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Q U I N T E S S E N C E I N T E R N AT I O N A L

Audiovisual video eyeglass distraction during dental treatment in children Diana Ram, DMD1/Joseph Shapira, DMD2/Gideon Holan, DMD3/ Florella Magora, MD4/Sarale Cohen, PhD5/Esti Davidovich, DMD, MSc6

Objective: To investigate the effect of audiovisual distraction (AVD) with video eyeglasses on the behavior of children undergoing dental restorative treatment and the satisfaction with this treatment as reported by children, parents, dental students, and experienced pediatric dentists. Method and Materials: During restorative dental treatment, 61 children wore wireless audiovisual eyeglasses with earphones, and 59 received dental treatment under nitrous oxide sedation. A Frankl behavior rating score was assigned to each child. After each treatment, a Houpt behavior rating score was recorded by an independent observer. A visual analogue scale (VAS) score was obtained from children who wore AVD eyeglasses, their parents, and the clinician. Results: General behavior during the AVD sessions, as rated by the Houpt scales, was excellent (rating 6) for 70% of the children, very good (rating 5) for 19%, good (rating 4) for 6%, and fair, poor, or aborted for only 5%. VAS scores showed 85% of the children, including those with poor Frankl ratings, to be satisfied with the AVD eyeglasses. Satisfaction of parents and clinicians was also high. Conclusion: Audiovisual eyeglasses offer an effective distraction tool for the alleviation of the unpleasantness and distress that arises during dental restorative procedures. (Quintessence Int 2010;41:673–679)

Key words: audiovisual distraction, behavior management, pediatric dentistry, video eyeglasses

The distress and unpleasantness associated with dental treatment in healthy children has been extensively researched. Negative attitudes toward dental care often result from discomfort with the invasiveness of treatment

1

Senior Clinical Lecturer, Department of Pediatric Dentistry, The

Hebrew University—Hadassah School of Dental Medicine, Jerusalem, Israel. 2

Professor, Chairman of the Department of Pediatric Dentistry,

The Hebrew University—Hadassah School of Dental Medicine, Jerusalem, Israel. 3

Clinical Professor, Department of Pediatric Dentistry, The Hebrew University—Hadassah School of Dental Medicine,

Jerusalem, Israel. 4

Professor Emeritus, Department of Anesthesiology and Critical

Care, Hadassah Medical Center, Jerusalem, Israel. 5

Visiting Professor, Department of Anesthesiology and Critical

Care, Hadassah Medical Center, Jerusalem, Israel. 6

Clinical Lecturer, Department of Pediatric Dentistry, The

Hebrew University—Hadassah School of Dental Medicine, Jerusalem, Israel. Correspondence: Dr Diana Ram, Department of Pediatric Dentistry, The Hebrew University Hadassah School of Dental Medicine, P.O. Box 12272, Jerusalem, Israel. Email: dianar@ ekmd.huji.ac.il

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despite efficacious pain relief with local anesthetics. A plethora of studies have assessed causes of fear and anxiety and have offered effective interventional modalities to prevent, reverse, or reduce the incidence of discomfort. Klingberg and Broberg1 recently reviewed the prevalence and multidimensional aspects of psychologic factors relating to dental behavior management in children. Numerous pharmacologic and nonpharmacologic techniques have been proposed for achieving nondisruptive behavior during the multiple visits necessary for nearly all pediatric dental restorative procedures. Behavioral management support is common, utilizing such means as tranquilizing verbal approaches, tell-show-do, physical contact by light touching and stroking, and relaxation exercises.2–5 Parental reassurance and brief intermittent opportunities allowing for release from the invasive treatment have been shown to reinforce children’s cooperative behavior.6,7 Although helpful, these methods are not always fully effective, especially for highly

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Q U I N T E S S E N C E I N T E R N AT I O N A L Ram et al

uncooperative patients. For them, pharmacologic means of sedation, such as the use of nitrous oxide, are indispensable to avoid unnecessary distress or even cancellation of subsequent scheduled visits. Presently, nitrous oxide/oxygen analgesia is used routinely during the dental treatment of anxious and uncooperative pediatric patients.8 Techniques for distraction include the use of external interventional stimuli and tools such as the Snoezelen multisensory adapted environment featuring a partially dimmed room with lighting effects,9 music, brief relaxation,5,10 storytelling,11,12 audio presentation through headphones or audiovisual story presentation on television,13 and presentation of videotaped material or a video game.14 More recently, virtual reality immersion15,16 and the use of audiovisual video eyeglasses16–18 have been introduced as promising techniques. Virtual reality immersion completely obstructs the dental environment and requires a computer with an advanced software program.19 In contrast, audiovisual distraction (AVD) is simple and inexpensive and does not interfere with dental treatment. This technique partially occludes the environment, while allowing child-clinician communication. A variety of programs enable adaptation to child preference. Video eyeglasses are currently being used in some dental settings. However, the few scientific publications primarily document their use with adults and with scaling rather than restorative dental treatment. While Bentsen et al found video eyeglasses not to decrease the unpleasantness and pain of restorative dental treatment, most patients reported an overall beneficial effect and said they would choose to wear video eyeglasses for similar events.18,20 In a study of dental prophylaxis with children using virtual reality immersion,15 all patients reported less anxiety and discomfort, with no significant differences between the study and control groups. Nonetheless, patients expressed preference for the use of video eyeglasses during further treatments. The aim of the current study was to examine the effects of AVD with video eyeglasses on the behavior of children undergoing dental restorative treatment and the self-reported

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satisfaction with the AVD treatment by children, parents, dental students, and experienced pediatric dentists. The hypothesis was that AVD using video eyeglasses would facilitate cooperative behavior and achieve a high level of patient satisfaction for most children during restorative dental treatment.

METHOD AND MATERIALS The subjects were 120 healthy children, 5 to 10 years old, who were treated at the pediatric dental outpatient clinic of the Hadassah Medical Center and a private pediatric dental clinic. Inclusion criterion was the need for at least two clinical sessions of operative procedures preceded by local anesthetic injection, in two sites of the same jaw, not due to emergency. Supervised undergraduate and postgraduate students and experienced pediatric dentists performed the simple and complex restorative dental treatment, including direct restorations, crowns, root canals, and extractions. All children had had previous restorative dental experience. The Ethical Committee of Hadassah Medical School approved the study. Participants were informed that they could withdraw from the study at any point without affecting their dental treatment. At initial evaluation, a pediatric dentist examined each child, assigned a Frankl behavioral rating score21 between 1 (worst behavior) and 4 (best behavior), and formulated a dental treatment plan. Children who for any reason could not receive nitrous oxide were assigned to the audiovisual group, and the others were assigned to the control group, which received nitrous oxide. AVD was achieved using audiovisual wireless eyeglasses with earphones (Mobile Theatre MT320, Prober Industries) (Fig 1). The video eyeglasses were worn over regular glasses, if required. The glasses partially occlude the environment and involve children in seeing and hearing a movie appropriate to their age. The children selected a film from known movies or cartoons such as Mickey Mouse, Toy Story, Dora, Madagascar, and Shrek.

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Q U I N T E S S E N C E I N T E R N AT I O N A L Ram et al

Ta b l e 1

Houpt Scale for general behavior

Aborted Poor Fair Good Very good

No treatment rendered Treatment interrupted; only partial treatment completed Treatment interrupted but eventually all completed Difficult, but all treatment performed Some limited crying or movement, eg, during local anesthesia No crying or movement

Excellent

Fig 1 A child receiving local anesthesia while wearing the AVD eyeglasses.

The nitrous oxide was supplied using a Quantiflex MDM (MATRX, USA) system with a maximum concentration of 50% nitrous oxide and 50% oxygen. At restorative dental appointments, children in the AVD group received the video eyeglasses before topical anesthesia and local anesthetic injections. An independent observer assessed and recorded the children’s behavior throughout the dental procedures and rated the general behavior according to the Houpt scale22,23 (Table 1). At the end of the dental procedure, the independent observer asked the children in the study group to rate on the visual analogue scale (VAS), from 0 to 10, their satisfaction with the AVD eyeglasses and to state whether they would want to use the eyeglasses on subsequent visits to the clinic. The parents and the clinicians were also asked to rate on a VAS their satisfaction with the AVD during the visit. In the control group, the independent observer only rated the child’s general behavior according to the Houpt scale. Frequencies and percentages were calculated for the categorical variables. The frequencies of the categorical variables between the study and control groups were compared using the chi-square test. For continuous variables, ranges, medians, means, and standard

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deviations were calculated. The Shapiro-Wilk test was used to analyze the normality assumption. Continuous variables were compared by the two-sample t test for differences in means (a parametric test) or by the Wilcoxon signed rank test (a nonparametric test). The Wilcoxon paired signed rank test was used to compare pairs of results. The level of statistical significance for all tests was P ≤ .05.

RESULTS The study group comprised 30 girls and 31 boys. The control group comprised 35 boys and 24 girls. The mean age of the study group (8.0 ± 1.84 years) was significantly higher (P = .001) than that of the control group (6.1 ± 1.42 years). No statistically significant differences were found between the study and control groups for gender, previous nitrous oxide experience, and complexity of the treatments (Table 2). The durations of both the first and the second treatments were significantly longer (P < .001) when AVD glasses were used compared to treatments with nitrous oxide. No statistically significant difference was found in duration of treatment within the study and control groups between the first and second visits.

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1 2 3 4 5 6


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Ta b l e 2

Characteristics of the study and control groups

Variable

Study group Control group (AVD glasses) (n = 61) (nitrous oxide) (n = 59)

Gender (male/female) Age (y) (mean ± SD) Behavior at examination according to Frankl scale Previous nitrous oxide/oxygen experience (yes/no) Complexity of treatment (simple/complex) Duration of first treatment (min) Mean ± SD Range Median Duration of second treatment (min) Mean ± SD Range Median

Table 3

P value

31/30 8 ± 1.84 3.1 ± 0.8 16/45 34/27

35/24 6.1 ± 1.42 2.6 ± 0.5 21/38 41/18

34.8 ± 19.1 15–105 30

25.4 ± 2.83 20–30 25

.0001

32.6 ± 12.5 20–100 30

25.0 ± 2.5 22–30 25

.0001

.001 .0016

Comparison between AVD and control groups of Houpt scale scores for first treatment AVD group

Control group

61 1–6 6 5.5 1.1

59 3–6 6 5.1 1.0

No. of children Range Median Mean Standard deviation

The behavior of the study group, as

The mean VAS ratings for children in the

assessed by the Frankl scale at the initial examination, was better than that of the control group (P = .001). For first dental treatments, general behavior, as assessed by the Houpt behavior rating scale, was significantly better, on average, in children treated with AVD eyeglasses than in the control group (P = .0215). General behavior during the AVD sessions, as rated by the Houpt scales, was excellent (rating 6) for 70% of the children, very good (rating 5) for 19%, good (rating 4) for 6%, and fair, poor, or aborted (rating 3, 2, or 1) for only 5% (Table 3). For second treatments, behavior scores were very high and similar in both groups, with no statistically significant difference between them.

study group, their parents, and the clinician were high, with mean values between 8 and 10, indicating a high level of satisfaction. Using the VAS scale, 85% of the children rated their satisfaction with the maximum score of 10, and only three rated satisfaction as less than 5.

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DISCUSSION This study confirms the hypothesis that AVD using eyeglasses facilitates cooperative behavior and achieves a high level of patient satisfaction for most children during restorative dental treatment. In addition, most of the

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Q U I N T E S S E N C E I N T E R N AT I O N A L Ram et al

parents, all the pediatric dentists, and most of the student dentists were highly satisfied. While the AVD technique is not meant to replace the trust-building communication that is inherent to good child patient–clinician relationships, or to replace the use of nitrous oxide, the authors recommend introducing AVD at dental appointments after trust is established, to enhance the positive patient attitude toward the dental experience. AVD eyeglasses provide an alternative means of relaxation for children who respond negatively to oral sedation or nitrous oxide sedation, or who lack the possibility of communication with the clinician, due to language barriers, for example. Nitrous oxide/oxygen sedation is a wellaccepted behavior management technique for noncooperative children. However, in some cases, this pharmacologic technique cannot be used because of anatomical reasons (enlarged adenoids, a runny nose, or any difficulty in breathing through the nose); psychologic reasons (the child refuses to have a nose mask, fear of the mask, claustrophobia); parents’ refusal of the use of nitrous oxide analgesia; or unavailable equipment (in some countries, the use of nitrous oxide by a clinician is not legal or is unavailable as in some undergraduate clinics). The present findings that AVD eyeglasses can serve as an alternative to nitrous oxide support previous studies.15,23 Children’s desire to use AVD eyeglasses on repeated visits confirms the favorable effect of the AVD experience. The high level of satisfaction at a second visit also indicates that the effect is not just a single novelty phenomenon. Nevertheless, the AVD method is not indicated in some situations. A few children who demonstrated disruptive behavior and refused treatment immediately rejected the AVD eyeglasses. Further, AVD eyeglasses are not appropriate for children who are highly vigilant and insist on controlling the situation. While effective local anesthesia generally prevents the sensation of pain during dental treatment, the use of the AVD eyeglasses is not sufficient to eliminate persistent pain. Other studies have shown distraction to be effective in reducing clinical and experimental pain24–28 and in diminishing anxiety levels,

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which in turn contribute to increased pain thresholds and tolerance.29 The need for maintenance and the un availability of eyeglasses for children with small faces limit the use of AVD eyeglasses. The average duration of dental treatment was found to be significantly longer in the AVD eyeglass group. In comparison, in a study of adults, the AVD technique was shown to shorten the dental cleaning procedure.18 The relatively long dental treatments in the current study is presumed to be due, at least in part, to the fact that student dentists, who on average work slower, were not allowed to administer nitrous oxide. Moreover, a few of the undergraduate students found the eyeglasses a technical obstacle that limited their access to the children’s teeth. In addition, some students noted that having to ensure correct positioning of the eyeglasses hampered their work. The use of AVD eyeglasses in a teaching dental clinic poses pros and cons. The eyeglasses could be particularly advantageous in such settings in which procedures take more time because of the inexperience of the students and the need for approval by a supervisor. Some students were extremely satisfied with the AVD eyeglasses and thought they would be useful for their future practice, yet others found them disturbing. Other studies have found experienced clinicians to be better prepared than students to cope successfully with children’s behavior management.2 Nevertheless, the distraction of children’s interest to watch a movie frees all clinicians to concentrate on their work without the need to pacify, reward, or verbally encourage. Creating positive memories is an important aspect of the dental restorative process for children. To this end, implementation of behavior management techniques from the beginning of therapy1,3,25 can curtail poor emotional consequences and decrease perception of pain. A recent study by Rocha et al29 stressed the importance of distress management interventions to minimize negatively distorted memories. Anxious patients in particular may report more pain and develop a negative expectation toward dental treatment in the future.29 Therefore, addressing the memory of an experienced event is central to the coping process.25,30,31 For children of all

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Q U I N T E S S E N C E I N T E R N AT I O N A L Ram et al

ages and temperament, the impressions of distress left by the first dental visit, as well as the experience linked with each successive dental procedure, build memories that affect conduct on upcoming appointments. The use of AVD eyeglasses inspires pleasant memories and positive attitudes toward the dental experience. This study has a number of limitations. For one, VAS scores were only obtained for the study group. Second, the independent observer who assessed the children’s behavior was obviously not blinded to whether AVD eyeglasses or nitrous oxide was used. Third, a number of clinicians, with different degrees of experience, treated the children. Student clinicians used AVD eyeglasses but not nitrous oxide. Fourth, the mean age of the study group was significantly higher than that of the control group, apparently because the AVD eyeglasses used were too large for very young children. On average, the children who used the AVD eyeglasses had better initial behavior.

4. Greenbaum PE, Lumley MA, Turner C, Melamed BG. Dentist’s reassuring touch: Effects on children’s behavior. Pediatr Dent 1993;15:20–24. 5. Lahmann C, Schoen R, Henningsen P, et al. Brief relaxation versus music distraction in the treatment of dental anxiety. A randomized clinical trial. J Am Dent Assoc 2008;139:317–324. 6. Gonzales JC, Routh DK, Armstrong FD. Effects of maternal distraction versus reassurance on children’s reactions to injections. J Pediatr Psychol 1993;18:593–601. 7. O’Callaghan PM, Allen KD, Powell S, Salama F. The efficacy of noncontingent escape for decreasing children’s disruptive behavior during restorative dental treatment. J Appl Behav Anal 2006;39: 161–171. 8. Adair SM, Waller JL, Schafer TE, Rockman RA. A survey of members of the American Academy of Pediatric Dentistry on their use of behavior management techniques. Pediatr Dent 2004;26:159–166. 9. Shapiro M, Mehmed RN, Sgan-Cohen HD, Eli I, Parush S. Behavioural and physiological effect of dental environment sensory adaptation on children’s dental anxiety. Eur J Oral Sci 2007;115:470–483. 10. Aitken JC, Wilson S, Coury D, Moursi AM. The effect of music on pain, anxiety and behavior in pediatric dental patients. Pediatr Dent 2002;24:114–118. 11. Stark LJ, Aillen KD, Hurst M, Nash DA, Rigney B, Stokes T. Distraction: Its utilization and efficacy with children undergoing dental treatment. J Appl Behav Anal 1989;22:297–307.

CONCLUSION

12. Fitcheck HA, Allen KD, Ogren H, Brant Darby J, Holstein B, Hupp S. The use of choice-based distrac-

Our observations support the use of AVD video eyeglasses as a method of behavior management leading to improved comfort and cooperation during pediatric dental restorative procedures in selected cases where nitrous oxide sedation cannot be used.

tion to decrease the distress of children at the dentist. Child Fam Behav Ther 2005;26(4):59–68. 13. Prabhakar AR, Marwah N, Raju OS. A comparison between audio and audiovisual distraction techniques in managing anxious pediatric dental patients. J Indian Soc Pedod Prevent Dent 2007; 25(4):177–182. 14. Seyrek SK, Corah NL, Pace LF. Comparison of three distraction techniques in reducing stress in dental patients. J Am Dent Assoc 1984;3:327–329. 15. Sullivan C, Schneider PE, Musselman RJ, Dummett Co Jr, Gardiner D. The effect of virtual reality during

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