Exploring Novel Behavior Modification Techniques—Comparing the Effectiveness of Bach Flower Therapy and Bubble Breath Play Therapy on Dental Anxiety in Pediatric Patients: A Randomized Clinical Trial

ABSTRACT

Aims and background

Pediatric patients' acclimatization to dental care is a necessary precondition for meeting their current and future oral health demands. Various behavior guidance techniques aimed at patient management, such as play therapy and Bach flower therapy (BFT), have gained popularity recently but with little evidence to prove their effectiveness. The present study aims to evaluate the effectiveness of BFT and bubble breath play therapy (BBPT) in clinical situations and compare them with the conventional Tell-Show-Do (TSD) technique.

Materials and methods

A total of 45 children (aged 4–8 years) with baseline anxiety were randomly divided into three groups: BFT, BBPT, and TSD. All children received either oral prophylaxis or restorative treatment. Dental anxiety was evaluated pretreatment, during, and posttreatment using Venham's anxiety and behavioral rating scale and physiological parameters.

Results

A significant reduction in mean pulse rate and blood pressure (BP) was observed postapplication of BFT and BBPT but not in the TSD group. However, intraoperatively, the TSD group showed maximum improvement in anxiety levels, with 80% of participants showing Venham's rating of 0.

Conclusion

TSD is found to be most effective in allaying dental fear. While Bach flower and BBPT could both improve baseline anxiety, they did not alleviate dental fear and anxiety during treatment. Nevertheless, these alternative techniques are useful, especially in patients with subjective fears.

Clinical significance

The ability to guide pediatric patients through their dental experience is a prerequisite for the success of any dental treatment in children. Various approaches for behavior guidance have evolved over the years. Studies evaluating the effectiveness of both the conventional and alternative behavior guidance techniques are necessary to help the clinician in exercising appropriate methods in practice.

How to cite this article

Balakrishnan V, Ramachandran P, Martha S, et al. Exploring Novel Behavior Modification Techniques—Comparing the Effectiveness of Bach Flower Therapy and Bubble Breath Play Therapy on Dental Anxiety in Pediatric Patients: A Randomized Clinical Trial. Int J Clin Pediatr Dent 2025;18(6):677–682.

INTRODUCTION

The basic foundation of pediatric dentistry is being able to guide children through their dental experience. In 1895, McElroy stated, “Although the operative dentistry may be perfect, the appointment is a failure if the child departs in tears.” Since then, pediatric dentistry has progressed to include behavior guidance as an integral part of successful treatment. Effective and efficient treatment, along with instilling a positive dental attitude in the pediatric patient, is fundamental in establishing pediatric dental practice.¹

Dental anxiety is often the factor that leads to behavioral problems in children, preventing them from engaging in dental treatment. Armfield suggested that dental fear/anxiety leads to avoidance of treatment, that in turn leads to worsened dental problems that require more intense interventions. This will lead to further exacerbation of anxiety, thus forming a vicious cycle.²

Various approaches for behavior guidance have evolved over the years—apart from conventional techniques, newer alternative techniques such as Bach flower therapy (BFT), music therapy, play therapy, audiovisual distraction, etc. are also found to have the potential to reduce anxiety. BFT, developed by Dr Edward Bach, is a suggested method to relieve stress prior to medical or dental appointments. They have been shown to be effective in reducing situational anxiety in those with high levels of baseline anxiety.³ However, few studies are available in the literature that evaluate the effect of BFT in a dental set-up. Bubble breath play therapy (BBPT) is a technique that helps children deal with anxiety by engaging them in the fun activity of play and thereby distracting them. In addition to being a distraction technique, BBPT also encourages deep and controlled breathing, which enhances relaxation. Tell-Show-Do (TSD) is one of the most frequently employed nonpharmacological techniques that initially involves explaining and demonstrating the dental procedure, followed by carrying out the procedure without straying from how it was informed.²

The potential of BFT or BBPT in reducing dental anxiety in children has not been explored much, and the comparative effects of these alternative techniques have not been evaluated with conclusive evidence. The present study was thus conducted to evaluate and compare the effectiveness of BFT and BBPT on the management of anxiety in pediatric patients during dental treatment and assess their benefits in comparison with the conventional TSD technique.

MATERIALS AND METHODS

The study was conducted after obtaining Institutional Ethics Committee approval at KLR Lenora Institute of Dental Sciences, Rajanagaram. About 45 subjects, aged between 4 and 10 years, who met the inclusion criteria, were selected from among children who reported to the Department of Pediatric and Preventive Dentistry. An informed consent was obtained after explaining the study and procedure to the parents.

Selection Criteria

The baseline anxiety of the participants was assessed using the Children's Fear Survey Schedule−Dental Subscale (CFSS-DS), which is a 15-item questionnaire on various aspects of dentistry that the children were required to score. Scoring ranges from 1 (not afraid at all) to 5 (very much afraid); a total score of 38 or more is defined as dental anxiety.⁴ For ease of understanding, the questionnaire was translated and prepared in the regional language. Children who had a score of 38 or more were included in the study.

None of the subjects had previous dental history, and all the subjects required either restoration without local anesthesia or oral prophylaxis. Children with systemic illness, physical or intellectual disabilities, or a known history of allergy to drugs were excluded from the study. Keeping in mind the accentuated anxiety that pain may cause, children requiring local anesthesia or any painful procedure were excluded.

Intervention

The children were randomly assigned to one of the three groups (n = 15): group I, BFT; group II, BBPT; and group III, TSD. In group I, children were administered four drops of “Rescue Remedy drops” diluted in 7 mL of water orally, 20 minutes before the treatment. The drops were acquired from an established homeopathy practitioner in the area. Children from group II were given commercially available “bubble burst toy sticks” and were asked to blow bubbles. Children were prompted to blow large bubbles with controlled breathing. In group III, children were explained the procedure in a language they would understand, and a demonstration of the procedure was given. The procedure was then performed without deviating from the explanation. All children received either dental restorations or oral prophylaxis, irrespective of the behavior guidance technique employed.

In all groups, the outcome was assessed using Venham's anxiety and behavior rating scale, which is a two-scale system with 6 scale points anchored on readily observable behaviour.⁴ The anxiety level of the child during the procedure was assessed by a second invigilator by observing facial expressions, verbal protests, and body movements. Physiological parameters of pulse rate and blood pressure (BP) were recorded at baseline, after administration of the behavior modification technique, and postoperatively using a digital BP machine (Dr Morepen).

Statistical Analysis

The results obtained were tabulated and sent for statistical analysis. The statistical analysis was done using the Statistical Package for the Social Sciences (SPSS) version 21.0. The mean pulse rate and BP in the three groups, and the change in the values over the duration of treatment, were compared using the one-way ANOVA test. Intergroup comparison of Venham's anxiety scores and Venham's behavior ratings was done using the Chi-squared test.

RESULTS

A total number of 45 participants in the study were equally allocated into the three groups with a sample size of n = 15 in each. There was homogeneity in the distribution of children regarding their age, gender, and baseline anxiety level (as evaluated using CFSS-DS).

The mean pulse rates at baseline were 98.2 bpm (group I), 99.6 bpm (group II), and 103 bpm (group III). A decrease in mean pulse rate was observed in all three groups following behavior modification. Postoperatively, group I (BFT) showed a further decrease in the pulse rate with a value of 89.4 bpm, while both the other groups showed an increase as compared to both intraoperative and baseline values (Table 1). The intragroup comparison showed a statistically significant decrease in the pulse rate in group I (BFT) with a p-value of p = 0.012 (Table 2).

Table 1:

Intergroup comparison of pulse rate and systolic BP

Time points	Groups	Mean pulse rate	p-value	Mean systolic BP	p-value
Preoperative	BFT	98.2	0.564	81	0.06
	BBPT	99.6		90.2
	TSD	103		96.8
After behavior modification	BFT	90.2	0.058	86.5	0.90
	BBPT	94.8		87.6
	TSD	100		95.9
Postoperative	BFT	89.4	0.005*	92.9	0.001**
	BBPT	100.5		100.5
	TSD	105		99.3

*Significant p ≤ 0.05; **Highly significant p ≤ 0.001

Table 2:

Intragroup comparison of pulse rate and systolic BP

Groups	Time points	Pulse rate p-value	Systolic BP p-value
BFT	Preoperative	0.012*	0.001**
	After behavior modification
	Postoperative
BBPT	Preoperative	0.8	0.001**
	After behavior modification
	Postoperative
TSD	Preoperative	0.39	0.12
	After behavior modification
	Postoperative

*Significant p ≤ 0.05; **Highly significant p ≤ 0.001

The systolic BP showed considerable variation throughout the procedure. While baseline values were similar, postoperative values were significantly different in the three groups. Group I (Bach flower group) showed an increase in systolic pressure after behavior guidance and then postoperatively. There was a highly significant (p = 0.001) difference in the systolic BP values in this group. However, the other two groups showed an initial reduction in systolic BP following behavior guidance and an increase in the values postoperatively. A highly significant change (p = 0.001) in pre- and postoperative systolic BP could be seen in group II (BBPT) (Table 2).

Changes in pulse rate and systolic BP in the three groups over time are represented in graphical form in Figure 1.

Fig. 1:

Representation of pulse rate and BP among three groups over the three time points

The comparison of anxiety levels in children during the treatment using Venham's anxiety and behavior rating scale showed a highly significant difference in the results, with group III (TSD) showing the most favorable behavior (Table 3).

Table 3:

Intergroup comparison of Venham's anxiety scores

Groups	Frequency of Venham's anxiety scores				Chi-square value	p-value
	0	1	2	3
BFT	2	3	6	4	24.7	0.001**
BBPT	9	5	0	1
TSD	12	3	0	0
Total	23	11	6	5

A Venham's rating of 0 (relaxed, smiling—total cooperation) was seen in 80% of the children in group III (12 out of 15) and 60% of children in group II (9 out of 15), while only in 13% in group I (2 out of 15). The majority of children from group I (40%) showed a score of 2 (verbal protest and crying), but none interfered with treatment. In group III, no child showed a Venham's rating of more than 1. Overall, more than half of the total children (51.11%) showed total cooperative behavior following administration of Bach flower, BBPT, or tell-show component of TSD (Figs 1 and 2).

Fig. 2:

Representation of frequency of Venham's anxiety scores in three groups

DISCUSSION

Fear or anxiety related to dentistry is regarded as a worldwide public health issue, as it is a prime cause that culminates in the refusal of dental care.⁵ Oral health deteriorates in children with dental anxiety due to their tendency to avoid or resist treatment. The literature suggests that children who are frightened of dentists have a considerably higher incidence of caries and gingival issues. Malak et al. assessed schoolchildren's feelings and attitudes toward dentists and observed that the mean decayed, missing, and filled teeth (DMFT) and community periodontal index (CPI) scores were significantly higher in children with dental fear. They further suggested that anxiety ought to be properly handled to guarantee improved oral wellness and to build a strong patient−doctor relation.⁵

Prior to deciding on a behavior guidance strategy, anxiety must essentially be quantified. Anxiety, being an emotional response related to anticipation, is produced by stress and causes some physiological effects in the body. Research on dental anxiety has shown that the stress and anxiety associated with dental procedures cause variations in pulse rate and BP of the body. Rayen et al. stated that systolic BP and pulse rate are directly correlated to dental anxiety.⁶ Furthermore, these parameters are sensitive to variations in dental anxiety levels that might occur during the course of treatment.² Thus, in the present study, changes in BP and pulse rate were used as a direct measure of physiological arousal to anxiety.

Objectively observing anxiety-induced behavioral patterns is a necessity to refine the management techniques in the dental setting. Anxiety rating scales are the most commonly used indices to assess children's response to dental treatment. Venham's anxiety and behavior rating scale followed in the present study is a highly useful rating scale that can be easily integrated into research design, as the rating procedure is rapid, simple, and nonintrusive, with a high degree of interobserver reliability.⁷ Thus, it was used as an indicator of observed anxiety. Any painful procedures were eliminated to improve the reliability of the anxiety rating scale, as pain might accentuate anxiety and interfere with the results.

Bach flower therapy was introduced by Dr Edward Bach, a homeopath, in 1930. He found 38 unique flower remedies that were derived from trees, shrubs, and plants, that are claimed to alleviate negative feelings and thereby relieve the underlying psychological problems of the patient.⁸ Although Bach therapy's exact mechanism of action has not been thoroughly studied or proven by science, these have been used with notable results to sustain emotional health, especially in children. Bach claims that the remedy's vibration works on a subtle energy level with the person, and dissolves ingrained behavioral patterns. The remedies can be administered directly to pulse points like the wrists, temples, and back of the ears, or they can be diluted in water and taken orally.⁹

Rescue Remedy, or Five-flower remedy, is a special combination of five different flower remedies: Helianthemum nummularium (rock rose), Impatiens glandulifera, Clematis vitalba (old man's beard), Ornithogalum umbellatum (star of Bethlehem), and cherry plum (Prunus cerasifera), which can be used as a preventive method in dreaded situations. It acts as a “first aid remedy” and is said to reduce tension. Four drops of Rescue Remedy diluted in water or juices is the recommended dosage for children. The drops can also be used directly, as they are tasteless and easy to administer. Using four drops four times daily has been recommended for better results.⁸

Another option is to begin taking flower remedies a few days prior to the appointment if the panic attack is severe. Rescue remedy is also available as Rescue Gummy Stars and Rescue Pastilles, which would be especially appealing to children since they come in the form of candies in different flavors.⁹

In the present study, a single dose of Rescue Remedy was administered to the patients prior to the treatment. Though patients showed reduced pulse rate following BFT, very few in the group showed a shift toward positive behavior during treatment, as assessed by Venham's rating scale. Even when BFT could improve underlying baseline anxiety, anxiety associated with dental tools and treatment could not be alleviated.

This is similar to a study by Dixit and Jasani, in which a single dose of BFT in children aged between 4 and 6 years resulted in a lowering of pulse rate compared to preoperative levels. This randomized controlled trial is the single study available that evaluates the effect of BFT on dental anxiety in children. The study, however, could not demonstrate any impact of the intervention on anxiety reported by the patients.³

In a study to assess the effectiveness of Bach therapy on children with ADHD, the results failed to show any significant effect of BFT compared to placebo. There was an improvement in the performance of the children, which significantly correlated with the length of treatment, but it could not be associated with effects beyond placebo response.¹⁰ This is in contrast to the claimed effects of BFT on rebalancing emotions in children.

On the contrary, a double-blind clinical trial evaluating Rescue Remedy suggested that it may be effective in reducing high levels of situational anxiety in individuals experiencing high levels of state anxiety. These results are consistent with the Rescue Remedy formulation's intended use, which is the alleviation of extreme anxiety.¹¹

Bubble breath play therapy is a concrete relaxation method designed to teach children deep and controlled breathing and a sense of self-control, thereby decreasing anxiety. It is essentially play therapy, a technique that has been proven to be effective in managing anxious children. Play is the most essential, distinct activity of childhood, and play therapy entails giving items or scenarios in the form of games to develop communication. It is a way of communicating with the child in the language they best understand—the language of play. It is also known that deep-breathing techniques raise vagal activity and lower stress hormone levels in the body, thus adapting the body to the “relaxation response.”

Bubble breath exercise is being used as a successful distraction technique in the management of pediatric patients in short procedures like immunization and cryotherapy of warts, etc., and also by psychologists as a mode of communicating with children.¹²

A study by Azher et al. to assess the efficacy of BBPT in managing anxious children in a dental setup showed improvement in behavior and anxiety ratings in Venham's rating scale. The pulse rates postprocedure were also reduced from the baseline, which points toward the effective relaxation brought by the technique.² In a similar study by Bahrololoomi et al., the results showed lower pulse rates and BP in children who received bubble blower breathing exercise, along with lower levels of anxiety when compared to the control group. The authors suggested that for children with moderate to severe anxiety, utilizing a bubble blower for breathing exercises is a useful diversion and relaxation technique. Deep breathing exercises cause large inhalations, which expand the lungs and activate pulmonary stretch receptors, stimulate the vagal and baroreceptor reflexes, suppress sympathetic activity, and dilate the arteries, thereby lowering the BP and pulse rate.¹³

Sridhar et al. recommended bubble breath exercise in decreasing procedural pain perception during dental treatment, but the effectiveness of the technique in reducing procedural anxiety was not proved.¹²

In the present study, BBPT was found helpful in distracting the patient and guiding him or her to the dental chair with improvement in anxiety compared to baseline—60% of children showed Venham's rating of 0. There was a reduction in pulse rate and a highly significant reduction in systolic BP from the baseline values following BBPT. But both the values showed a spike after treatment, which could mean increased anxiety levels during the procedure that could be attributed to the site and sound of dental instruments. The results are in agreement with the study by Azher et al. and indicate that BBPT does not necessarily allay dental fear completely.² Nevertheless, BBPT is a feasible method to build up a patient−doctor relationship and helps to manage behavioral issues.

Tell-Show-Do, based on learning theory, which was introduced by Addleston in 1959, is one of the most essential behavior management techniques that is almost universally acceptable to children, parents, and dentists. Effective communication about the dental procedure to children helps to diminish the impression in children's minds that dental treatment is scary or overwhelming.¹⁴

Tell-Show-Do was found to be most effective in managing anxious children in the present study as assessed by Venham's rating scale. This could be attributed to the fact that TSD helps the patients to comprehend the situation, thus making them more cooperative to treatment. A mean reduction in the physiological parameters was seen following the tell-show element of TSD; however, the results were not significant. This could probably be because TSD restricts children to only verbal expression, and hence effective resolution of physiological arousal due to anxiety issues is not possible.

Similar results were shown in the study by Lekhwani et al., where there was an improvement in the score of Venham's anxiety scale but only a minimal reduction in heart rate following the TSD technique. It was suggested that TSD and its modifications are safe, least invasive, and most accepted among behavior guidance techniques.¹⁵

In the present study, the most effective reduction in physiological parameters was seen for BFT, which suggests that BFT could be useful in improving psychophysiological parameters in children with high-level anxiety at baseline. Similar suggestions have been reported in previous studies, where Rescue Remedy was useful in reducing anxiety in students with baseline anxiety but had no benefits in treating trait anxiety.¹¹

On the contrary, subjective assessment of anxiety showed that TSD was most effective in improving dental fear. BBPT showed comparable results but was less effective than TSD, while BFT showed the least effective reduction in observed anxiety. These results mirror the results of a similar study by Azher et al., who suggested that while BBPT can help to distract the child, thereby relaxing them, TSD works best to calm dental anxiety.²

Multiple techniques to assess anxiety were used in the study to ensure the reliability of the results. Additionally, the procedure was standardized with a single operator performing the procedures and a single examiner assessing the anxiety levels in all the subgroups. However, blinding of the operator, examination, and patients was not possible due to the nature of the intervention, which could have led to some bias. Further studies with a larger sample size and involving pain-inducing procedures like local anesthesia are warranted in this field. Furthermore, studies using a combination of different techniques are recommended.

Clinical Significance

Effective treatment in pediatric dentistry is dependent to a large extent on the effective management of dental fear and anxiety and the resultant adverse behavioral characteristics shown by children. Proper behavior guidance is possible only when there is proper knowledge about the various techniques and their effectiveness in reducing anxiety. Keeping in mind the novel techniques that are introduced with the changing scenario, it is important to assess how useful these methods are in the dental set-up.

CONCLUSION

Within limitations, it can be concluded that:

• Bach flower therapy can be used as a strategy to manage children with baseline anxiety during their first visit. It can act as an adjuvant to standard behavior-modification techniques that need to be applied prior to treatment.

• Bubble breath play therapy acts as a distraction and may be used to enhance rapport with the patient; however, it does not alleviate dental fears.

• Tell-Show-Do is found to be most effective in alleviating dental fear.

ORCID

Veena Balakrishnan https://orcid.org/0009-0009-1469-6559

Punithavathy Ramachandran https://orcid.org/0000-0002-0232-4055

Satyam Martha https://orcid.org/0000-0003-4739-3000

Sri Ramya Maganti https://orcid.org/0000-0003-4067-8396

Kondapalli Haritha https://orcid.org/0000-0003-3968-9987