Comparison of Dental Anxiety Between Aerosol and Non-Aerosol Dental Procedures in Children Aged Between 5-13 Years

Introduction

Dental anxiety is the most important factor to consider while managing children in dentistry. It has psychological, cognitive, and behavioural ramifications. It is well established that dental anxiety can linger into adulthood, resulting in neglect or avoidance of dental needs, which has a significant impact on oral health. In extreme cases, young people with dental anxiety may refuse treatment even when they are in severe pain that could be relieved by the right care. Children and adolescents suffering from dental anxiety may exhibit disruptive behaviours ranging from fidgetiness to full-fledged tantrums during treatment. Dental anxiety has clinical implications that shouldn't be understated. Since dental anxiety is linked to fewer dental visits and a higher prevalence of dental caries, it is the most important issue in oral health. To measure children's dental anxiety, two approaches have been widely utilized. Self-reports and behavior rating scales utilized by dental professionals or trained coders who are delivering treatment are examples of these.¹ The conventional or classic restorative methods use dental burs, rotary handpieces, and local anaesthetics to relieve pain. Patients delay or avoid getting dental care because of the discomfort associated with traditional cavity preparation.²

In the past few years, caries treatment methods have been created that seem to cause children less worry than the conventional restorative methods. The use of a chemo-mechanical caries-removing gel and atraumatic restorative treatment (ART) are two of these novel methods. These novel therapeutic strategies adhere to the least intervention principle in dentistry. Stainless-steel crown (SSC) is widely used by pediatric dentists to restore primary molars with severe caries, enamel, or dentin abnormalities, and after pulp treatments. Primary molar restoration with SSC exhibits superior long-term outcomes for high-risk patients than amalgam/GIC/ Composite restorations. Conventional SSC placement involves tooth preparation whereas the Hall Technique (HT) is based on the idea that the bacterial substrate can be eliminated by employing Glass Ionomer Cement to cement stainless steel crown over the caries lesion. Hence it is an atraumatic restorative procedure in children eliminating the use of local anesthesia or aggressive caries removal with burs. It has long been understood that HALL technique is well tolerated in children. Even though most of them with dental anxiety blame traumatic dental events, there is still some debate over their exact cause of this anxiety.³

Anxiety brings about many physiological changes in body such as increased respiratory rate, increased perspiration, blood pressure, heart rate, and pulse rate. All these signs are due to the production of stress hormones in the blood such as cortisol, adrenaline, and nor-epinephrine.

There is paucity of studies comparing aerosol with non-aerosol treatment procedures in pediatric dentistry i.e., using drill and no drill technique. The airotor which is commonly used, is seen to be a major source of anxiety in patients probably because of its vibrations and high pitch sound. Thus, in our study, we aimed to consider a physiological method of anxiety assessment by recording pulse rate using a pulse oximeter, ⁴ the psychological method of subjective scoring of anxiety levels using an animated emoji scale (AES)⁵ and an operator assessment of patient anxiety during the treatment procedure using Face, Legs, Activity, Cry, Consolability (FLACC) to grade the level of anxiety reduced by different restorative procedures in children.⁶

Therefore, this study was designed to assess dental anxiety produced by different restorative procedures in children.

Materials and Methods

The present clinical trial commenced after obtaining clearance from the Institutional Ethical Committee. The informed written consent was obtained from guardian/ parents and assent from child patients.

This was a randomized interventional clinical study undertaken involving the patients visiting Department of Pedodontics and Preventive Dentistry. Computerized random sequencing of the subjects as per the treatment requirement (group allocation) was done using random. org. The recruited participants were of both genders, aged between 5-13 years. The participants included in the study were as per inclusion and exclusion criteria.

Inclusion criteria

1. Children aged between 5-13 years requiring dental procedures i.e., restorations and crowns.

Exclusion criteria

1. Patients with a history of hospitalisation or surgery and those with chronic illness.

2. Patients with a history of diagnosed neuro behavioural disorders such as autism, attention deficit hyperactivity disorder and learning disability.

3. Patients with congenital syndromes or intellectual disability.

4. Trauma patients complaining of fracture or swelling etc.

The sample size was estimated using GPower software v. 3.1.9.4 (Franz Faul, Universität Kiel, Germany)

The sample size was estimated to be 120 divided into two groups (Aerosol technique group and non-aerosol technique group) and four sub-groups. Sixty patients were allotted to each group and 30 patients to each subgroup. Subjects requiring restorations were divided into 1b and 2b, and crowns were divided into 1a and 2a.

Sub-Group 1a- Conventional stainless-steel crown

Sub-Group 1b- Conventional restorative procedures

Sub-Group 2a- HALL technique

Sub-Group 2b- Atraumatic restorative treatment

During the first dental visit, diagnosis was made and the child was familiarized with the clinic. On the day of the treatment before initiating the dental procedure, physiological parameters were measured using pulse oximeter, and the self-reported state of anxiety was recorded using animated emoji scale. During the procedure, anxiety levels were evaluated using FLACC scale by the operator. After completion of treatment, anxiety level was measured again using pulse oximeter and animated emoji scale before discharging the patient.

Statistical analysis

Statistical Package for Social Sciences [SPSS] for Windows Version 22.0 Released 2013. Armonk, NY: IBM Corp., was used to perform statistical analyses.

Results

Between Aerosol and Non-aerosol technique groups, the distribution of age and gender was not statistically significant (Table 1).

Pre-treatment anxiety levels as indicated by physiological parameters such as pulse rate and self-reported anxiety levels using the animated emoji scale showed no statistical significance during the pre-operative period in any group (Table 2).

During the treatment of children using aerosol or non-aerosol technique, assessment of anxiety levels and discomfort was done using FLACC scale and it showed statistical significance between the groups. Maximum relaxation was seen in children undergoing ART (group 2b), followed by group 2a, then group 1b and the least comfort was seen in group 1a as shown in Table 3.

Comparing mean pulse rate post operatively for anxiety levels between the groups showed statistically significant results with maximum pulse rate in aerosol groups as compared to non-aerosol groups. Maximum discomfort was seen in group 1b (conventional SSC) and the minimum discomfort in 2b (HALL technique). In group 1, the mean anxiety level and discomfort during post operative period were higher than the pre-operative period. Whereas in group 2, the mean anxiety level at post-operative assessment was lesser than the preoperative period. (Table 4)

Wilcoxon signed rank test was used to determine the difference in anxiety levels between the groups during pre-operative and post-operative period, which showed a statistical difference between the airotor and non-airotor groups as shown in the Table 5.

The anxiety assessment between pre operative and post operative periods in group 1 showed higher score in pre operative period in group 1, while group 2 showed lower post operative scores which was statistically significant in ART group.

Discussion

Dental anxiety can be defined as a feeling of apprehension about dental treatment, not necessarily related to a specific stimulus,⁷ while fear is a normal emotional reaction towards more specific threatening stimuli in the dental situations.⁸ Panksepp (1982) stated that the distinction between fear and anxiety appears to be based solely on intensity.⁹ In both adults and children, a history of dental discomfort is highly connected with dental anxiety, which has a complex cause. Children's experiences of pain and trauma were found to be more strongly connected with anxiety than those with objective dental pathology, according to a comparison between anxious and non-anxious children as per the study conducted by Townend et al. ¹⁰ In another study, some interesting findings were revealed on the incidence of dental fear and dread in comparison to 10 other common phobias and subtypes of a particular phobia. Dental fear was more common than other fears (snakes, heights, and physical harm) but was still judged high (24.3%). Unexpectedly, dental phobia (3.7%) was the most common among those tested.11 These findings ought to raise concerns among academicians and dental professionals regarding this very serious problem, with the aim of identifying remedial measures.

In the present study, we found that distribution of age and gender had no statistically significant association with anxiety levels, but maximum discomfort was seen in the group which used airotor i.e., aerosol technique group. Similar results were found in another study conducted by Chhabra N et al., where no statistically significant difference was observed between the dental anxiety levels of male and female children. The sight of injection, a stranger's touch, and the sound and technique of the dentist's drilling were the stimuli that caused children most anxiety.¹²

Maximum relaxation was seen in children treated by ART (non-aerosol technique), and the least comfort was seen in group undergoing conventional stainless steel crown placement as shown in Table 3. Conversely, a study concluded that there was no discernible change in the levels of anxiety among children treated with ART, conventional restorative methods and chemo-mechanical caries removal gel.¹³ According to this study, in children solely receiving ART treatment, the treatment setting, armamentarium and preparatory visits may have a role to play in determining the degree of dental anxiety. In dentistry, the importance of encouraging young patients to communicate their thoughts on their treatment experiences is rising.¹⁴ There is a growing understanding that children's opinions are significant and reliable because they are the ones who experience the treatment and its effects. Dentists have only recently started asking children for this kind of information. The following clinical considerations might be taken into account when speculating on why children who received the Hall Technique accepted it better than conventional SSC: The relative briefness of the procedure, lack of local anesthetic injection, and absence of high- or low-speed handpieces.

As this study was conducted involving limited sample size and age limit, a larger sample size and younger age group children can also be included in future studies for better assessment.

Conclusion

In the present study, we tried to grade the dental restorative procedures. The results of our study shows that the procedures using aerosol techniques are more anxiety provoking, may be because of the vibrations and high pitch noise of airotor used. This frequently contributes to the avoidance of dental treatment by children. Therefore, alternative techniques should be employed wherever possible to alleviate anxiety in pediatric patients leading to effective patient management. There are few effective techniques available that can lead to better dental fear and anxiety management. Early assessment of anxiety levels assist dentists in minimizing fear and gaining trust in children.

Future suggestions

Whenever the restorative procedures are indicated in anxious children, it is always better to perform atraumatic restorative techniques, HALL technique over conventional restorations and crowns. This can reduce the fear and anxiety associated with treatments so that enhanced cooperation from the child for that particular treatment is obtained and also can aid in shaping the children to be better dental patients in future.

Conflict of Interest

None