Abstract
Background
Early dental experiences play an important role in shaping a child's attitude toward dentistry. Non-pharmacological behavior management techniques such as Tell-Play-Do (TPD), modeling, and Tell-Show-Do (TSD) aim to reduce dental anxiety and improve cooperation during treatment.
Aim
To compare the effectiveness of Tell-Play-Do and Filmed Modeling, integrated with the Tell-Show-Do method, with Tell-Show-Do alone among children aged 4–7 year during restorative treatment.
Materials & method
This randomized clinical trial included 99 children (Frankl rating 2 or 3) requiring restorative treatment. Participants were randomly allocated to three groups: Group 1 (TPD), Group 2 (Filmed Modeling), and Group 3 (TSD). Behavior was assessed using the Facial Image Scale (FIS), and anxiety levels were measured using pulse rate at four different intervals: before intervention, after intervention, during the procedure, and at the end of the procedure. Data were analyzed using ANOVA, the Kruskal–Wallis test, paired t-tests, and the Wilcoxon signed-rank test.
Results
All three groups showed a reduction in anxiety over time, as indicated by decreasing FIS scores and pulse rates. Significant reduction was observed in TPD and filmed modeling groups in within-group comparisons. Pulse rate analysis demonstrated a statistically significant decrease from baseline to the end of the procedure in the TPD and Filmed Modeling groups.
Conclusion
Tell-Play-Do and Filmed Modeling are more effective than the TSD technique in reducing dental anxiety among children.
The study protocol was registered on the Central Trials Registry – India (CTRI/2023/08/057068).
Keywords: Behavior management, Dental anxiety, Tell-Play-Do, Filmed modeling, Tell-Show-Do
1. Introduction
The first dental experience plays a crucial role in shaping a child's attitude towards dentistry and influencing future dental outcomes.1 Children's cooperation is essential for delivering successful and high-quality dental care.2 For many, a visit to the dentist can be distressing, evoking fear and anxiety. These emotions may lead to behavioral changes during dental treatment, affecting the quality of care.3 Therefore, alleviating dental anxiety in children is vital not only for reducing immediate fear but also for preventing anxiety from persisting into later stages of life.4
Behavior guidance techniques, both non-pharmacological and pharmacological, are used to reduce anxiety, promote a positive dental attitude, and facilitate safe, effective, and high-quality oral health care for infants, children, adolescents, and individuals with special health care needs (SHCN).5 In pediatric dentistry, two of the most widely used non-pharmacological approaches for reducing dental anxiety during a child's first visit are Live Modeling and the Tell-Show-Do (TSD) technique.6, 7, 8
Live modeling, through real-life demonstrations or recorded videos, has been shown to effectively reduce dental anxiety in young children.1,9 This technique helps normalize the dental environment and reassures children by modeling a positive treatment experience. Furthermore, it transforms unfamiliar situations into familiar ones, helping children approach dental visits with greater confidence.10 The TSD technique, based on learning theory, helps children gradually understand the use of dental instruments and procedures.9,11 A child's cognitive development influences their ability to comprehend information, and children aged 4–7 years may find it difficult to grasp concepts that lack a clear framework.12,13
Building on the TSD technique, it has evolved into a modified approach known as Tell-Play-Do (TPD), which emphasizes experiential learning. This engaging technique allows young children to interact with dental-themed toys representing diagnostic instruments such as mouth mirrors and airotors. Through play, children explore the dental environment while learning fundamental concepts in a fun and interactive manner.14
Despite the investigation of numerous behavior management approaches, identifying the most effective strategy for reducing fear and anxiety in young children and obtaining parental acceptance remains challenging. The present study specifically aims to compare the effectiveness of two behavioral approaches—Tell-Play-Do and Filmed Modeling, both combined with the Tell-Show-Do method—with Tell-Show-Do alone in children aged 4–7 years undergoing restorative dental treatment.
2. Materials and methods
2.1. Ethical approval and consent
The study protocol was approved by the Institutional Review Board (IRB), and ethical clearance for the study was obtained from the Institutional Ethics Committee (YMTDC/IEC/OUT/2023/193). Necessary permissions were secured from the relevant authorities, and written consent was obtained from the parents of the children before the commencement of the study. The study was conducted in compliance with the Declaration of Helsinki and Good Clinical Practice (GCP) guidelines. The study protocol was registered on the Central Trials Registry – India (CTRI/2023/08/057068).
2.2. Study design
This parallel arm randomized clinical trial was designed to compare the effectiveness of three non-pharmacological behavior guidance techniques: Tell-Play-Do, Filmed Modeling, and Tell-Show-Do on dental anxiety and behavior in pediatric patients undergoing restorative treatment.
2.3. Study setting and population
The study was conducted in the Department of Pediatric and Preventive Dentistry at a private dental college and hospital in a metropolitan city in India. Patients were recruited from this department during the period from August 2024 to January 2025.
2.4. Eligibility criteria
The participants included in the study were children aged 4 to 7 years with a Frankl's behavior rating score of 2 (negative) and 3 (positive). Children with no prior dental experience who required restorative treatment using an airotor were eligible. Children who were physically, medically, developmentally, or mentally compromised, as well as those whose parents did not provide consent were excluded from the study.
2.5. Randomization and allocation concealment
A total of 99 participants were enrolled and randomly assigned in a 1:1:1 ratio to one of the three intervention groups using a computer-generated randomization sequence. Allocation was concealed using sealed opaque envelopes. Due to the nature of the intervention, blinding of participants and operators was not feasible; however, the outcome assessor was blinded to group assignments (Fig. 1).
Fig. 1.
CONSORT Flowchart.
2.6. Sample size determination
The sample size was calculated based on previous literature comparing Tell-Play-Do (TPD) and Live Modeling.6 Assuming a difference of 0.6 in the existing population with power greater than 80% and an alpha value of <0.05, a sample size of 30 per group was required. Accounting for a 10% attrition rate, a final sample of 33 children per group (n = 99) was recruited.
2.7. Intervention
Group 1: Tell-Play-Do (TPD).
The child was introduced to the operating room and seated on the dental chair. The operator used a customised dental toy and introduced dental imitating instruments using appropriate euphemisms. The restorative procedure was explained in phrases suitable for the child's developmental level. The children were allowed to hold dental imitating instruments (including airotor to play) and perform a dental procedure on the dental model for 10 min (Fig. 2).
Fig. 2.
Tell-Play-Do intervention.
Group 2: Filmed Modeling.
The child was introduced to the operating room and seated on the dental chair. The operator then presented a 4-min video on a mobile device, showing a 6-year-old child exhibiting cooperative behavior during a restorative procedure in the department.
Group 3: Tell-Show-Do (TSD).
The children were conditioned to receive dental treatment by TSD technique. This involved explaining and demonstrating the procedure and the instruments used during treatment. First, the procedure was explained to the child using euphemisms. Then, a visual demonstration of the procedure was given using dental instruments.
All participants subsequently underwent the restorative dental procedures involving an airotor under rubber dam isolation.
2.8. Outcome measures
The primary outcome measures of the study were the child's behaviour, assessed using Facial Image Scale (FIS) and anxiety levels assessed by recording pulse rate using a fingertip pulse oximeter. Both outcomes were evaluated at four time points: before the intervention, after the intervention, during the restorative procedure, and at the completion of the procedure.
2.9. Statistical analysis
Data was compiled on MS Office Excel 2013 and statistical analysis was performed using the statistical package for Social Sciences (SPSS V. 21). Descriptive statistics, including frequency, percentages, means, and standard deviation, were used to summarize the data. For within-group comparisons, the Wilcoxon Signed-Rank Test was used to assess differences in FIS scores across time points, while the Paired t-test was applied to evaluate changes in pulse rate. Between-group comparisons of FIS scores and pulse rates were performed using Analysis of Variance (ANOVA), with post hoc analyses conducted for pairwise group comparison. The Kruskal-Wallis test was used to compare changes in scores across multiple time intervals among the groups. Categorical data were analyzed using the Chi-square test to explore associations between nominal variables. All statistical tests were two-tailed, and a p-value of <0.05 was considered statistically significant. 95% confidence intervals (CI) were calculated where applicable to provide an estimate of the precision of the results.
3. Results
A total of 99 children were equally distributed across three groups: Tell-Play-Do (TPD), Filmed Modeling (FM), and Tell-Show-Do (TSD), with 33 participants in each group. The mean age of participants was comparable across the TPD (5.24 ± 1.34 years), FM (5.45 ± 1.52 years), and TSD (5.09 ± 1.50 years) groups, with no statistically significant difference (p = 0.599). Gender distribution and age group representation were also comparable across groups (p = 0.204 and p = 0.328, respectively), indicating baseline homogeneity. Outcomes were analyzed using both between-group and within-group comparisons to assess differences among interventions and changes over time.
3.1. Between-group comparisons
3.1.1. Facial Image Scale (FIS)
Intergroup comparison of FIS scores at the four time points (before intervention, after intervention, during the procedure, and at the end of the procedure) revealed no statistically significant differences among the three groups (Kruskal–Wallis test, p > 0.05) (Table 1).
Table 1.
Mean score and change of FIS of children (Kruskal-Wallis test).
| N | Mean (SD) | Min. | Max. | Percentiles (Median) |
Kruskal-Wallis test |
||||
|---|---|---|---|---|---|---|---|---|---|
| 25th | 50th | 75th | H | p | |||||
| Facial Image Scale | |||||||||
| Before Intervention | 99 | 1.97 (1.16) | 1.00 | 5.00 | 1.00 | 2.00 | 2.00 | 0.940 | 0.625 |
| After Intervention | 99 | 1.48 (0.73) | 1.00 | 5.00 | 1.00 | 1.00 | 2.00 | 3.593 | 0.166 |
| During procedure | 99 | 1.46 (0.67) | 1.00 | 4.00 | 1.00 | 1.00 | 2.00 | 2.616 | 0.270 |
| End of procedure | 99 | 1.27 (0.57) | 1.00 | 4.00 | 1.00 | 1.00 | 1.00 | 3.450 | 0.178 |
| Change | |||||||||
| After Intervention | 99 | −0.48 (1.02) | −4.00 | 2.00 | −1.00 | 0.00 | 0.00 | 0.995 | 0.608 |
| During procedure | 99 | −0.51 (1.16) | −4.00 | 2.00 | −1.00 | 0.00 | 0.00 | 2.016 | 0.365 |
| End of procedure | 99 | −0.70 (1.21) | −4.00 | 3.00 | −1.00 | 0.00 | 0.00 | 3.952 | 0.139 |
SD: Standard deviation; CI: Confidence interval. Test Applied- Kruskal-Wallis Test.
Similarly, comparison of the changes in FIS scores between time intervals among the TPD, FM, and TSD groups showed no statistically significant differences. The mean changes in FIS scores for TPD, FM, and TSD groups were −0.64 ± 1.11, −0.33 ± 0.96, and −0.48 ± 1.00 for before vs. after intervention (p = 0.490); −0.67 ± 1.05, −0.42 ± 1.23, and −0.42 ± 1.20 for before vs. during the procedure (p = 0.621); and −0.79 ± 1.11, −0.79 ± 1.22, and −0.52 ± 1.30 for before vs. end of the procedure (p = 0.575) (Fig. 3a).
Fig. 3.
Change in FIS scores and pulse rate of children in different groups.
3.1.2. Pulse rate
Intergroup comparison of pulse rate showed no statistically significant differences among the groups at baseline, after intervention, or during the procedure (p > 0.05). However, a statistically significant difference was observed among the groups at the end of the procedure (p = 0.049) (Table 2).
Table 2.
Mean score and change in pulse rate of children (Kruskal-Wallis test).
| N | Mean (SD) | Min. | Max. | Kruskal-Wallis test |
||
|---|---|---|---|---|---|---|
| H | p | |||||
| Pulse Rate (bpm) | ||||||
| Before Intervention | 99 | 104.14 (10.17) | 77.00 | 130.00 | 0.792 | 0.673 |
| After Intervention | 99 | 102.21 (10.31) | 75.00 | 130.00 | 1.378 | 0.502 |
| During procedure | 99 | 102.79 (10.49) | 80.00 | 126.00 | 3.313 | 0.191 |
| End of procedure | 99 | 101.47 (11.02) | 72.00 | 133.00 | 6.019 | 0.049* |
| Change | ||||||
| After Intervention | 99 | −1.93 (7.92) | −25.00 | 28.00 | 3.561 | 0.169 |
| During procedure | 99 | −1.35 (9.15) | −29.00 | 32.00 | 3.305 | 0.192 |
| End of procedure | 99 | −2.67 (9.32) | −26.00 | 26.00 | 6.435 | 0.040* |
SD: Standard deviation; CI: Confidence interval; bpm: beats per minute Test applied – Kruskal Wallis test, *: A p-value of ≤0.05 was considered statistically significant.
The change in pulse rate between time intervals was also compared across the three groups. The mean change in pulse rate before vs. after intervention was −1.91 ± 9.68 bpm in TPD, −3.76 ± 6.12 bpm in FM, and −0.12 ± 7.37 bpm in TSD, with no statistically significant difference (p = 0.177). Similarly, changes before vs. during the procedure were −2.48 ± 10.67 bpm, −2.36 ± 8.56 bpm, and 0.79 ± 7.89 bpm for TPD, FM, and TSD groups, respectively (p = 0.260). However, the change from before intervention to the end of the procedure was −5.42 ± 8.38 bpm, −3.58 ± 8.80 bpm, and 1.00 ± 9.79 bpm, respectively, showing a statistically significant difference among the groups (p = 0.014) (Fig. 3b).
3.2. Within-group comparisons
3.2.1. Facial Image Scale (FIS)
Within-group analysis demonstrated significant reductions in FIS scores over time within the intervention groups (Table 3).
Table 3.
Within group (paired) comparison of FIS scores of children in different groups.
| Groups | Mean | Wilcoxon Signed Ranks Test |
|
|---|---|---|---|
| Z | p | ||
| Facial Image Scale | |||
| Before Intervention vs After Intervention | |||
|
0.64 (1.11) | −3.009 | 0.003* |
|
0.33 (0.96) | −1.877 | <0.0001* |
|
0.48 (1.00) | −2.539 | 0.011* |
| Before Intervention vs During procedure | |||
|
0.67 (1.05) | −3.259 | 0.001* |
|
0.42 (1.23) | −1.805 | 0.071 |
|
0.42 (1.20) | −1.929 | 0.054 |
| Before Intervention vs End of procedure | |||
|
0.79 (1.11) | −3.578 | <0.0001* |
|
0.79 (1.22) | −3.303 | 0.001* |
|
0.52 (1.30) | −2.177 | 0.029* |
TPD: Tell-Play-Do, TSD: Tell-Show-Do, SD: Standard deviation; CI: Confidence interval. Test applied – Wilcoxon Signed Rank Test, *: A p-value of ≤0.05 was considered statistically significant.
In the TPD group, statistically significant reductions were observed between baseline and after intervention (p = 0.003), baseline and during the procedure (p = 0.001), and baseline and end of the procedure (p < 0.0001).
In the Filmed Modeling group, significant reductions were noted between baseline and after intervention (p < 0.0001) and baseline and end of the procedure (p = 0.001), while the change during the procedure was not statistically significant (p = 0.071).
In the TSD group, significant reductions were observed between baseline and after intervention (p = 0.011) and baseline and at the end of the procedure (p = 0.029), whereas the change during the procedure did not reach statistical significance (p = 0.054).
3.2.2. Pulse rate
Within-group pulse rate analysis revealed that the Filmed Modeling group showed a significant reduction in pulse rate after intervention (p = 0.001).
At the end of the procedure, both the TPD group (p = 0.001) and Filmed Modeling group (p = 0.026) demonstrated statistically significant reductions in pulse rate compared to baseline. No significant changes were observed in the TSD group (Table 4).
Table 4.
Within group (paired) comparison of pulse rate of children in different groups.
| Groups | Mean | Paired t-test |
|
|---|---|---|---|
| t | p | ||
| Pulse Rate (bpm) | |||
| Before intervention vs After Intervention | |||
|
1.91 (9.68) | 1.133 | 0.266 |
|
3.76 (6.12) | 3.528 | 0.001* |
|
0.12 (7.37) | 0.094 | 0.925 |
| Before Intervention vs During procedure | |||
|
2.48 (10.67) | 1.338 | 0.190 |
|
2.36 (8.56) | 1.586 | 0.123 |
|
−0.79 (7.89) | −0.573 | 0.570 |
| Before Intervention vs End of procedure | |||
|
5.42 (8.38) | 3.719 | 0.001* |
|
3.58 (8.80) | 2.334 | 0.026* |
|
−1.00 (9.79) | −0.587 | 0.562 |
TPD: Tell-Play-Do, TSD: Tell-Show-Do: SD: Standard deviation; CI: Confidence interval; bpm: beats per minute. Test applied – paired t-test,*A p-value of ≤0.05 was considered statistically significant.
A summary of the key intergroup comparisons of anxiety outcomes at the end of the procedure is presented in Table 5.
Table 5.
Summary of key intergroup comparisons of anxiety outcomes at the end of the procedure.
| Outcome | TPD (n = 33) Mean (SD) | Filmed Modeling (n = 33) Mean (SD) | TSD (n = 33) Mean (SD) | p value |
|---|---|---|---|---|
| FIS score | 1.18 ± 0.39 | 1.24 ± 0.66 | 1.39 ± 0.61 | 0.298 |
| Pulse rate (bpm) | 97.67 ± 10.80 | 101.76 ± 10.06 | 105.00 ± 11.24 | 0.024* |
TPD – Tell-Play-Do, TSD – Tell-Show-Do, FIS – Facial Image Scale, bpm – beats per minute; Test applied – ANOVA, *Statistically significant (p ≤ 0.05).
4. Discussion
Children and adolescents frequently experience dental fear due to uncertainty, leading to treatment delays and impacting care quality.15 Patients with fear require 20% extra chairside time, highlighting the importance of effective behavior control in pediatric dentistry.16 During early visits, approaches such as TSD and modeling serve as the foundation for educating and guiding children's dental treatment habits.14,17
The TSD technique serves as a foundation for behavior management in dentistry by introducing children to the dental setting, educating them on procedures, and offering demonstrations prior to treatment.6,18 Bandura introduced modeling in 1967 to reduce the anxiety in children during dental treatments, using both live and filmed examples.10,15,19 While live modeling can occasionally result in disruptive behavior, filmed modeling has been demonstrated to reduce dental anxiety.20,21 Vishwakarma et al. modified the TSD technique to produce the Tell-Play-Do (TPD) method, which includes a play component to promote learning and cooperation. This technique employs dental imitation toys, which allow children to feel comfortable by interacting with instruments such as a mouth mirror and probe prior to the actual treatment.6
A child's first dental visit has a significant impact on their future attitude toward dental care, therefore, creating a favorable environment is crucial.22 This study evaluated children with no prior dental experience, using the Frankl rating scale for cooperation, and focused on those who scored 2 (negative) or 3 (positive).23,24 FIS was chosen to assess anxiety because it is simple to use and reliable, especially for young children who may struggle with traditional surveys.25,26 However, the single-item format can make it difficult to detect specific anxiety components, and it may not be appropriate for older children.27 Messer observed that pulse rate and blood pressure are reliable measures of anxiety.28 An elevated pulse rate can indicate stress, making a finger pulse oximeter a useful tool for measuring anxiety in children.29 Thus, this study assessed children's anxiety using FIS scores and a portable finger pulse oximeter.
The present study demonstrated a gradual decline in mean FIS scores across all assessment time points, indicating a reduction in self-reported dental anxiety as the procedure progressed. However, intergroup comparisons revealed no statistically significant differences among the three behaviour management techniques. These findings suggest that, although the interventions may contribute to anxiety reduction, the magnitude of difference between techniques was not statistically significant. Similar observations were reported by Lekhwani et al. and Kevadia et al., who also found no significant intergroup differences between TSD and its various modifications.14,30
Nevertheless, within-group analysis in the present study revealed significant reductions in FIS scores across all behavioral intervention groups, with the Tell-Play-Do group demonstrating the most consistent improvement from baseline to the end of the procedure. This may be attributed to the interactive nature of the TPD technique, where children actively engage with dental imitation instruments and procedures through play. Such experiential exposure may help children become familiar with the dental environment, thereby reducing fear, enhancing communication with the dentist, and improving cooperation during treatment.
Pulse rate, an objective physiological indicator of anxiety, showed a progressive decline across the four measured time points, suggesting a gradual reduction in physiological stress as the dental procedure progressed. Although no statistically significant intergroup differences were observed at baseline, after intervention, or during the procedure, a significant difference emerged among the groups at the end of the procedure. This indicates that the cumulative effect of behavioral interventions may contribute to improved physiological relaxation by treatment completion. Within-group analysis further revealed significant reductions in pulse rate in the Tell-Play-Do and Filmed Modeling groups, indicating decreased dental anxiety in children receiving these interventions.
Similar findings have been reported by Radhakrishna et al., who observed lower mean pulse rates following behavioral interventions compared with conventional techniques.13 The observed reduction in pulse rate in the TPD group may be attributed to the interactive nature of the technique, which allows children to engage with dental instruments and procedures through play, thereby familiarizing them with the dental environment and reducing fear.6 Likewise, filmed modeling provides observational learning, enabling children to relate to cooperative behavior demonstrated in the video and approach the dental procedure with greater confidence.13,30
However, contrary findings were reported by Safar et al., who observed significant pulse rate differences during the procedure in modeling and TSD groups but not in the TPD group.1 This discrepancy may be due to the nature of the intervention employed. Safar et al.1 used a Tell-Play-Doh toy set in the TPD intervention, which may not fully mimic the dental procedure, whereas dental imitating instruments (including an airotor) were provided to children in the present study, likely helping them better comprehend the dental environment. This understanding could enhance their coping mechanisms and reduce anxiety during actual dental visits. Future research might explore the effectiveness of different types of interventions to further improve children's experiences in dental settings.
4.1. Strengths of the study
The study presents several key strengths. The use of a parallel-arm design with assessor blinding enhances the methodological rigor and minimizes the risk of observer bias. The comparison of three distinct non-pharmacological behavior management techniques—Tell-Play-Do, Filmed Modeling, and Tell-Show-Do—within a single study setting provides a comprehensive evaluation of their relative effectiveness. Importantly, both subjective (FIS) and objective (pulse rate) measures of anxiety were assessed across four standardized time points, providing a multidimensional evaluation of the child's behavioral response. Additionally, the interventions tested are cost-effective, easy to implement in routine clinical practice, and directly applicable to pediatric dental settings, thereby enhancing the practical relevance of the findings.
4.2. Limitations of the study
This study has certain limitations. It was conducted in a single institutional setting, which may limit the generalizability of the findings to broader populations. The inclusion of children aged 4-7 years representing a wide developmental spectrum may have introduced variability in cognitive understanding and emotional regulation, potentially influencing individual responses to the interventions. Additionally, inherent limitations of the Facial Image Scale and variability in children's self-reporting may have influenced the assessment of anxiety.
5. Conclusion
This randomized clinical trial demonstrated that both TPD and Filmed Modeling techniques are more effective than the conventional Tell-Show-Do approach in reducing dental anxiety among children aged 4 to 7 years. Significant improvements were observed in both subjective behavior (Facial Image Scale) and physiological response (pulse rate), particularly in the TPD group, which consistently showed the greatest anxiety reduction across all treatment phases. These findings highlight the value of incorporating interactive and observational behavior guidance strategies into routine pediatric dental care to enhance child cooperation and treatment outcomes.
Parent's/Guardian's consent
Parental consent was obtained before the start of the study.
Ethical clearance
The study protocol was approved by the Institutional Review Board (IRB), and ethical clearance for the study was obtained from the Institutional Ethics Committee (YMTDC/IEC/OUT/2023/193).
Human subjects statement
The study protocol was approved by the Institutional Review Board (IRB), and ethical clearance for the study was obtained from the Institutional Ethics Committee (YMTDC/IEC/OUT/2023/193). All procedures involving human participants were conducted in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments. Written informed consent was obtained from all parents or guardians.
Sources of funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Declaration of competing interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Acknowledgements
None.
Contributor Information
Aditi Avinash Gaikwad, Email: gaikwadaditi469@gmail.com.
Indu Varkey, Email: induvarkey08@gmail.com.
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