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ABSTRACT

OBJECTIVE: To assess the effect of dental coloring books on dental anxiety to the children visiting for dental treatmentSTUDY DESIGN: A Randomized controlled trial

rd thPLACE AND DURATION: At Islamic International Dental Hospital from 3 March 2014 to 30 July, 2014METHODOLOGY: A sample of 90 children was collected and randomly divided equally into two groups. Group - 1 (Control Group) were not given anything while Group - 2 (Experiment Group) were given books associated with dental treatment they were waiting for the dental treatment. To measure the anxiety level Modified Children Dental Anxiety Scale MCDAS (f) along with dental treatment related questionnaire were used for both groups for the measurement of the anxiety. RESULTS: Children who were provided the dental related coloring books were found to have lower anxiety levels, in comparison to the control group (p < 0.05). The results showed that children of group II showed that 40% were relaxed about visiting and examination to dentist. Overall less than 10 % were very worried about the injection, filling and extraction of the tooth. The coloring of dental related book helped them to reduce their dental anxiety. CONCLUSION: This study highlighted that the coloring books are useful in reducing the dental anxiety level among children.KEYWORDS: Children, Dental anxiety, Modified Children Dental Anxiety Scale, Dental related coloring books

HOW TO CITE THIS:Saeed MHB, Kazmi S, Iqbal R, Arif M, Durrani M, Abid K. Effects of dental coloring books for reducing dental anxiety in children. Isra Med J. 2017; 9(5): 347-50.

This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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4 treatment are interchangeable related terms, but the difference is that the children expression is more towards the dental anxiety as compare to being fearful. Worldwide in the field of dentistry, anxiety related behavioral problems are now

5 taken as Issue related to public health. Therefore due to dental anxiety many children avoid the dental treatment thus results

6into the compromised oral hygiene . Studies showed that 5-6 % of population fears from visiting the dentist for treatment and

7majority of them among were children about 16%. American Academy of Pediatric dentistry has played a vital role to reduce the dental anxiety by introducing many pharmacological and

6-7non- pharmacological techniques.One of the technique used to reduce the dental anxiety among

8, 9children is questionnaires with positive images, but Modified Children Dental Anxiety Scale (MCDAS) (faces version) was selected due to brief, relevant, and widely accepted questionnaire. Moreover children could rate their emotional response in a better way by looking at the images (Smiley

10 Faces).This anxiety remains a challenge for the density. Mostly the children visiting the dental office are unaware of the upcoming event. Different interventions have been reported to modify the anxiety levels of children before and during dental visits, with

8varying success rates. Therefore, keeping that in mind a simple and reliable study is needed to assess anxiety. In this regard coloring book and modified children Dental anxiety Scale (MCDAS) based study was performed to assess and reduce the fear of children visiting the dentist. If it's helpful then in future it will also be needed in the dental reception area to up come the

INTRODUCTION

Dental anxiety is a feeling of worry, nervousness, or unease about something which can lead to an uncertain outcome or

1extreme distress. It is common to have a child afraid of a dentist or the dental procedure. The terms dental fear, anxiety and odontophobia are most commonly used in the dental office. Pediatric patients can either be a) anxious or fearful b) slightly or not worried depending on number of personal, social or

2 environmental factors. Children visiting the dental surgery feels fear and dread in the dental waiting reception. Children suffering from the dental anxiety becomes subject of concern and their management while dental treatment becomes quite

3challenging. Dental anxiety or fear arising from the dental

1 2 3Muhammad Humza Bin Saeed , Shakeel Kazmi , Rida Iqbal ,4 4 4Madeeha Arif , Mahreen Durrani , Kainat Abid

ORIGINAL ARTICLE

Effects of Dental Coloring Books for Reducing Dental Anxiety in Children

1. Assistant Professor of Community Dentistry, 2. Assistant Professor of Oral Biology, 3. House Officer of Oral and Maxillofacial Surgery, 4. House Officer of Periodontology, Islamic International Dental College, Riphah International University.

Correspondence to:Muhammad Humza Bin SaeedAssistant Professor of Community Dentistry, Islamic International Dental College,Riphah International UniversityEmail: humza.saeed@riphah.edu.pk

Received for Publication: 29-03-17Accepted for Publication: 04-12-17

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each face showing a different anxiety level. For example, a smiling face depicts a 'relaxed' or 'not worried' state. Similarly, next answer options are arranged in an increased order of nervousness leading to 'worried' to 'worried a lot state'. In addition this questionnaire consists of 7 questions related to visit to dentist, teeth examination, injection for the treatment, having filling done, removal of tooth, sleep while treatment going on and sedation. Statistical analysis: Statistical package for the social sciences (SPSS) 17 version was used for analyzing the data. Mann Whitney U test was used to measure the anxiety level among group I and group II.

RESULTS

A total of 90 participants were included which were divided equally into two groups by gender and age ranging between 5-10 years. It was observed that coloring the dental stuff related book with the help of pencils helped the children to reduce the anxiety level. In addition the Modified Child Dental Anxiety Scale (facial) MCDAS (f) was used to evaluate in the dental anxiety level. The responses of both groups about the seven questions were shown in table - I and II. The table - I showed that 19 (42.2%) were very worried about going to the dentist as compared to the table - II whereas 1 (2.2%) were very worried about visiting dentist in table - II. In addition majority of children 17 (37.8%) in table I very much worried about the having injection during treatment and filling of the teeth. However on the other hand Group II showed that 3(6.6%) and 4(8.9%) children were relaxed about the injection into the gum and filling of the tooth. In terms of having teeth examine table I showed that 16 (35.6%) were very slightly worried as compared to 2 (4.5%) of table - II. The response showed that 13 (28.9 %) children of group I were very worried about the removal of the teeth and to put to sleep during the treatment. However 3 (6.7%) were very worried about the extraction of teeth and sleeping during the treatment. The result about the conscious sedation was bit different. 16 (35.5%) children of table I were very slightly worried as compared to table - II, 2 (4.4%) were fairly worried.Table - I and II illustrates the frequencies and percentages of the various anxiety levels of the experimental and control groups. Overall the impact of the coloring books were positive on the table - II.

potential difficulty. The use of coloring books in order to reduce dental anxiety among children has not been tested. This study was conducted to assess the effect of dental coloring books on dental anxiety to the children visiting for dental treatment

METHODOLOGY

This randomized controlled trial was conducted at International Islamic Dental Hospital. Children were selected from the dental

rdhospital waiting area for their first checkup in the month of 3 thMarch 2014 to 30 July, 2014. Inclusion Criteria for the

participation were children aged 5 to10 years. It was made sure that all the children attended by their parents/guardians. Mentally challenged, visual impairment and below age 5 and above 10 years were excluded. 90 school children were selected and equally divided in two groups. Group I (Control Group) and Group II (Experimental Group). Modified Children Dental Anxiety Scale (MCDAS) (faces version) were used in both groups in order to measure the anxiety levels.All the coloring books were related to dental treatment such as teeth brushing, children sitting on the dental chair, examination by the dentist, dental chair, healthy and decayed tooth. Children were provided the coloring pencils and they were briefed to color it. Motivational stickers of cartoons were given to the participants. The purpose of this exercise were to reduce the dental anxiety and improve the social learning among the participants. Group I and II were provided the Modified Children Dental Anxiety Scale (MCDAS) (faces version) and it was made sure that when the anxiety level was recorded in a normal and uninfluenced the end it was observed that environment. Inchildren were very positive, ease and relaxed. All the responses were filled by the children in the presence of authors. In the end questionnaire were provided to the both groups and were asked to fill it with the help of Modified Children Dental Anxiety Scale (MCDAS) The responses were 1 to 5 (faces version) (Figure - 1).starting from left to the right of the faces. 1 means relaxed, to 5 means sad. The parents were requested not to help their children, however they can only explain the questions. Questionnaire Survey: The questionnaire was easy, comprehend and quick to complete. Out of these options the children selected the best one. Questionnaire comprised of the

10Modified Child Dental Anxiety Scale (facial) MCDAS (f). It is a precise questionnaire and aids in screening dental anxiety levels in children in a better way. MCDAS (f) has a row of five faces,

FIGURE - 1: - FACES OF THE MODIFIED CHILD DENTAL ANXIETY SCALE (MCDAS)

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also be kept in consideration that physically and mentally challenged children should be dealt in a different way as this method is not applicable to them, more work needs to be done

14in the field of special care dentistry. Studies showed that Modified Child Dental Anxiety Scale (facial) MCDAS (f) is very useful in determining the dental anxiety

10 among children. Despite of limitations such as sample size, age group, and this studies showed that coloring books helped among the children to reduce the dental anxiety. However the study was confined to the dental waiting area therefore its recommended that some work will be done at the dental chair prior dental treatment.

CONCLUSION

This study highlighted that the coloring books are useful in reducing the dental anxiety level among children. There is still little work done on it and need to be done more in order to improve the dental anxiety level.

CONTRIBUTION OF AUTHORS:Saeed MHB: Conceived Idea, Final approvalKazmi S: Final approval, Data Collection, Writing manuscriptIqbal R: Statistical analysis, project collaboration, Manuscript writingArif M: Literature SearchDurrani M: Data Collection, Data InterpretationAbid K: Data Analysis, Data Interpretation

Disclaimer: None.Conflict of Interest: None.Source of Funding: None.

DISCUSSION

The impact of coloring books on the children visiting dental clinics was assessed in this study. The studies also showed that the Modified Child Dental Anxiety Scale (facial) MCDAS (f) quite

8,9reliable to reduce the dental anxiety. In addition non complained patients, irregularity in dental checkups, unhappy with dentist's attitude, less numbers of filled teeth surfaces, female gender and low income are six factors related to dental

11anxiety. Similarly the factors like dentist appearance also plays a vital role for building the confidence level among patience and

12dentist the techniques related to relaxation and attitudes of dentist were also counted a highly effective in reducing the

13 dental anxiety during dental treatment.The use of coloring books is a distraction technique which is cost effective and easily effective. However, the effectiveness of coloring books and stickers in the waiting room has not been reported to show any change in the anxiety levels of children waiting for dental treatment. The present study found that there was a significant reduction in the anxiety levels among children of the experimental group, in comparison to that of the control group. Seven questions related to dental treatment were asked (for example visiting to the dentist, filling and extraction of the tooth, injection and anesthesia) from each groups respectivelyA questionnaire consisted of seven questions. Overall, the option worried a lot made a huge difference between group I and II with 50 %. Its remarkable difference between two groups. It showed that given the coloring book option made a difference as children of group II were aware of the upcoming treatment. Similarly the children of group II were three and half times relaxed then the children of group I overall. Moreover it should

TABLE – I: FREQUENCY DISTRIBUTION OF ANXIETY LEVELS OF CONTROL GROUP (N=45)

TABLE - II FREQUENCY DISTRIBUTION OF ANXIETY LEVELS OF EXPERIMENTAL GROUP (N=45)

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7. Alsarheed M. Children's Perception of Their Dentists. Eur J Dent. 2011;5(2):186-90.

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10. Howard KE, Freeman R. Reliability and validity of a faces version of the Modified Child Dental Anxiety Scale. Int J Paediatr Dent. 2007;17(4):281-88.

11. Doerr PA, Lang WP, Nyquist LV, Ronis DL. Factors associated with dental anxiety. J Am Dent Asso. 1998;129(8):1111-19.

12. Corah NL, Gale EN, Illig SJ. The use of relaxation and distraction to reduce psychological stress during dental procedures. J Am Dent Asso. 1979;98(3):390-94.

13. Patır Münevveroğlu A, Ballı Akgöl B, Erol T. Assessment of the Feelings and Attitudes of Children towards Their Dentist and Their Association with Oral Health. ISRN Dentistry. 2014;1-4.

14. Turner S, Chambers SA, Freeman R. Measuring dental anxiety in children with complex and additional support needs using the Modified Child Dental Anxiety Scale (faces) (MCDASf). J of Dent Oral Hyg. 2012;13(1):3-10.

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