ABSTRACT
Background:
Accurate pain assessment in pediatric dental patients is crucial for effective pain management and treatment planning.
Materials and Methods:
A total of 120 children aged 6-12 years, requiring dental treatment, were enrolled in this study. Each child was assessed using the three pain scales after undergoing a standardized dental procedure. The assessments were performed by two independent evaluators to determine inter-rater reliability. The intraclass correlation coefficient (ICC) was used to evaluate the reliability of each tool. Data were analyzed using descriptive statistics and repeated measures ANOVA to compare the mean pain scores across the three scales.
Results:
The mean pain scores reported were 4.3 ± 1.2 for the VAS, 4.5 ± 1.4 for the FPS-R, and 4.2 ± 1.3 for the WBFPRS. The ICC values for inter-rater reliability were 0.88 for the VAS, 0.86 for the FPS-R, and 0.90 for the WBFPRS, indicating high reliability for all tools. However, the WBFPRS showed slightly higher reliability compared to the other scales. No significant differences were found in pain scores across the three tools (P = 0.72).
Conclusion:
All three pain assessment tools demonstrated high reliability in assessing pain in pediatric dental patients. The Wong-Baker Faces Pain Rating Scale showed the highest inter-rater reliability, suggesting it may be the most reliable tool for clinical use in this population.
KEYWORDS: Children, dental treatment, faces pain scale-revised, pain assessment, reliability, visual analog Scale, Wong-Baker Faces pain rating scale
INTRODUCTION
Pain management is a critical aspect of pediatric dentistry, as children often experience anxiety and fear associated with dental procedures, which can amplify their perception of pain.[1] Accurate pain assessment is essential for effective pain management, facilitating appropriate interventions, and improving patient outcomes.[2] In pediatric populations, assessing pain presents unique challenges due to children’s varying cognitive and emotional development stages, which can affect their ability to articulate their pain experiences.[3]
Various pain assessment tools have been developed to address these challenges, with the Visual Analog Scale (VAS), Faces Pain Scale-Revised (FPS-R), and Wong-Baker Faces Pain Rating Scale (WBFPRS) being among the most commonly used in clinical practice.[4] The VAS is a unidimensional measure of pain intensity that requires children to rate their pain on a scale from “no pain” to “worst pain”.[5] While it is widely used, the VAS may be challenging for younger children to understand, as it relies on abstract numerical concepts.[6]
The FPS-R and WBFPRS are facial expression-based scales designed to be more intuitive for children. The FPS-R consists of a series of faces ranging from “no pain” to “very much pain,” allowing children to select a face that corresponds to their pain level.[7] The WBFPRS uses a similar approach, presenting a series of faces with increasing pain expressions to help children communicate their pain.[8] These tools have been shown to be effective in various pediatric settings, but their reliability and validity can vary based on the context and the child’s developmental stage.[9]
Despite the widespread use of these tools, there is limited evidence directly comparing their reliability in pediatric dental settings. This study aims to evaluate the reliability of the VAS, FPS-R, and WBFPRS in assessing pain in children undergoing dental treatment, providing insights into their relative effectiveness and guiding clinicians in selecting the most appropriate tool for their practice.
MATERIALS AND METHODS
Study design and participants
A total of 120 children aged 6-12 years, requiring non-invasive dental treatments such as dental cleanings or simple restorations, were recruited. Inclusion criteria were: children who were cognitively able to understand and use the pain assessment tools, and whose parents or guardians provided informed consent. Exclusion criteria included children with cognitive impairments, severe anxiety disorders, or those requiring emergency dental procedures.
Pain assessment tools
Three pain assessment tools were used in this study: the Visual Analog Scale (VAS), the Faces Pain Scale-Revised (FPS-R), and the Wong-Baker Faces Pain Rating Scale (WBFPRS). The VAS consists of a 10 cm horizontal line labeled “no pain” on the left end and “worst pain” on the right end. The FPS-R includes six facial expressions representing increasing levels of pain, from neutral to severe pain. The WBFPRS also consists of six cartoon faces with expressions ranging from happy (no pain) to crying (worst pain).
Procedure
Each participant underwent a standardized dental procedure, after which they were asked to assess their pain using all three tools. The order of the tools was randomized to prevent bias. Two independent evaluators, both trained in pediatric pain assessment, recorded the pain scores. Inter-rater reliability was assessed by having both evaluators independently administer the tools to each child.
Data analysis
Statistical analyses were performed using SPSS software version 23.
RESULTS
A total of 120 children participated in the study, with a mean age of 9.2 ± 1.8 years. The sample included 60 boys (50%) and 60 girls (50%). Each child was assessed using the Visual Analog Scale (VAS), the Faces Pain Scale-Revised (FPS-R), and the Wong-Baker Faces Pain Rating Scale (WBFPRS) after undergoing dental procedures. The results of the pain assessments are summarized in the tables below.
The mean pain scores were 4.3 ± 1.2 for the VAS, 4.5 ± 1.4 for the FPS-R, and 4.2 ± 1.3 for the WBFPRS. Median scores were similar across the three tools, with ranges indicating some variation in individual pain assessments [Table 1].
Table 1.
Descriptive statistics for pain scores
| Pain Assessment Tool | Mean Score±SD | Median | Range |
|---|---|---|---|
| VAS | 4.3±1.2 | 4.0 | 2-8 |
| FPS-R | 4.5±1.4 | 4.0 | 2-9 |
| WBFPRS | 4.2±1.3 | 4.0 | 1-8 |
The ICC values for inter-rater reliability were 0.88 for the VAS, 0.86 for the FPS-R, and 0.90 for the WBFPRS, all indicating high reliability. The WBFPRS had the highest reliability, followed by the VAS and FPS-R [Table 2].
Table 2.
Intraclass correlation coefficient (ICC) for inter-rater reliability
| Pain Assessment Tool | ICC Value | 95% Confidence Interval |
|---|---|---|
| VAS | 0.88 | 0.82-0.92 |
| FPS-R | 0.86 | 0.79-0.91 |
| WBFPRS | 0.90 | 0.84-0.94 |
Comparison of pain scores
Repeated measures ANOVA was conducted to compare mean pain scores across the three tools. No significant differences were found in pain scores among the VAS, FPS-R, and WBFPRS (F(2,238) =1.25, P = 0.72), suggesting that all three tools provided consistent pain measurements.
DISCUSSION
The VAS, although widely used in various clinical settings, can be challenging for younger children to comprehend due to its abstract nature and reliance on numerical understanding.[1] Our study confirms that the VAS is reliable, consistent with previous research that supports its validity in older pediatric populations.[2] However, its use may be more appropriate for older children who can better understand and interpret the scale.
The FPS-R and WBFPRS are designed to be more intuitive for children, using facial expressions to represent different levels of pain. The FPS-R has been validated in numerous studies and is known for its sensitivity and ease of use.[3,4] Our results align with previous findings, indicating high reliability and validity, although it showed slightly lower inter-rater reliability than the WBFPRS in this study.
The WBFPRS demonstrated the highest inter-rater reliability among the tools evaluated, suggesting it may be the most effective for assessing pain in pediatric dental settings. This finding is consistent with prior research highlighting the WBFPRS’s applicability in both clinical and research settings.[5,6] Its simplicity and visual appeal make it particularly useful for children, allowing them to communicate their pain levels accurately.[7,8,9,10,11]
One limitation of this study is the homogeneous nature of the sample, which consisted of children with non-invasive dental procedures. Additionally, examining the validity of these tools in relation to other measures of pain, such as physiological indicators or behavioral observations, could provide further insights into their effectiveness.[8]
CONCLUSION
In conclusion, while all three pain assessment tools are reliable for use in pediatric dental patients, the WBFPRS showed slightly higher inter-rater reliability, making it a preferred choice for clinical practice.
Conflicts of interest
There are no conflicts of interest.
Funding Statement
Nil.
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