Effectiveness of origami and puzzle game in alleviating dental anxiety and pain perception during local anesthesia administration in children: a randomized clinical trial

Abstract

Background

Children experience anxiety in unfamiliar dental environments, impacting their behavior and impeding dental treatment. Local anesthetic infiltration (LA) induces anxiety in children. Distraction is recommended to alleviate the pain and anxiety associated with LA administration. Origami and puzzle games are promising, economical, nonpharmacological techniques to minimize dental anxiety and can enhance intellectual and cognitive development. This study aimed to evaluate the effectiveness of origami and puzzle games as distraction techniques for reducing dental anxiety and pain during local anesthesia infiltration in children aged 5–10 years during local anesthesia infiltration.

Methods

Fifty-two healthy children, aged 5–10 years, undergoing dental procedures requiring local anesthesia were chosen and divided into two groups. Each group comprised 26 children as determined by simple randomization. Group I: Puzzle game group; Group II: Origami group. In both groups, a physiological measure (pulse rate by pulse oximeter) was measured prior to, during, and following LA administration, while the face, legs, activity, cry, and consolability (FLACC) scale was used to record anxiety levels before and after the intervention. The FLACC Scale, an objective measure, was used to record pain perception during LA administration, whereas the faces pain scale, a subjective measure, was used to record pain perception following LA administration. This was followed by the needful treatment. Pulse rates were compared between the two groups using independent and paired t-tests for inter-and intragroup assessments, respectively. The Wilcoxon signed-rank test and Mann–Whitney U test were used to analyze anxiety and pain scores.

Results

Intragroup comparisons of pulse rates before, during, and after LA administration were statistically significant (P < 0.001). Inter-group comparison of pulse rates was also statistically significant during LA administration (P = 0.04); however, there was no significant difference before intervention and after LA administration. However, after the intervention, the mean anxiety scores were significantly reduced in the puzzle game group (P = 0.004). The mean pain scores of the FLACC and Faces Pain Scale-Revised were lower (P < 0.001) in the puzzle game group than in the origami group.

Conclusion

Puzzle games were the most effective in lowering children's pain and anxiety during LA administration.

INTRODUCTION

Dental anxiety is a widespread concern in children, particularly when it comes to their first dental visit. It often stems from the uncertainty and skepticism surrounding the dental setting, which can significantly impact their behavior and lead to neglect of necessary treatment, ultimately affecting their oral health negatively [1]. Child involvement is essential for successful dental treatment [2]. Local anesthesia is essential to ensure pain-free dental procedures and serves as a fundamental component of pain management techniques [3]. Adequate pain management during dental procedures not only prevents the sensation of pain but also builds a foundation of trust between the patient and the dentist. This approach helps alleviate fear and anxiety, while promoting a positive outlook on dental care. However, inadequate pain management during dental procedures may have significant psychological and physical consequences [4]. Employing age-appropriate, reassuring language, distraction techniques, topical anesthetics, precise injection techniques, and appropriate pharmacological methods significantly contributes to ensuring a positive patient experience during the administration of local anesthetics [5]. Distraction is a behavioral management technique that successfully reduces pain and behavioral anxiety in children by removing their focus from difficult dental treatments. Their effectiveness is maximized when tailored to a child's developmental stage [6,7,8]. Distraction can be categorized into two key types: passive distraction, which involves the child remaining still and calm, while the dentist actively redirects their focus. In contrast, active distraction stimulates children’s involvement in activities during dental treatment [9].

Play materials are important in educational settings because they are visual, entertaining, attractive, and arouse children’s willingness to participate [10]. Origami and puzzle games are used as play therapies to relieve hospitalization-related anxiety. Origami, a traditional paper-folding technique that originated in Japan, is used worldwide. The name 'origami' comes from the Japanese words 'oru,’ which means 'to fold,’ and 'kami,’ which means 'paper'[11]. It serves as a diversion activity that gives children the opportunity to explore their creativity by shaping colored papers into meaningful forms and sizes. Participating in such activities can encourage children to socialize, express themselves verbally, and share their perspectives on their environment because play therapy helps children deal with difficult situations, such as being admitted to the hospital or having other medical contacts. This can help them communicate their feelings through improved rapport with the hospital staff, which lowers anxiety and fear [12]. In a hospital setting, a program of supervised and directed distraction offers a warm, welcoming, and joyful environment that supports the child's continued development. Play activities should be offered to improve the communication skills, coping mechanisms, and behaviors toward medical personnel. This was demonstrated in a case study by Sundaram (1998), who found that play and art were effective in promoting therapeutic processes. Through these two processes, young children are able to express themselves, become more self-aware, and process the effects of the illness or damage at an internal level [13].

Puzzle-solving is an effective engaging technique that supports children's cognitive development and can help reduce anxiety. Puzzles, which are typically made of wood or cardboard, encourage children to develop calmness, diligence, and patience as they complete them. The satisfaction that children feel upon finishing a puzzle motivates them to explore and learn new things. As puzzle solving is non-invasive and non-pharmacological, it serves as a valuable method to alleviate anxiety by diverting attention from unpleasant feelings and physiological stress [14].

Educationally, puzzles foster multiple developmental domains: cognitive skills such as problem-solving, spatial reasoning, logical thinking; language skills through vocabulary and concept learning; motor skills by improving dexterity and hand-eye coordination; social and emotional development by fostering self-care, perseverance, and confidence; and creativity through imaginative play. For these reasons, puzzles are highly recommended tools for parents and practitioners to support children’s overall development and academic success, while providing enjoyable learning experiences [10].

These well-known techniques are simple to implement, require no specialized equipment, and are economical. Although they have proven successful in hospitalized pediatric patients, they are rarely implemented in dental settings. Therefore, this study investigated the potential benefits of using origami and puzzle games as distraction techniques to address dental anxiety and pain perception in children receiving local anesthesia.

METHODS

1. Ethical approval and protocol registration

The research protocol (IEC/NDCH/2024/FEB-APR/P-11) was approved by the Institutional Review Board and Ethics Committee of Dr. YSR University of Health Sciences. The Clinical Trials Registry of India registration number for this study is CTRI/2024/06/069124.

2. Study design, setting, and duration

This was a randomized parallel-group clinical trial with an equal allocation ratio. The research focused on children who visited the Department of Pediatric and Preventive Dentistry during a 2-month timeframe, from June 2024 to August 2024.

3. Sample size

Using G*Power analysis, the sample size was estimated based on an effect size of 0.80, an alpha level of 0.05, and 80% power. With a 1:1 allocation ratio, the total sample size required was 52, which was divided into 26 participants per group.

4. Study materials

The study design involved the comparison of two groups:

Group I: Puzzle game group, where a jigsaw puzzle was given to the child, consisting of a picture printed on cardboard with different shapes, and the child was asked to assemble it to form a picture before LA administration.

Group II: Origami group, where the child was given origami paper and asked to fold it according to the instructions printed on it, which eventually formed the shape of an animal or bird before the LA injection procedure.

After topical anesthesia was applied, local anesthesia was administered to children in both Groups via a dental syringe equipped with a 27-gauge needle, and a solution of 2% lidocaine with 1:100,000 epinephrine.

5. Assessment

Pulse rate, as a physiological measure, was recorded using a pulse oximeter (BPLC101A2Pulse Oximeter). This non-invasive, objective technique was adopted to assess physiological changes resulting from the subjective nature of anxiety. Pulse rate measurements were recorded at five-minute intervals prior to the intervention, during, and after the dental injection.

Anxiety level was recorded using a subjective measure (Facial Image Scale [FIS]) before and after the intervention. FIS was developed by Buchanan and Niven in 2002 to assess state anxiety through a series of five faces ranging from 'very happy' to 'very unhappy. Children chose the face that best described their current emotional state. Scoring was based on a 1-to-5 point scale, where 1 corresponded to the happiest face and 5 to the unhappiest face [15].

Pain perception was recorded using an objective measure (face, leg, activity, cry and consolability [FLACC]) during LA administration. FLACC scale was developed by Sandra Merkel, Terri Voepel-Lewis, and Shobha Malviya at C.S. Mott Children’s Hospital, University of Michigan health system in the year 1997. The FLACC scale is a viable and acceptable interrater reliability tool for assessing children's pain. It uses five categories, each scored on a scale of 0–2, to generate a total pain score ranging from 0–10 [16].

After LA was administered, a subjective measure, the Faces Pain Scale-Revised, was used to record pain perception. The Faces Pain Scale-Revised (FPS-R) is a self-reported instrument used to gauge pain levels in children. It is a version of the original Faces Pain Scale, which uses a well-known 0–10 scale to rate pain symptoms. There is a strong linear correlation between the FPS-R and visual analog pain scales in children aged 4–16 years. This scale is user-friendly, requires no special equipment, and only requires printed copies of facial expressions [17].

6. Methodology

Participants in the study were recruited using convenience sampling. All children, along with their parents or guardians, were briefed on the study's objectives and procedures. Patients who provided signed informed consent were included in this study.

Inclusion criteria:

• • Children aged 5–10 years with no previous LA exposure

  • Healthy children attending the dental hospital

  • Children who are willing to participate

  • Children indicated for dental procedures under Local anesthesia

Exclusion criteria:

• • Medically compromised children

  • Special needs children

  • Children with a previous history of LA exposure

  • Children with dental emergencies, including trauma, acute pulpitis, dental abscesses, cysts, and pericoronitis.

To ensure randomization and conceal treatment allocation, a computer-generated random sequence was used to create sequentially numbered opaque sealed envelopes. Each participant selected an envelope upon enrolment. To maintain consistency, a single experienced pediatric dentist performed all procedures in both groups. However, neither the participants nor dental staff were blinded to the group assignments, which may have influenced their perceptions. However, the statistical analyst was unaware of the group assignments until after data analysis to minimize bias.

7. Treatment

Prior to LA administration, the puzzle game and origami were given to the children according to their respective groups. In Group I, the puzzle game involved providing a child with a jigsaw puzzle featuring a picture printed on cardboard consisting of various shapes. The child was asked to arrange pieces to complete the image before local anesthesia was administered (Fig. 1). For the children in Group II, origami play therapy consisted of handing each child a piece of origami paper and asking them to fold it according to the provided printed guidelines. Following the step-by-step guide, the child eventually formed the shape of an animal or bird before local anesthesia (Fig. 2). After applying topical anesthesia, 1 ml of 2% lidocaine solution containing epinephrine at a concentration of 1:100,000 was carefully injected into the oral mucosa. Dental personnel measured the pulse rate five minutes before, during, and five minutes following after injection. In both groups, anxiety levels were measured using a subjective measure (facial image scale) before and after the intervention. During LA administration, pain perception was recorded using the FLACC scale by evaluating designated behaviors during needle puncture. Following local anesthesia, the children were asked to rate their pain experience during the dental injection using the Faces Pain Scale-Revised. Each child selected the face that best represented their pain, and the corresponding facial scores were recorded.

Fig. 1. Child playing puzzle game.

Fig. 2. Child performing origami.

8. Statistical analysis

Following systematic organization and tabulation of the collected data, statistical analyses were performed using Statistical Package for Social Sciences (SPSS) software version 20. Demographic data from the two study groups were compared using the chi-square and independent t-tests. Paired and independent t-tests were used for inter- and intra-group comparisons of pulse rates, respectively. The Wilcoxon signed-rank test for intra group comparison and the Mann–Whitney U test for intergroup assessment of facial image scale scores were used. Fisher's exact test for intergroup comparison of the FPS-R and the Mann–Whitney U test for the FLACC scale were used.

RESULTS

Fig. 3 illustrates a flowchart of this study. Of the 60 eligible children, 52 were successfully included, randomized, and allocated to the study groups.

Fig. 3. Consolidated standards of reporting trials (CONSORT) flow diagram.

The study included 52 children (25 females, 27 males). The puzzle group included 50% males (n = 13) and 50% females (n = 13). In the Origami group, 53.8% (n = 14) of the patients were males and 46.2% (n = 12) were females. The study groups had similar sex distributions; however, the difference was not statistically significant (P = 0.78). Similarly, the age distribution between the groups did not show a statistically significant difference (P = 0.07), with mean ages of 7.76 ± 1.88 years for the Puzzle group and 6.68 ± 1.91 years for the Origami group (Table 1).

Table 1. Demographic details.

Demographic details		Puzzle game group N (%)	Origami group N (%)	P-value
Gender				0.78 (NS)
	Females	13 (50)	12 (46.2)
	Males	13 (50)	14 (53.8)
Age		7.76 ± 1.88	6.68 ± 1.91	0.07 (NS)

^*chi square test, ^†independent t test, N, number; NS, non-significant.

The pulse rates among the study groups at various intervals were compared, and the findings from the one-way ANOVA demonstrated a significant difference in pulse rates at various intervals in the intragroup comparisons (Table 2).

Table 2. Comparison of pulse rates among the study groups at various intervals.

Groups	Before	During	After	Repeated measures anova
Puzzle group	93.5 ± 2.08	102.2 ± 1.88	98 ± 1.9	P = < 0.001*
Origami group	93.7 ± 2.19	104.5 ± 5.05	97.7 ± 2.33	P = < 0.001*

Repeated measures Anova P < 0.05^* significant

The results of the independent t-test showed a statistically significant difference (P = 0.04) in the intergroup comparison of pulse rates during LA administration; however, no significant difference was observed between the two groups in the scores obtained before and after LA administration (Table 3 and Fig. 4).

Table 3. Intergroup comparison of pulse rates at various intervals among study groups.

Intervals	Groups	Mean ± SD	t-value	P-value
Before	Puzzle group	93.5 ± 2.08	0.26	0.796 (NS)
	Origami group	93.7 ± 2.19
During	Puzzle group	102.2 ± 1.88	2.112	0.04*
	Origami group	104.5 ± 5.05
After	Puzzle group	98 ± 1.9	0.522	0.604 (NS)
	Origami group	97.7 ± 2.33

Independent t Test, NS, non-significant; SD, standard deviation.

Fig. 4. Intergroup comparison of pulse rates at various intervals among study groups.

For both the Puzzle group and Origami group, intragroup comparisons of the mean pulse rates showed statistically significant differences (P < 0.001) between the scores recorded before, during, and after the administration of local anesthesia (Table 4).

Table 4. Intra group comparison of pulse rates at various intervals among study groups.

Groups	Intervals		Mean diff	t-value	P-value
Puzzle group	Before	During	-8.69	-26.20	< 0.001*
		After	-4.46	-12.53	< 0.001*
	During	After	4.23	15.16	< 0.001*
Origami group	Before	During	-10.77	-10.65	< 0.001*
		After	-4.00	-9.31	< 0.001*
	During	After	6.77	7.40	< 0.001*

Paired t-test P < 0.05^* significant

Intra group comparison of scores on the facial image scale showed a statistically significant (P < 0.001) reduction in anxiety scores before and after the intervention across the two groups (Table 5).

Table 5. Intra group comparison of scores of the Facial Image Scale (FIS).

Groups	Intervals	Mean ± SD	P-value
Puzzle group	Before	3.27 ± 0.604	< 0.001*
	After	1.58 ± 0.758
Origami group	Before	3.08 ± 0.628	< 0.001*
	After	2.15 ± 0.613

Wilcoxen sign rank test P < 0.05^* significant

Mann–Whitney U test showed a statistically significant difference (P = 0.004) in the intergroup comparison of FIS scores between the two groups after the intervention. However, no significant difference was observed between the two groups before the intervention (Table 6).

Table 6. Inter group comparison of scores of Facial image scale (FIS).

Intervals	Groups	Mean ± SD	u-value	P-value
Before	Puzzle group	3.27 ± 0.604	285.0	0.271 (NS)
	Origami group	3.08 ± 0.628
After	Puzzle group	1.58 ± 0.758	190	0.004*
	Origami group	2.15 ± 0.613

Mann-Whitney u test P<0.05^* significant

The intergroup comparison of FLACC scores using the Mann–Whitney U test showed that there was a statistically significant difference between the puzzle group and origami group, with a p-value of 0.034 (Table 7, Fig. 5).

Table 7. Inter group comparison of FLACC scores.

Intervals	Groups	Mean ± SD	u-value	P-value
During	Puzzle group	2.16 ± 0.688	214.0	0.034*
	Origami group	2.56 ± 0.58

Mann-Whitney u test P < 0.05^* significant

Fig. 5. Inter group comparison of FLACC scores.

Inter group comparison of FPS-R scores demonstrated a statistically significant difference between the groups, with a p-value of 0.001 (Table 8, Fig. 6). These findings suggest that the Puzzle group reported lower pain scores than the Origami group.

Table 8. Inter group comparison of Faces Pain Scale-Revised (FPS-R) score.

Scales	Puzzle group	Origami group	χ2 value	P-value
No pain	0 (0)	0 (0)	24.3	0.001*
Mild pain	15 (60)	0 (0)
Moderate pain	10 (40)	18 (72)
Severe pain	0 (0)	7 (28)

Fisher's exact test P < 0.05^* significant

Fig. 6. Inter group comparison of Faces Pain Scale-Revised (FPS-R) score.

DISCUSSION

Many factors contribute to dental fear and anxiety in children, acting as triggers or exacerbating existing conditions [18]. While anxiety is a normal physiological response that helps people cope with adversity, it can be problematic in the dental setting. However, preoperative anxiety can have detrimental effects, such as prolonging the duration of hospitalization and increasing the need for analgesics and anesthetics [19]. The prevalence of preoperative anxiety ranged from 41.7% to 75.4% [20]. Ortiz et al (2014) observed that anxiety was prevalent among children, with 57.2% exhibiting anxiety before dental procedures and 46.2% during dental procedures [21].

Pain management is a crucial consideration when administering local anesthesia in dental practice, especially when treating children. Consequently, various procedural, behavioral, and pharmacological approaches have been suggested to mitigate pain and discomfort during pediatric dental treatment [22]. Moreover, play therapy can significantly minimize the anxiety and tension experienced by children. While engaged in play, children have the opportunity to communicate their fear, anxiety, anger, joy, visions, and dreams. These playful experiences enhance creativity and facilitate adaptation to unfamiliar environments, such as medical settings. Consequently, anxious children often become less anxious overall [23]. In the current study, a puzzle game (Group I) was used for distraction because puzzle games are multifunctional and offer a wide array of benefits. These games are designed to boost cognitive skills, as they require children to channel their attention towards the game [24]. Alimul (2012) stated that appropriate games for children are those that enhance their ability to match and distinguish between gross and fine motor coordination while also helping them manage their emotions, such as puzzle games [25].

Origami (Group II)was used for distraction because origami has proven to be a beneficial method for minimizing anxiety resulting from hospitalization. Origami offers children the chance to create various shapes by folding paper, allowing them to take pride in their accomplishments. This aligns with the theory of psychosocial development in school-aged children, approximately 5–11 years ages, which posits that they begin to cultivate interest by exploring their environment. Children who are encouraged to feel proud of themselves can improve their self-esteem and reduce their anxiety. Positive reinforcement by parents and teachers creates a sense of competence and self-belief in children (Agustina & Puspita, 2010) [26].

This study focused on children aged 5–10 years because there is a reported prevalence of dental treatment anxiety of 24.5% in this age group among Indian children [27].

In the present study, we regarded the objective measure of pulse rate as a physiological indicator of anxiety. The children showed a notable increase in pulse rate with the administration of local anesthesia in the intergroup comparison. Comparable results were reported by Venkiteswaran et al., who reported a remarkable increase in heart rate during the administration of local anaesthesia [28]. This may be because exposure to anxiety-provoking situations in children results in increased corticoid release, subsequently increasing the heart rate and systolic blood pressure [29]. Furthermore, the use of local anesthesia containing epinephrine, which acts as a vasoconstrictor, may cause an increase in children's heart rate.

In the current study, anxiety was measured using the FIS, a self-reporting tool used to quickly assess a patient's emotional state during dental procedures. We found a statistically significant reduction in anxiety between the two groups after the intervention. Anxiety was decreased more in Group I after giving the Puzzle game (mean = 1.58 ± 0.758)when compared to the Origami group (mean = 2.15 ± 0.613). This study was consistent with Kaluas et al (2015) researchers believed that implementing Puzzle play therapy is more effective than story telling therapy in minimizing anxiety among pre-school children during hospital care, where the average anxiety response score before therapy was 34.71 and decreased to 28.71 after therapy [30]. This was in accordance with Golitaleb et al. (2023) concluded that puzzle solving could be a beneficial treatment method for alleviating anxiety in children [31]. Similarly, a study by Pribadi (2018) stated that there was a statistically significant (p = 0.00) reduction in the anxiety level in children in both the Origami and Puzzle-solving Play therapy groups, where puzzle solving was more effective than origami, with a mean value of 8.00 [24]. Similarly, Ramdaniati and Hermaningsih demonstrated that puzzle therapy helps lower anxiety levels in young children (preschoolers) who are hospitalized [32]. This may be because puzzle play therapy is meaningful in reducing anxiety in children because it requires patience and perseverance as they assemble pieces, gradually helping them develop a calm, diligent, and patient mindset when facing and solving problems.

In this study, anxiety was also reduced in Origami group (mean = 2.15 ± 0.613), this was following the study done by Mathew CS et al (2018) [33] and Thakur M (2021) [34] where comparison of origami with a control group showed that origami led to lower anxiety levels. This may be because origami serves as a diversion activity for children, allowing them to shape colored paper into meaningful forms and sizes. This activity is associated with cognitive development and socialization and promotes learning while also encouraging various behavioral changes in children. In contrast, a study by Srinivasan et al (2023) reported that compared to origami, building blocks, and tell shows, clay therapy was rated as a highly effective method for reducing anxiety [35].

The Faces Pain Scale-Revised (FPS-R) was used to quantify subjective pain in this study. This scale was selected due to its strong cross-cultural validity, proven construct validity (through hypothesis testing), and sensitivity to changes in pain levels, making it superior to other pain assessment tools. The FPS-R design, which avoids smiles and tears, is also beneficial particularly for assessing pain in young children [17]. Objective pain was evaluated using the FLACC scale, known for its high internal consistency, criterion validity, reliability, and responsiveness. Although these measures are sensitive to pain, their ability to differentiate between discomfort that is related to pain and that which is not limited. To receive a score of "zero," the newborn must be "smiling" and "laughing or giggling," respectively, according to the descriptors for the "face" and "cry" elements in FLACC. However, pain does not necessarily occur in the absence of these actions. The FPS-R is a valuable instrument for assessing children's pain, but it is important to carefully consider its limitations such as lower user preference, difficulties with younger or developmentally delayed children, limited cross-cultural validation, the possibility of misinterpreting facial expressions, and unsuitability for people with severe cognitive impairments [36].

The intergroup comparison of FLACC and FPS-R scores demonstrated a significant decrease in the pain score in the puzzle game group compared to the origami group. This may be due to, engaging in play activities enables children to communicate their emotions, helping them temporarily forget their pain.[37]. This was by Supartini et al(2014), they stated that while playing, children can divert their attention from pain (distraction) and experience relaxation through the associated enjoyment [38]. Similarly, Godino-Ianez et al. showed that play therapy effectively reduced postoperative pain, improved behavior and attitude, and reduced anxiety in hospitalized children [39]. Similarly, puzzle solving significantly reduces the detrimental effects of hospitalization in children according to Kaluas et al. (2015) [30].

Based on our findings, puzzle play therapy proved to be more effective than origami play therapy in lowering anxiety and pain in children. Puzzle play therapy offers numerous advantages over origami, including the enhancement of fine motor skills and hand-eye coordination, increased motor speed, better understanding of competitive environments, heightened spatial awareness, and improved shape recognition and combination skills.

These therapeutic play activities significantly helped reduce stress and anxiety in children. These activities allow them to convey their feelings such as anxiety, fear, pain, and a sense of losing control. Therefore, it is essential to incorporate play activities as fundamental components in clinical practice.

Limitations

There are limited studies on these two play therapy techniques in pediatric dentistry. Therefore, further studies are warranted.

Conclusion

Based on the results of our study, puzzle games and origami are both useful for managing dental anxiety and pain in children. However, the Puzzle game was the most effective in minimizing pain and anxiety during LA administration in children. Therefore, these techniques are effective alternatives to distraction techniques in pediatric dentistry.

Recommendations

These conventional approaches offer simplicity and affordability, are readily available and easy to use, eliminate screen time, and can be conveniently used on a patient's chair. These techniques are short, safe, and do not require significant energy. In the future, a suitable technique should be selected based on the child's choice, parental history, or both.