Distraction techniques for pediatric dental anxiety

Distraction with cartoon animation

AV distraction techniques can reduce anxiety according to the reticular activation theory. Sufficient or excessive sensory input can inhibit painful stimuli, leading to the blocking of anxiety signals in the brain, resulting in reduced perception or complete absence of those feelings.^[11,12]

The combination of auditory and visual distraction is known as AV distraction. It aims to shift the patient’s attention away from discomfort, anxiety, or fear by showing favorite shows in the form of moving images and sounds or animations so that the patients ignore any discomfort and show a good response.^[11] The audiovisual form that preschool children like is cartoons or moving pictures. This media is very interesting for children, especially preschool-age children who have high imagination, by focusing attention on something the child likes, for example, watching cartoons.^[13]

The distraction technique by displaying cartoon films on the anxiety level of the pediatric patients is as expected and can lower their anxiety level. In line with research conducted by Febrian et al., there is a significant difference in anxiety levels and anxiety scores based on children between those treated using audiovisual and not using audiovisual for patients undergoing dental treatment, with a score difference of 0.3.^[14] In line with research conducted by Febrian et al., there was an effect of AV distraction on the anxiety level of school-aged children who had teeth extracted with infiltration anesthesia of 19.6%.^[14]

Research by Padmanabhan et al.,^[12] the study group with cartoon distractions showed lower average levels of anxiety when compared to the control group (without distractions). The results were statistically significant. These findings can be attributed to the fact that children in the study group with AV distraction did not feel anything different during treatment, and they continued to show lower average levels of anxiety even after treatment was completed. These results align with earlier research that indicates subjects exhibit reduced anxiety levels following the completion of the operation or meeting.^[15-17]

Distraction with video games

Video games are electronic games designed to create interactive systems with visual feedback. In the medical field, video games have been used as a tool for rehabilitation, psychological education, and psychotherapy. Video games can be considered a form of distraction because they involve the patient’s active participation through hearing, sight, and touch. While playing video games, a person’s attention is generally focused on the game, which can help reduce anxiety and increase compliance with treatment.^[18]

Research by Sjamsul et al.,^[18] resulted in an average decrease in anxiety levels. It may be inferred that video game distraction is useful in lowering the anxiety levels of children aged 7–10 years under anesthetic infiltration, since the difference between the anxiety levels with and without distraction was 40.40% and 72.40%, respectively.^[18] Because video games can help patients and doctors physically or mentally, they have been employed for a wide range of health-related reasons across all ages. Video games are widely utilized to promote more physical activity, manage illnesses, divert attention from discomfort, and educate people about health. Of these, studies on video games that incorporate physical or psychological therapy are the most successful in reaching their objectives, while studies that try to enhance disease management are the least successful.^[19]

Attar et al. discovered that anxiolysis and analgesia are better provided by active distractions that enhance visual, cerebral, and motor participation in pediatric patients than by passive distractions.^[20] Prabhakar et al. assessed children’s anxiety when four dental visits: assessment, preventative treatment, tooth preparation and restoration, and the extraction process. They found that acoustic distraction is less effective than audiovisual (AV) distraction.^[21] Next, by contrasting three methods of diverting patients’ attention to lessen their stress (video games, humor audio programs, and video-comedies), Seyrek et al. describe the video program. Additionally, video games work better than audio applications.^[22] According to Allani et al., The results also showed that an improvement in the physiological desire coincided with effective distraction, which could suggest a degree of emotional involvement or immersion with a film.^[23] The use of video games is an effective technique to present ideas about behavior adjustment in a fun and interesting way, according to Varun et al. study, which found that 78% of kids exhibited positive behavior after utilizing dental simulation. It has also been demonstrated that playing video games helps kids between the ages of 5 and 8 behave better.^[24]

Thompson et al. claim that a thorough learning model for behavior modification through video games is founded on social learning theory and that stages such as motivation, attention, retention, and reproduction are included in models of likelihood (maximum probability).^[25] The initial step in digesting the information in the message and promoting change is likely to be capturing and maintaining someone’s attention. According to Bandura, social learning aims to change behavior in a significant way by giving people the abilities and self-assurance to engage in new behaviors. Games that combine these abilities and confidence with a fun component can alter behavior by increasing motivation.^[24]

Distraction with VR

The effect of VR on anxiety can be explained by two mechanisms: Exposure and distraction. VR is a technique for distraction and attention diversion that is being used in the medical field nowadays. VR creates a VR that immerses patients in a simulated, interactive world using cutting-edge technology. The patient is distracted from pain by this contemporary system’s stimulation of sight, sound, and movement.^[26]

VR distraction can help kids feel less anxious. The gate control theory states that anxious stimuli will be received when one is feeling nervous. The stimulation signal then travels across both big and tiny nerve fibers, inactivating the cell inhibitors and opening the cell gates. The offered diversion will shut the open gates, reducing or preventing the brain from receiving the worried sensation.^[27] Children’s anxiety will decrease because of endorphins being released in response to pleasurable sensory stimulation.^[28]

According to research on the effects of VR on the management of either chronic or acute pain, Pourmand et al. found that VR was helpful in treating a range of acute pain conditions, and Indovina et al. discovered that VR can effectively reduce discomfort in patients undergoing challenging procedures such as physical therapy and burn treatment.^[29,30]

Distraction with a stress ball

Play therapy is a technique in which the therapist uses play materials to treat psychological issues such as anxiety. During pediatric surgical procedures such as phlebotomy and catheter installation, active distraction has been used to alleviate pain through play therapy using stress balls or elastic rubber balls, which change their shape and color when pressed. The idea behind this therapy is to lessen the focus on pain.^[31]

In a study by Stalvey and Brasell, the stress ball is a great distraction tool for relaxing tension and anxiety.^[32] In addition, stress balls have been shown to help kids with their gagging reflex.^[32] During treatment, the patient feels more empowered since they have direct control over the stress ball, which reduces anxiety and improves patient satisfaction without interfering with the dental operation. A safe, widely available, and reasonably priced therapy that can help patients feel less anxious about their treatment is the hold stress ball.^[33]

Audio distraction

Listening to your favorite music or hearing birds or water splashing are examples of auditory distractions. People are urged to select music they enjoy, especially soothing genres like classical music, and to focus on the song’s rhythm and lyrics. In addition, patients are permitted to move their bodies in time with the song, including swaying and tapping their feet or fingers. Among the many classical music compositions, Wolfgang Amadeus Mozart’s (1756–1791) work is the most highly recommended. Mozart’s music is among the most well-known.

Music has been shown to alleviate mental stress and physical discomfort in several studies, including the “Mozart Effect.” Mozart’s compositions have melodies and high frequencies that, in contrast to other classical music, can inspire and boost the brain’s creative and motivating regions. The simplicity and purity of Mozart’s compositions themselves are equally significant. This does not preclude the usage of other classical composers’ compositions, either.^[9]

Furthermore, patients who are going through several surgeries or challenging procedures in the hospital may find that music therapy helps them feel less anxious. Because listening to music can help patients feel better and experience less discomfort. In addition, music therapy helps hasten hospital patients’ recovery from depression. In addition, music therapy might help new parents feel more at ease after giving birth. It is simple to distract oneself by listening to music, which also helps the patient breathe more easily by relaxing the nerves. In addition, listening to music lowers the risk of heart attacks, normalizes blood pressure, and strengthens muscles.^[34]

A total of several studies investigating distraction techniques for reducing dental anxiety in pediatric patients were included in this review. The characteristics of the selected studies, including the author, year of publication, study design, sample size, age range, type of distraction technique, outcome measures, and main findings, are summarized in Table 1. Overall, the included studies evaluated various distraction methods such as AV distraction, video games, VR, stress balls, and music therapy during dental procedures in children.

To evaluate the methodological quality of the included studies, a RoB assessment was conducted. Randomized controlled trials were assessed using the Cochrane Risk of Bias tool, while non-randomized studies were evaluated using the ROBINS-I approach. The assessment considered several domains, including selection bias, performance bias, and detection bias. The overall RoB for each study is presented in Table 2.