A Randomized Controlled Trial on Comparative Evaluation of the Efficacy of Cognitive Behavioral Play Therapy and Tell-show-do Technique in the Behavior Modification of Uncooperative Children during Restorative Procedure Using Airotor

Abstract

Aim:

The aim of the study was to evaluate the efficacy of cognitive-behavioral play therapy (CBPT) and Tell-Show-Do (TSD) technique in the behavior modification of uncooperative children during restorative procedures using airotor.

Materials and Methods:

Sixty-two children (6–11 years) with dental caries (international caries detection and assessment system score 3) requiring restorations without local anesthesia, were divided into two groups: Group I – CBPT, and Group II – TSD. Children in Group I were introduced to the dental instrument using verbal explanations and a demonstration on a customized toy. They were then allowed to role-play as the dentist on the customized toy. Children in Group II received an explanation and a demonstration of the procedure before undergoing it. The behavior and anxiety levels of the children were assessed at three different points during the course of the trial. Pulse rate record served as an objective measure of anxiety.

Results:

The intergroup comparison of the behavior and anxiety scores between Group 1 and Group 2 exhibited a significant difference in the posttreatment scores. Group 1 showed a greater improvement in the behavior and anxiety scores in comparison to Group 2.

Conclusion:

The CBPT by way of role-play promotes a change in the cognitive and behavioral patterns of children in the dental clinic.

INTRODUCTION

Dental anxiety is a nonspecific feeling of apprehension, worry, uneasiness, or dread, the source of which may be vague or unknown;[1] Children with dental anxiety constitute a challenge to the dental team as a consequence of disruptive behavior. The sound and sensation associated with the airotor drill are one among the various anxiety-provoking stimuli in pediatric dentistry. Wardle and Lahmann et al. observed that dental injection was found to be most powerful as an anxiety-provoking stimulus, followed by the dental drill.[2,3] Similarly according to Vishwakarma et al., sight, sound, and sensation of the airotor are to be rated as the most fear-eliciting stimuli.[4] Behavior management techniques aim at the enhancement of a child’s coping skills to achieve complete disposition and acceptance of dental care, and essentially reduce the perception that the dental treatment is overwhelming or dangerous.[5] The behavior management methods recommended by the American Academy of Pediatric Dentistry include voice control, Tell-Show-Do (TSD), positive reinforcement, distraction and nonverbal communication, Hand-Over-Mouth-Exercise, protective stabilization, and pharmacological interventions such as conscious sedation, nitrous oxide, and general anesthesia.[6]

TSD is one of the simplest and most commonly used behavior guidance techniques that helps pediatric patients cope with dental situations. The child is familiarized with the dental setting thereby facilitating a reduction in anxiety.[7]

Play, regarded as the universal and inseparable part of childhood, is the mode through which children express themselves more directly and fully. As cognitive-behavioral play therapy (CBPT) combines cognitive and behavioral theories within a play therapy model, the present study aims to evaluate the efficacy of CBPT in comparison with the conventional TSD technique in the behavior modification of uncooperative children during the restorative procedure using dental airotor.

MATERIALS AND METHODS

The parallel arm randomized controlled trial was performed at a dental educational institution following ethical approval from the institutional review board. The clinical trial was registered at the Clinical Trials Registry–India (CTRI Reg. no: CTRI/2021/05/033675). Sixty-two children in the age range of 6–11 years, with no previous dental experience, were selected. Informed written consent was obtained from the parent/legal guardian based on the Indian Council of Medical Research guidelines.

Inclusion criteria

Children with Frankl’s behavior rating 2 and dental caries with a localized enamel breakdown without clinical signs of dentinal involvement (International Caries Detection and Assessment System (ICDAS) score 3) requiring restorations without local anesthesia were selected.

Exclusion Criteria

Children with a previous history of dental treatment, systemic illnesses, physical or intellectual disabilities, and deep dentinal caries lesions were excluded.

A statistician who was blinded to the study performed block randomization using a block size of 4. The block sequences (ABBA, BABA, ABAB, etc.) were computer-generated followed by a random allocation of the samples to the blocks using a random number table. A and B represented groups 1 and 2, respectively. The treatment group codes so generated (A, B) were entered into cards and sealed in opaque envelopes for allocation concealment. Figure 1 illustrates the flow of participants in the study according to CONSORT guidelines.

Figure 1.

Flow of participants in the study based on CONSORT guidelines

In Group I (CBPT), the child first obtained a verbal explanation of the planned dental procedure and was familiarized with the tactile and auditory sensations associated with the airotor, three-way syringe, and suction followed by a demonstration of the procedure on a customized toy with a wide-open mouth. The child was then made to role-play using the dental instruments instead of simulated instruments for 10–15 min before the dental treatment [Figure 2].

Figure 2.

Group 1 – Cognitive behavioral play therapy using role play

In Group II (TSD), the child was explained about the procedure in a manner the child would comprehend followed by a demonstration of the visual and tactile aspects of the dental instruments used for the dental restoration procedure. The procedure was then performed without deviation from the explanation and demonstration [Figure 3].

Figure 3.

Group 2 – Tell-show-do

The behavior and anxiety levels were assessed at baseline, following CBPT/TSD, and following dental restoration. Pulse rate determination with pulse oximeter served as an objective measure of anxiety. The Venham behavior and anxiety rating scale was used to rate the anxiety and behavior. Precalibrated examiner blinded to the study groups made the recordings.

Statistical analysis

All data were analyzed using the SPSS (version 25.0) SPSS Version 25, Chicago, Illinois, software package. The level of significance was set at 5% (i.e., P < 0.05). Mean values of pain, anxiety, and behavior measures were obtained for each group. Mann–Whitney U test was used for intergroup comparison. Friedman’s test was used for within-group comparison of pulse rate, anxiety, and behavior at different time points.

RESULTS

Table 1 illustrates the demographic details of the participants. No significant difference was observed in the mean age and distribution of gender between the two groups. Intragroup comparison [Table 2] of the pulse rate at different periods in Group 1 showed a statistically significant improvement between the baseline versus postintervention, baseline versus posttreatment, and postintervention versus posttreatment scores. Group 2 also exhibited a statistically significant upgrade in the baseline versus postintervention and baseline versus posttreatment scores. However, no significant change was observed in postintervention versus posttreatment scores in Group 2. Intergroup comparison [Table 3] of the pulse rate between the groups 1 and 2 exhibited a significant variation statistically between baseline and postintervention scores. However, no significant change was observed between the posttreatment scores in groups 1 and 2. Table 4 illustrates the intragroup comparison of the behavior and anxiety scores in Group 1 and Group 2. On intragroup comparison of study parameters during restorative treatment using airotor, a statistically significant amelioration in the behavior and anxiety scores was present between the baseline versus postintervention and baseline versus posttreatment period. However, no statistically significant difference was observed in the scores of study parameters between the postintervention and posttreatment periods. The intergroup comparison of the behavior and anxiety scores [Table 5] between Group 1 and Group 2 exhibited a significant difference in the posttreatment scores. Group 1 showed a greater improvement in the behavior and anxiety scores in comparison to Group 2.

Table 1.

Demographic details of study participants

Demographic details	Group 1, n (%)	Group 2, n (%)	Mean, n (%)
Age (years), (mean±SD)	7.74±1.949	7.16±1.675	7.45±1.826
Gender
Males	11 (35.5)	15 (48.4)	26 (41.9)
Females	20 (64.5)	16 (51.6)	36 (58.1)
Total	31 (100)	31 (100)	62 (100)

SD=Standard deviation

Table 2.

Intragroup comparison of the pulse rate between Group 1 and Group 2

Groups	Variable	Baseline versus postintervention (beats/min)	Baseline versus posttreatment (beats/min)	Postintervention versus posttreatment (beats/min)
Group 1	Z	4.255	6.795	2.540
	P	<0.001*	<0.001*	0.033*
Group 2	Z	4.191	3.210	−0.381
	P	<0.001*	<0.001*	1.000

*Level of significance at P<0.05. Related samples Friedman’s test (Bonferroni correction applied)

Table 3.

Intergroup comparison of the pulse rate between Group 1 and Group 2

Group	Baseline (beats/min)		Postintervention (beats/min)		Posttreatment (beats/min)
	Mean±SD	Range	Mean±SD	Range	Mean±SD	Range
Group 1	107.23±12.325	78–137	99.58±11.543	76–122	94.74±13.015	73–142
Group 2	98.90±11.040	73–120	92.23±11.433	54–107	93.90±8.746	76–114
Test statistic	−2.803		−2.150		−0.042
P	0.005*		0.032*		0.966

*Level of significance at P<0.05, Mann–Whitney U-test. SD=Standard deviation

Table 4.

Intragroup comparison of the behavior and anxiety scores between Group 1 and Group 2

Groups	Variable	Baseline versus postintervention	Baseline versus posttreatment	Postintervention versus posttreatment
Behavior
Group 1	Z	4.763	6.287	1.524
	P	<0.001*	<0.001*	0.383
Group 2	Z	4.509	3.683	0.826
	P	<0.001*	0.001*	1.000
Anxiety
Group 1	Z	6.731	4.699	2.032
	P	<0.001*	<0.001*	0.126
Group 2	Z	4.255	3.747	0.508
	P	<0.001*	0.001*	1.000

*Level of significance at P < 0.001

Table 5.

Intergroup comparison of the behavior and anxiety scores between Group 1 and Group 2

Variable	Group	Baseline		Postintervention		Posttreatment
		Mean±SD	Range	Mean±SD	Range	Mean±SD	Range
Behavior	Group 1	1.58±0.672	1–3	0.58±0.672	0–2	0.23±0.560	0–2
	Group 2	1.48±0.508)	1–2	0.77±0.560)	0–2	0.61±0.615	0–2
	Test statistic	−0.359		−1.428		−2.914
	P	0.720		0.153		0.004*
Anxiety	Group 1	1.71±0.783	1–4	0.68±0.653	0–2	0.19±0.477	0–2
	Group 2	1.39±0.495	1–2	0.68±0.541	0–2	0.52±0.626	0–2
	Test statistic	−1.614		−0.160		−2.402
	P	0.106		0.873		0.016*

*Level of significance at P<0.05, Mann–Whitney U-test. SD=Standard deviation

DISCUSSION

The sight of needles, drilling noise/sound along with the sensation of a high frequency of vibration, smell of cut dentin, and eugenol are the provocation factors attributed to dental anxiety.[8]

The management of children’s behavior is a vital component of pediatric dental practice. The quality of the dental visit both psychologically and technically plays an inherent role in eliciting a positive dental attitude. Behavior management techniques are aimed at enhancing a child’s cooperation, establishing proper communication, decreasing fear and anxiety, rendering successful and good quality dental care, building a trusting relationship between the dentist, child, and parent, and promoting positive dental attitude.[9]

An unfamiliar environment may lead to an increase in the level of children’s anxiety. Systematic desensitization or reciprocal inhibition has been observed to be one of the most effective methods in reducing maladaptive anxiety.[10] TSD is the popular method used for behavior shaping through systematic desensitization in pediatric dentistry.

The concept of learning by doing is pivotal in reducing children’s fear and anxiety toward dental treatment and promoting adaptive behavior. Thus, behavior modification techniques involving preexposure to dental equipment will give children a first-hand experience of their use, sounds, and clinical effects. In conventional TSD management, the children will only listen to and observe the treatment process immediately before they are subjected to treatment and hence might not be emotionally prepared for the treatment always.

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.[11]

In the present study, the intergroup comparison of the behavior and anxiety scores between the CBPT group and TSD group exhibited a significant difference in the posttreatment scores. The CBPT group demonstrated a greater improvement in behavior and anxiety scores in comparison to the TSD group.

Dramatic play with hospital-related toys can significantly reduce fears specific to the hospital environment. In the present study, in contrast to TSD, the CBPT in addition to educating and familiarizing the children with dental equipment also allows them to role-play the dentist in the clinic on a customized doll. The technique facilitates acclimatization with the dental office environment, hence making the child gradually feel in control of the situation. In the present study, the dental instruments were used to desensitize the pediatric patients instead of simulated toys to prevent deviation from what is shown and used. According to Wolpe and D’Zurilla real-life contact with anxiety-promoting stimuli may be beneficial in reducing anxiety responses.[10,12]

Limitations

Blinding of the participants could not be achieved in view of the behavior guidance intervention. The parallel study design may contribute to interparticipant variability.

CONCLUSION

CBPT and TSD techniques, both demonstrated amelioration in the behavior and anxiety scores. However, CBPT manifested better improvement in comparison to TSD technique. The CBPT by way of role-play promotes a change in the cognitive and behavioral patterns of children in the dental clinic. Although both the methods are safe and noninvasive, the CBPT may impart long-lasting benefits, by way of promoting more positive reminiscences of the dental treatment.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.