Assessment of Different Distraction Behavioral Methods in Pediatric Dental Clinic: A Systematic Review

Dental anxiety is one of the main problems dentists may face during the treatment of pediatric dental patients; therefore, clinicians tend to perform different behavior management techniques to reduce dental anxiety in children. This review aimed to systematically compare and evaluate the published literature regarding the effects of distraction techniques on anxiety, pain perception, and patient experience during dental practice. A detailed electronic search was conducted on 3 databases including PubMed, Google Scholar, and Cochrane Library. The databases were searched for articles published in the English language between 2015 and 2022. Among 102 studies, 27 studies fulfilled the criteria of eligibility and were included in this study to be analyzed. Numerous approaches have been proposed for the reduction of dental anxiety, out of which the use of audio-visual aids and instruments, active distraction such as tablets, smartphones, and virtual reality glasses showed governance in decreasing the children’s anxiety followed by cognitive and behavioral methods.


Introduction And Background
Commonly dental anxiety and dental fear occur in children [1]. It is defined as an emotional reaction to constant distress associated with dental treatment and procedures [2,3]. It can involve the emotional, behavioral, physiological, and cognitive components that may vary between personalities [2,3]. The primary function of fear and anxiety is associated with the activation of the sympathetic system and the patient's reaction. The patient perceives this as a signal of threat and danger due to unusual surroundings, noise production in dental setups, potentially painful or invasive procedures, and previous negative experiences [4][5][6][7]. Pain has also a psychosomatic factor centered on the extent of responsiveness focused on the noxious stimulus modifying the discomfort and pain [8]. The incidence and prevalence of dental anxiety and fear range from 6% to 42% among children of different ethnicities and backgrounds [8].
The management of uncooperative children with a fear of pain and dental anxiety can be a demanding job for the health care professionals as well as for the parents/guardians and also for the children [9]. Many psychosomatic interventions have been utilized for the management of distress, anxiety, and dental pain that aids in the development of coping mechanism [9]. The dental care providers used different techniques and therapies to manage patient's distress and anxiety such as traditional behavior management, music, virtual reality, magic tricks, eyeglass systems, in-ear headphones, gaming consoles, videos, hypnosis, and systematic desensitization [9][10][11].
In current years, many studies have been published for the evaluation of the efficiency and beneficial effects of distraction methods and techniques, which can be employed for the behavioral management of patients and their parents/guardians [8]. A systematic review conducted by Prado et al. only included 20 studies and found low certainty of evidence that distraction techniques reduced dental anxiety [8]. Another study by Allani et al. only focused on the effectiveness of distraction techniques rather than the usefulness and longterm benefits of the techniques [11]. Knowledge of the usefulness of distraction techniques may be useful for the dental team to manage anxiety and create a pleasant environment to improve the children's dental experience [1]. To date, no researcher has critically reviewed up-to-date literature on all methods of distraction techniques during dental treatment. Thus, this study was aimed at the assessment of distraction techniques in the reduction of children's pain perception and anxiety in dental setups.

Study Selection
Two independent reviewers (MD and RA) screened the articles based on the inclusion criteria. The screening is in phases. The first phase of the screening is going through the abstracts and titles of the studies in order to select relevant articles. Studies that did not meet the eligibility criteria were excluded. The second phase of the screening is the evaluation of the full text of the remaining articles based on the same inclusion criteria. Articles that did not meet the exclusion criteria were excluded during the second phase. The remaining articles were retained for quality assessment. Disagreement between the researchers was settled by means of discussion with the other authors until a consensus was reached.

Data Extraction
Data were extracted from the included studies into a pre-defined Excel sheet. The two reviewers (MD and RA) extracted the data twice to minimize errors that may occur, in case of any discrepancies, consensus was reached. The following data were extracted from the included studies; author's first name, year of publication, study type, journal name, participants, age in year, distraction method or techniques reported, study results, and conclusion.

Quality Assessment of the Included Studies
The quality of the included studies was assessed by the reviewers using the Cochrane Collaboration's Risk of Bias tool (Version 5.4) comprises seven domains: sequence generation, allocation concealment, blinding of participants and personnel, blinding of the outcome, incomplete outcome data, selective outcome reporting, and other bias. Each of the domains is made up of "high", "low" and "unclear" risks of bias. The quality assessment of the non-randomized study was assessed through the Newcastle Ottawa tool.

Synthesis of Results
The data extracted from the included studies were analyzed in a descriptive approach. Data were presented in mean and standard deviation. We could not perform a meta-analysis due to methodological heterogeneity.

Study Selection
The three databases generated 165 articles, 82 from PubMed, 67 from Google Scholar, and 16 from Cochrane Library. The two independent reviewers (MD and RA) performed screening and 27 relevant articles met the eligibility criteria and were retained for the systematic review. PRISMA flow diagram shows the selection process as presented in Figure 1.

Quality Assessment of Individual Studies
The results of the risk of bias assessment using Cochrane Collaboration's Risk of Bias tool were presented in  [12][13][14][15][16][17]. Also, selective reporting was another identified issue in some of the studies [14,18,19]. Another risk of bias identified is sample size selection, most of the studies failed to randomize the participants into the group and also failed to present a power test for the sample size calculation [20][21][22]. According to Newcastle Ottawa, the prospective study's [23] shortcoming was a lack of ascertainment of exposure and inadequate follow-up. Whereas for the cross-sectional study [24], a high risk of bias was identified for the outcome assessment and adequate follow-up (

Study Characteristics
Twenty-seven studies related to pediatric dentistry published between 2015 and 2022 were included in the review. Out of which 25 were RCTs, one prospective study, and one cross-sectional study [23,24]. The sample size ranged from 28 in the study of Ghadimi et al. [24] to 123 in Shekhar et al.'s study [25]. The age of participants ranged from three years old to 12 years old [26,27]. Nine distraction techniques were identified: audiovisual, aroma therapy, virtual reality, video eyeglasses, intellectual color game, vibration, bubble blower, magic trick, and fidget spinner, kaleidoscope [13][14][15][16][17][18]20,21,24,25,[27][28][29][30][31][32][33][34][35][36]. All the distraction techniques used were presented in Table 3. The full details characteristics of included studies can be found in Table 4.   The parameters of the study were the dental anxiety, pain and behavior. Statistically significant reduction was measured in anxiety within the groups but not between the groups. And no statistically significant differences were observed for pain and behaviour scores The results showed significant differences (p = 0.029) in experimental and the controlled group by using the

Synthesis of Results
A detailed explanation of the results according to different distraction behavior methods on pediatric patients at the dental clinic were presented in Table 3. The findings and conclusion from individual studies were presented in Table 4.

Audiovisual Distraction Method in Comparison to Other Distraction Method
In a study, children aged four years to seven years were randomized into the audiovisual group and muted video group [18]. During the dental procedures, the PR, FDR, and SEM scales were measured, and they found a significant result in the audiovisual distraction method compared to muted video method [18]. Another study measured DSS-SF, heart rate, and behavioral change in children with the pediatric disease to assess the anxious children's behavior, the results showed a significant difference at a 5% level in the audiovisual group and visual group compared to the control group [16]. Khandelwal et al. compared the audiovisual to tell-show-do (TSD) method on children aged five years to eight years, cartoons and animated clips were used in the audiovisual groups, the study reported a statistical reduction in anxiety (p < 0.05) in both groups [29].
Chaturvedi et al. had 40 pediatric patients aged between six years and 10 years and were randomized into the audiovisual group, the first group was asked to wear eyeglasses, and the other group was without eyeglasses [14]. Pain and anxiety were measured in both groups using VAS and WBPRS scales, statistically significant reduction (p < 0.05) in anxiety was measured for the group with audiovisual eyeglasses [14]. The pulse rate measured by pulse oximeter was also highly statistically significant in audiovisual eyeglasses group [14]. A similar study [24] used verbal method, video eyeglasses, and earphones in the first audiovisual group and digital screens in the second audiovisual group, the study recorded the highest mean FLACC score for pain in the verbal group (6.88), then digital screens (3.67) and least in video eyeglass/earphone (1.94).
Rajeswari et al. randomized 45 children into three groups; audiovisual, cognitive behavioral play therapy, and TSD group, statistically significant reduction in anxiety scores were detected in all three groups (p = 0.001) [15]. However, high score in anxiety reduction was measured in cognitive behavioral play therapy (p = 0.0) than in others [15].

Other Distraction Method in Comparison to No Distraction Method
A bubble blower was used for breathing exercises among 35 children aged seven years to 10 years [37]. The bubble blower can be used as a beneficial and effective distraction method to reduce the moderate to severe anxiety and pain during the invasive dental procedures (IANB), Bahrololoomi et al. recorded a significant result for the WBFPS and FLACC scales by using a bubble blower for the breathing exercise [37]. Magic tricks are another distraction technique that helped reduce the level of anxiety among children [36]. Thosar et al. compared magic tricks to an audiovisual using Venham's picture test on children aged four years to 11 years old, the study found that the pulse rate and the blood pressure (hemodynamic parameters) of the children were reduced throughout the second appointment, while the oxygen saturation level was seen to increase in both groups [36]. Another technique is vibration which helped more in the management of the patients than the conventional method [17]. Moreover, intellectual Colored Games distraction tool helped in the management of child's behavior [23].

Discussion
A major reason for the increase of dental caries and poor oral health in pediatric patients has reported to be dental anxiety [1]. Several methods have been proposed across the world to overcome this particular problem and ensure compliant visits to dentists [9][10][11]. Anxious pediatric patients can end up harming both themselves and the practitioner [5][6][7]. Moreover, the presence of anxiety can result in failure to complete the procedure in time, waste of materials and rescheduling of appointments [6].
The various methods that are used to curb dental anxiety includes the use of audio and visual aids, behavioral therapy and TSD methods during the treatment allowing the child to get treated in a calm and familiar environment [29,31,33]. Play stations or virtual reality devices have been more effective as compared to conventional methods of distraction such as voice modulations, jokes and changing topics of discussion [13]. The opposite of these facts has been reported in studies whereas school-based presentations and role-play have been found to be more useful as compared to TSD techniques [38].
A comparison between audio-visual and TSD technique showed that TSD is less productive than audio-visual aid [29]. This phenomenon has been supported by several studies which found audio-visual aid superior to other methods [38,39]. A significant improvement was noticed in the behavior of children aged between four and six years old who were exposed to audio-visual aid with a p-value of 0.001 as compared to the control group during dental procedures. However, no significant difference in pain expression was found [10]. The perception of pain in pediatric patients can also be significantly reduced as reported by several studies [33]. There has been considerable debate regarding whether audio-visual methods as a single modality are more effective or whether one of these techniques is preferred over the other [18]. It has been found that video distraction without sound does not prove to be useful in decreasing dental anxiety making audio a necessary component for distraction [18]. This is in contrast to the result reported in the study by Mishra et al. where no significant difference was found in the effectiveness of audio and audio-visual aids. Audio-visual aids if further divided into categories show audio aids comprising of stories to be more effective than rhymes or movie songs as reported in a study [15]. Dental anxiety can be considered a psychological phenomenon where the environment and the sounds of the dental clinic can disturb the pediatric patient resulting in an obvious reluctance to undergo dental procedures [40]. Activities that can distract the mind can be particularly useful in overcoming fear and anxiety [8,11]. The use of smartphones and virtual reality glasses transporting the patient to an imaginary world has been found to be instrumental in this regard [30]. Abbasi et al. in their study conducted on pediatric patients found smartphones to take a lead on dental songs and videos in distracting anxious patients [40]. A more constructive method of alleviating anxiety in pediatric patients includes the use of cognitive behavioral therapy which has superseded the effectiveness of audiovisual aid and conventional TSD technique [15]. In addition, several forms of advanced behavioral therapy have also been used [32]. This also includes the use of intellectual methods such as counting activities and identification games which have been found to be useful in overcoming anxiety in pediatric patients [23]. This finding has also been supported by several studies [41]. Recent advances in dentistry have led to the use of other innovative techniques such as music therapy and aromatherapy during dental procedures [34].
Studies have indicated that the use of music alone provides an insignificant improvement in dental anxiety [26]. However, the use of music and aromatherapy in combination has proven to be more powerful [42].
There are several dental procedures that can incite extreme anxiety in pediatric patients [2]. Innovative and efficacious methods need to be designed for such procedures. Studies have shown that breathing exercises using a bubble blower can be helpful in decreasing anxiety during administration of Inferior alveolar nerve block (IANB) [37]. Moreover, studies have shown audio-visual techniques to be effective and behavioral therapy has also been found to be profoundly helpful to curb anxiety during these procedures [43,44]. Menedez et al. found two techniques that are covering the patient's eyes method and the hand-eye-mouth distraction strategy to be equally significant [45].

Limitations
The study encountered some limitations during the analysis and interpretation of data. The first limitation is the inability to conduct a meta-analysis due to the high percentage of heterogeneity among the included studies. Some of the included studies used the audio-visual distraction method as a control, while some studies used the audio-visual as an intervention [15,36]. A meta-analysis required studies with unrelated intervention and control groups. Another shortcoming was searching period limits, as the study addresses articles published between 2015 and 2023. Articles published before 2015 might be relevant to the present studies but were excluded from the review. Future researchers should try expanding the search limit to capture more articles as this may allow the conduct of meta-analysis.

Conclusions
Dental anxiety is a major concern in the dental treatment of pediatric patients. Several methods to reduce dental anxiety have been proposed out of which the use of audio-visual aids, active distractions such as smartphones, and virtual reality show a clear dominance in reducing anxiety followed by cognitive and behavioral methods. There is considerable ambiguity in the method of judgment of both anxiety and its alleviation in patients, therefore requiring further research to be done in this area to develop a uniform method to evaluate anxiety levels and identify the most useful distraction techniques.

Conflicts of interest:
In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.