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Year : 2022  |  Volume : 33  |  Issue : 1  |  Page : 58-62
Evaluation of different pre-treatment behaviour modification techniques in 4–7-year olds: A randomised controlled trial

1 Department of Pediatric and Preventive Dentistry, ITS-CDSR, Muradnagar, Ghaziabad, Uttar Pradesh, India
2 Department of Pediatric and Preventive Dentistry, DAD Clinic, Zirakpur Chandigarh, India
3 Department of Pediatric and Preventive Dentistry, GDC Silchar, Assam, India

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Date of Submission27-Apr-2021
Date of Decision12-May-2022
Date of Acceptance23-May-2022
Date of Web Publication09-Aug-2022


Purpose: The aim of this study is to evaluate and compare the effectiveness of five pre-treatment behaviour modification techniques in 4–7-year olds in reducing dental anxiety by evaluating pulse rate, partial pressure of oxygen, systolic blood pressure, diastolic blood pressure, salivary flow rate, salivary pH, and through modified facial anxiety scale. Material and Methods: Using simple random sampling technique (drawing of lots), 125 children were equally distributed into 5 groups of 25 each: Group 1: tell-show-do (control); Group 2: tell-show-play-doh; Group 3: Playmobil Dentist; Group 4: mobile dentist games; Group 5: role play as dentist. Samples in each group were treated in a single appointment after using the behaviour modification techniques. Class I or Class II cavities were prepared on carious primary molar and restored using glass ionomer cement. Patient's anxiety level was assessed by recording blood pressure, pulse rate, oxygen saturation, salivary pH, salivary flow rate, and facial anxiety scale at different time intervals, that is before the treatment, during the treatment, and after the treatment. Results: All the intervention Groups (Groups 2–5) showed reduced anxiety scores in both physiological and facial anxiety compared to the control group, that is tell, show do. The modified distraction techniques aid in better modification. Conclusion: Tell-show-play-doh, Playmobil dentist games, mobile dentist games and role play as dentist are effective distraction techniques as compared to conventional tell-show-do techniques which can be incorporated in day-to-day clinical practice to reduce dental anxiety in paediatric patients.

Keywords: Behaviour modification, blood pressure, distraction, oxygen saturation, tell-show-do

How to cite this article:
Goyel V, Mathur S, Dhingra N, Nair U, Singh S, Phukan AH. Evaluation of different pre-treatment behaviour modification techniques in 4–7-year olds: A randomised controlled trial. Indian J Dent Res 2022;33:58-62

How to cite this URL:
Goyel V, Mathur S, Dhingra N, Nair U, Singh S, Phukan AH. Evaluation of different pre-treatment behaviour modification techniques in 4–7-year olds: A randomised controlled trial. Indian J Dent Res [serial online] 2022 [cited 2022 Oct 4];33:58-62. Available from:

   Introduction Top

The first visit of a paediatric patient at dental office is always accompanied by fear and anxiety and has a negative impact on a child's psychology making the dental experience an unpleasant one.[1] As perfectly stated by McElory (1895): 'Although operative dentistry may be perfect, the appointment is a failure if a child departs in tears'. It focuses the importance of behaviour management over clinical excellence in paediatric dentistry.[2] The biggest challenge for any paediatric dentist is to maintain communication with a child, as not all children have the capability for expressing their fears and anxiety, due to their limited communication skills at a younger age.

It is difficult for 4–7-year olds, who are in their preoperational period of psychological development, to understand the dentist frame of reference.[3]

Child dental anxiety has been a matter of concern for many years and can be defined as a nonspecific feeling of apprehension, worry, uneasiness or dread, the source of which may be vague or unknown.[4] It may be due to sight, sound and sensation of air rotor which results in poor coping during dental procedures and eventually gives birth to behaviour management problems.

Behaviour modification is the attempt to alter human behaviour and emotion in a beneficial way and in accordance with the laws of learning. Behaviour management techniques are a set of procedures aimed at enhancing a child's useful coping skills, in order to achieve complete willingness and acceptance of dental care and ultimately reduce the child's perception that the dental situation is overwhelming or dangerous.[5] It can be pharmacological or non-pharmacological. While the pharmacological behaviour management techniques include pre-medications like sedatives, hypnotics, anti-anxiety drugs, antihistamines, conscious sedation and general anaesthesia, the non-pharmacological behaviour management techniques include voice control, hypnosis, classical conditioning, aversive conditioning, and distraction like tell-show-do technique.

According to AAPD guidelines (2015), 'Distraction is the technique of diverting the patient's attention from what may be perceived as an unpleasant procedure'. Giving the patient a short break during a stressful procedure can be an effective use of distraction prior to considering more advanced behaviour guidance techniques.[6]

The tell-show-do technique is based on the principles of learning theory and is performed by dentists themselves in the operatory.[7] Playing with a dental imitation toy and using euphemisms instead of demonstrating on a model or observing one provides a better explanatory concept of the dental procedure. With this idea, the tell-show-do technique was modified into the tell-show-play-doh technique. Play-doh is a reusable, flour-based modelling compound used by children for arts and crafts projects.

Another technique used was Playmobil Dentist with patient, that is search of cavities with dentist and with patient. It includes all dental equipment that may encourage children to explore and learn to behave positively in dental environment while having fun. Third technique explored was smartphone dentist games that are available online, giving the child a first-hand experience of their usage, sounds produced and clinical effects obtained. Yet another technique was incorporated where children were made to role play paediatric dentistry. In this technique, a child was asked to roleplay as a dentist and allowed to examine another paediatric patient.

All these techniques were compared with the one already practiced that is tell-show-do technique, that is closely aligned with desensitisation, where child is introduced to a procedure in a stepwise fashion.

It is an established fact that there is a strong inverse relationship between a child's dental anxiety and successful dental treatment.[8]

Thus, the aim of present study was to compare the effectiveness of five pre-treatment behaviour modification techniques in 4–7-year olds in reducing dental anxiety by evaluating pulse rate, partial pressure of oxygen, systolic blood pressure, diastolic blood pressure, salivary flow rate, salivary pH and modified facial anxiety scale.

Hypothesis: There is no significant difference between various distraction techniques influencing blood pressure, pulse rate, oxygen saturation, salivary pH, salivary flow rate, facial anxiety scale and patient's anxiety.

   Material and Methods Top

This randomised, interventional, clinical study was conducted in the Department of Pediatric and Preventive Dentistry, ITS Dental College Muradnagar, CDSR, after obtaining approval from the Institutional Review Board and Ethics Committee with ethical clearance no: ITSCDSR/IIEC/RP/2018/026 and written informed consent from the parents and assent from the children. The study included 125 children, aged 4–7 years.

Sample size was calculated using the following formula:

where (from z distribution table values) at type I error of 5%, zβ is the standard normal variate for power (for 90% power it is 1.282); d is the difference between mean score = 0.20; standard deviation (SD) score = 0.218; r = 1:1.


Inclusion criteria:

Children in the age group of 4–7 years with Frankl's behaviour rating score of 1 or 2 and no prior dental experience.

Exclusion criteria:

  1. Children with Frankl's behaviour rating score of 3 or 4.
  2. Those with extensively damaged teeth.
  3. Those having teeth with lesions involving pulp or extending below gingiva.
  4. Those having carious teeth with pre-shedding mobility.
  5. Specially challenged children.

Using a simple random sampling technique (drawing of lots), selected children were equally distributed into 5 groups of 25 each, as shown in [Figure 1].
Figure 1: Distribution of samples

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The study was undertaken in the Department of paediatric and preventive dentistry from January 2019 to October 2019. A total of 125 patients in the age group of 4–7 years were randomly selected from the OPD according to inclusion criteria and were equally divided into 5 groups.

Samples in all groups, which were reporting to the department in morning hours, were thoroughly examined; for 10 min, either of the behaviour modification techniques was performed before clinical procedures, that is tell, show do, tell, show-play-doh, Playmobil Dentist, mobile dentist games, or role play as dentist. Class I or Class II was prepared on carious molars and restored using glass ionomer cement in single appointment. The subjective assessment for the facial anxiety was done by the same examiner who executed the behaviour modification technique to remove chance of bias.

All children were treated by a single operator in order to avoid bias. Evaluation and modulation of anxiety levels during the child's first dental visit were done using multiray/multiparameter to measure anxiety and haemodynamic parameters. The hemodynamic and ventilatory changes were evaluated by monitoring systolic pressure, diastolic pressure, heart rate and oxygen saturation (SpO2) by a well-trained and calibrated investigator. Pulse oximetry and a blood pressure cuff (sphygmomanometer) were used to monitor the hemodynamic changes and these instruments were calibrated before recording of every patient. The facial anxiety scale [Figure 2] was used to measure the anxiety of child by psychological parameters.

Salivary flow rate was evaluated by asking the patient to spit in the Eppendrof tubes [Figure 2].
Figure 2: Anxiety scale

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Salivary pH was evaluated with the help of pH paper [Figure 2].

All the parameters were recorded at three time intervals:

T1: As soon as the patient enters the department.

T2: During the pre-treatment behaviour modification technique.

T3: After the treatment.

Statistical analysis

All the data collected and entered in MS Excel and analysed using SPSS (Statistical Package for Social Sciences) 16.0 for Windows (SPSS Inc., Chicago, IL, USA, 2001). The normality of data was tested by Shapiro–Wilk test. Descriptive statistics and frequency distribution, including the mean, median, SD and standard error of the mean, were calculated for all measurements.

The significance of difference of means between two groups, that is inter-group comparison for normal data, was tested by ANOVA one-way test, and intra-group comparison was tested by paired t-test (parametric test) and the qualitative data association tested by Kruskal–Wallis H test. The level of significance and confidence interval were 5% and 95%, respectively.

   Results Top

The results of the present investigations have been evaluated under the following headings.

All the intervention groups (Groups 2–5) showed reduced anxiety scores in both physiological and facial anxiety when compared to the control group. None of the patients in any group refused treatment and only single technique of behaviour modification was used for each patient to remove bias.

Intra-group comparison of systolic BP, diastolic BP, pulse rate, SpO2, salivary flow rate and salivary pH

When pre- and post-behaviour modification values were compared for SpO2 and salivary flow, Group I (tell-show-do) showed highly significant values. In Group 2, all the values showed significant results except SpO2. In Group 3, systolic BP, diastolic BP, pulse rate and salivary pH showed significant results. In Group 4, pulse rate and salivary pH showed significant results. In Group 5, systolic BP, SpO2 and salivary flow rate showed significant results.

Inter-group comparisons of systolic BP, diastolic BP, pulse rate, SpO2, salivary flow rate and salivary pH

In the inter-group comparison among all the groups, it was observed that at T3 out of six quantitative values four values, that is systolic BP (P value = 0.000), diastolic BP (P value = 0.044), pulse rate (P value = 0.000) and salivary flow rate (P value = 0.006), showed significant results.

Facial anxiety scale comparison among different time

It was observed that Group 2 showed significant values, that is P value = 0.027.

While the hypotheses 1, 2, 5, 6 and 7 were rejected, 3 and 4 were accepted.

   Discussion Top

Treating a child is like a big challenge for any dentist, as paediatric patient differs from adult patient, psychologically, emotionally and physically.[9] The apprehension and anxiety child experience during the treatment does not allow the dentist to provide quality of treatment.[10]

The main aim of paediatric dentistry is to create a positive attitude in children following a dental visit. In quest to search for a novel yet reliable behaviour modification technique, various techniques have been studied in the past and are still being explored.

According to theory of cognitive development by Piaget, children at the age of 4–7 years belong to intuitive stage; the three main areas of focus in this stage are constructivism, cognitive equilibrium and animism; during this stage children consider themselves to be a scientist, like to explore things, make new observations, get unduly influenced by own perception of environment and correlate things with other objects which they are more used to be accustomed. The evolution in attention, vocabulary and concentration abilities in this stage is an indication for adapting themselves for social communication.[11]

Therefore, this stage is a cream age for testing various behaviour modification techniques and instilling positive dental attitude in child.

According to the study by Rosenberg and Katcher (1976),[12] anxiety-provoking situations alter physiological functions like pulse rate and blood pressure. This increase in pulse rate and blood pressure can be used to assess dental anxiety in children. Studies by Messer et al.(1977)[13] confirmed that the physiological changes occur in the body as a result of the stress suffered by patients during dental procedures and these physiological changes are very useful for measuring anxiety level in a patient before and after the dental treatment. McCarthy et al.[14] (1957) obtained similar results, alternation in pulse rate, blood pressure and oxygen saturation redirectly attributed to stress during dental procedures and are indications of physiological arousal. So, in the present study, pulse rate, oxygen saturation and blood pressure were used as reliable indicators to evaluate anxiety level of children. It was observed in the present study that mean difference of SpO2 remains insignificant among all the groups; however, there was a reduction in mean pulse rate, after treatment, for all the groups, that is tell-show-play-doh, Playmobil dentist games, cell phone dentist games and role play as dentist indicated low anxiety levels in these groups when compared to the tell-show-do group.[14]

Studies relate hemodynamic, vascular and respiratory changes to anxiety in adults[8],[15] and it is proved that the average increase in both systolic and diastolic blood pressures was higher in children than in adults.[16],[17] In the present study, there was mean reduction of both systolic and diastolic blood pressures among all groups as compared to control group, that is tell-show-do.

Studies conducted by Buchanan et al. (2002)[18] and Guinot Jimeno et al. (2011)[19] found that for subjective measurement, the ideal measure should be valid, allow for limited cognitive and linguistic skills, and be easy to administer and score in a clinical context. For the present study, we used facial anxiety scale for subjective scoring of fear and anxiety, which shows significant values in tell-show-play-doh group.

Bergdahl and Bergdahl (2000)[20] evaluated 1202 individuals in 3 groups and showed that unstimulated salivary flow rate under 0.1 mL/min and low pH are seen more frequently in patients with depression, anxiety and stress. The results revealed that stress and anxiety had a significant relationship with decrease in unstimulated salivary flow rate and decrease in pH. In this study, it was notably easier to carry out the procedure using the tell-show-play-doh and smartphone dentist game techniques than the tell-show-do technique. Effective handling of patients pre-operatively and during the procedure was observed in the tell-show-play-doh, Playmobil dentist games, cell phone dentist games and role play as dentist techniques when compared with the tell-show-do technique.

The tell-show-do technique remains the most commonly used technique in paediatric dentistry and is still considered the technique with which dentists and parents are comfortable and justifies being the method of choice, although modification of the tell-show-do to tell-show-play-doh technique is considerably effective in reducing the pulse rate and improving behaviour than the conventional tell-show-do technique.

Smartphone dentist games educating child patients about the use of common dental equipment like the air rotor, ultrasonic scalers, suction tip and so on will help reduce dental fear or apprehension. Playmobil dentist games help the paediatric patient to get the feel of clinical environment and all the equipment used in dentistry, thus reducing their apprehension and anxiety. Role play as dentist is a kind of self-modelling for the paediatric patient, instilling positive dental attitude, making child more cooperative and reducing dental anxiety.

This study was designed to compare the efficiency of the tell-show-play-doh, Playmobil dentist games, cell phone dentist games and role play as dentist and the tell-show-do techniques in reducing child anxiety during dental treatment. The results of this study showed that the tell-show-play-doh, Playmobil dentist games and role play as dentist were more effective than the tell-show-do technique on child anxiety levels and increased cooperative behaviour during dental treatment among 4–7-year-old children.

Dental toys, role play as dentist, mobile dentist games and distraction techniques are unique, immersive and engaging, integrating many sensory experiences and thus capturing a greater degree of attention. Another distinguishing feature of these distraction techniques is that they give illusion that objects which create dental anxiety in child's mind initially become user-friendly.

   Conclusion Top

Tell, show-play-doh, role play as dentist, Playmobil game, mobile dentist games and distraction techniques are highly viable techniques with a high potential to alleviate anxiety associated with various dental procedures. They are safe, non-invasive techniques that do not require any previous education and training and has lasting effects in terms of more positive memories of the treatment leading to greater willingness to return to the treatment.

Informed consent

Informed consent was taken from all the participants.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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Correspondence Address:
Dr. Vinita Goyel
Senior Lecturer, Department of Pediatric and Preventive Dentistry, ITS-CDSR, Muradnagar, Ghaziabad, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijdr.ijdr_373_21

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