetic. The children were assessed for physiological measures related to emotional state (such as pulse rate), anxiety and observed behaviour.

Childhood dental anxiety is a common problem, and these distraction approaches sound promising, safe and relatively easy to implement.

Share your views on the research.

Why was this study needed?

The feeling of nervousness about seeing a dentist is known as dental anxiety. Low levels may be relieved by reassurance, whereas more severe cases often require sedation or general anaesthesia.

Prevalence of dental anxiety in children ranges from 6 to 20%, and a 2013 national survey in the UK found very high levels of dental anxiety in 14% of young people aged 12, and in 10% of 15 year-olds. Interventions to divert children’s attention away from seemingly unpleasant experiences can contribute to better attendance and long-term improvements in oral health. 

The study aimed to assess a range of audiovisual distraction techniques in children during dental treatment under local anaesthesia.  

Previous trials on the topic had produced uncertain conclusions, and so a systematic review was needed to combine the research.

What did this study do?

The review included nine relatively recent controlled trials, with 528 participants. All studies were conducted in healthy children aged 3 to 14 years and assessed the effectiveness of an audiovisual intervention during dental treatment.

Where reported, the duration of treatment was approximately 30 minutes, and the projection content typically included animated movies or cartoons. The sound was provided by headphones or earplugs. Primary outcomes included physiological measures of anxiety, such as heart/pulse rate and oxygen saturation. Studies also measured children's reported anxiety levels and ability to undergo treatment. The effects of audiovisual distraction were compared with control or standard care groups. The studies were carried out in the Middle East, Far East and Western Europe, though not in the UK.  

The quality of individual studies was assessed as poor, because of the risk of bias from a lack of blinding. However, this was probably unavoidable because of the nature of the intervention.

What did it find?

  • Audiovisual distraction slightly reduced the heart/pulse rate in children (mean difference [MD] -3.78, 95% confidence interval [CI] -6.73 to -0.83). Six trials, 352 participants in total.
  • The intervention had no significant effect on oxygen saturation in children (MD 0.47, 95% CI -0.35 to 1.29), two trials.
  • Audiovisual distraction reduced reported anxiety levels and improved children’s cooperation during treatment, according to the studies that used self-reports (nine trials) and behaviour rating scales (seven trials).

What does current guidance say on this issue?

The British Society of Paediatric Dentistry provides 2011 guidance on non-pharmacological behaviour management techniques, including on the use of distraction techniques.

Some of these methods aim to improve communication during the treatment process, while others are intended to eliminate disruptive behaviour or reduce dental anxiety. On audiovisual distraction for children, the guidance notes an existing lack of consensus on effectiveness.

What are the implications?

Audiovisual distraction appears to be a promising approach which may help reduce children’s dental anxiety. The intervention is safe, simple to administer, and does not require excessive implementation costs. Its use can be easily extended to adult populations, too.  

The findings require a cautious interpretation, as there were differences in how the intervention was delivered and whether children had prior experiences of dental treatment or previous health conditions which may have affected their responses. Further supporting evidence on specific techniques could provide useful confirmation in a UK setting.

The findings of this study are most relevant to dental teams, although they may be also helpful to parents and caregivers.

Citation and Funding

Zhang C, Qin D, Shen L, Ji P, Wang J. Does audiovisual distraction reduce dental anxiety in children under local anesthesia? A systematic review and meta-analysis. Oral Dis. 2018; March 2. DOI: 10.1111/odi.12849.

This research was supported by Program for BMP9 Regulates Osteogenic/Odontogenic Differentiation of iSCAP (Stem Cells from the Apical Papilla) through MAPK Pathway and Program for Innovation Team Building at Institutions of Higher Education in Chongqing (CXTDG201602006).

Bibliography

BSPD. Non-pharmacological behaviour management. London: British Society of Paediatric Dentistry; 2002, updated 2011.

NHS Choices. Fear of the dentist. London: Department of Health; updated 2015.

NHS Digital. Children’s Dental Health Survey 2013. Report 1: attitudes, behaviours and children’s dental health. Leeds: Health and Social Care Information Centre; 2015.

NHS Inform. Coping with a fear of the dentist. Edinburgh: Health Scotland; updated 2018.

Why was this study needed?

The feeling of nervousness about seeing a dentist is known as dental anxiety. Low levels may be relieved by reassurance, whereas more severe cases often require sedation or general anaesthesia.

Prevalence of dental anxiety in children ranges from 6 to 20%, and a 2013 national survey in the UK found very high levels of dental anxiety in 14% of young people aged 12, and in 10% of 15 year-olds. Interventions to divert children’s attention away from seemingly unpleasant experiences can contribute to better attendance and long-term improvements in oral health. 

The study aimed to assess a range of audiovisual distraction techniques in children during dental treatment under local anaesthesia.  

Previous trials on the topic had produced uncertain conclusions, and so a systematic review was needed to combine the research.

What did this study do?

The review included nine relatively recent controlled trials, with 528 participants. All studies were conducted in healthy children aged 3 to 14 years and assessed the effectiveness of an audiovisual intervention during dental treatment.

Where reported, the duration of treatment was approximately 30 minutes, and the projection content typically included animated movies or cartoons. The sound was provided by headphones or earplugs. Primary outcomes included physiological measures of anxiety, such as heart/pulse rate and oxygen saturation. Studies also measured children's reported anxiety levels and ability to undergo treatment. The effects of audiovisual distraction were compared with control or standard care groups. The studies were carried out in the Middle East, Far East and Western Europe, though not in the UK.  

The quality of individual studies was assessed as poor, because of the risk of bias from a lack of blinding. However, this was probably unavoidable because of the nature of the intervention.

What did it find?

  • Audiovisual distraction slightly reduced the heart/pulse rate in children (mean difference [MD] -3.78, 95% confidence interval [CI] -6.73 to -0.83). Six trials, 352 participants in total.
  • The intervention had no significant effect on oxygen saturation in children (MD 0.47, 95% CI -0.35 to 1.29), two trials.
  • Audiovisual distraction reduced reported anxiety levels and improved children’s cooperation during treatment, according to the studies that used self-reports (nine trials) and behaviour rating scales (seven trials).

What does current guidance say on this issue?

The British Society of Paediatric Dentistry provides 2011 guidance on non-pharmacological behaviour management techniques, including on the use of distraction techniques.

Some of these methods aim to improve communication during the treatment process, while others are intended to eliminate disruptive behaviour or reduce dental anxiety. On audiovisual distraction for children, the guidance notes an existing lack of consensus on effectiveness.

What are the implications?

Audiovisual distraction appears to be a promising approach which may help reduce children’s dental anxiety. The intervention is safe, simple to administer, and does not require excessive implementation costs. Its use can be easily extended to adult populations, too.  

The findings require a cautious interpretation, as there were differences in how the intervention was delivered and whether children had prior experiences of dental treatment or previous health conditions which may have affected their responses. Further supporting evidence on specific techniques could provide useful confirmation in a UK setting.

The findings of this study are most relevant to dental teams, although they may be also helpful to parents and caregivers.

Citation and Funding

Zhang C, Qin D, Shen L, Ji P, Wang J. Does audiovisual distraction reduce dental anxiety in children under local anesthesia? A systematic review and meta-analysis. Oral Dis. 2018; March 2. DOI: 10.1111/odi.12849.

This research was supported by Program for BMP9 Regulates Osteogenic/Odontogenic Differentiation of iSCAP (Stem Cells from the Apical Papilla) through MAPK Pathway and Program for Innovation Team Building at Institutions of Higher Education in Chongqing (CXTDG201602006).

Bibliography

BSPD. Non-pharmacological behaviour management. London: British Society of Paediatric Dentistry; 2002, updated 2011.

NHS Choices. Fear of the dentist. London: Department of Health; updated 2015.

NHS Digital. Children’s Dental Health Survey 2013. Report 1: attitudes, behaviours and children’s dental health. Leeds: Health and Social Care Information Centre; 2015.

NHS Inform. Coping with a fear of the dentist. Edinburgh: Health Scotland; updated 2018.

Does audiovisual distraction reduce dental anxiety in children under local anesthesia? A systematic review and meta-analysis

Published on 3 March 2018

Zhang, C.,Qin, D.,Shen, L.,Ji, P.,Wang, J.

Oral Dis , 2018

OBJECTIVES: To perform a systematic review and meta-analysis on the effects of audiovisual distraction on reducing dental anxiety in children during dental treatment under local anesthesia. METHODS: The authors identified eligible reports published through August 2017 by searching PubMed, EMBASE, and Cochrane Central Register of Controlled Trials. Clinical trials that reported the effects of audiovisual distraction on children's physiological measures, self-reports and behavior rating scales during dental treatment met the minimum inclusion requirements. The authors extracted data and performed a meta-analysis of appropriate articles. RESULTS: Nine eligible trials were included and qualitatively analyzed; some of these trials were also quantitatively analyzed. Among the physiological measures, heart rate or pulse rate was significantly lower (p=0.01) in children subjected to audiovisual distraction during dental treatment under local anesthesia than in those who were not; a significant difference in oxygen saturation was not observed. The majority of the studies using self-reports and behavior rating scales suggested that audiovisual distraction was beneficial in reducing anxiety perception and improving children's cooperation during dental treatment. CONCLUSION: The audiovisual distraction approach effectively reduces dental anxiety among children. Therefore, we suggest the use of audiovisual distraction when children need dental treatment under local anesthesia. This article is protected by copyright. All rights reserved.

Expert commentary

Dental decay is one of the most prevalent conditions in children and painful dental episodes in childhood are often cited by adults with dental anxiety.

Behaviour management and conscious sedation are mainstays of paediatric dental practice but do not work for all children. It is therefore exciting to see a systematic review demonstrating how audiovisual distraction (TV, computer games and 3D video glasses) reduce physiological measures of dental anxiety.

If these approaches can also be shown to allow known anxious children to accept treatment the child-friendly dental surgery could soon be a very different place.

Barbara Chadwick, Professor Paediatric Dentistry, School of Dentistry, Cardiff University