ORIGINAL RESEARCH

https://doi.org/10.5005/jp-journals-10077-3241
Journal of South Asian Association of Pediatric Dentistry
Volume 5 | Issue 3 | Year 2022

Magic: A Modern Alleviating Constituent of Anxiety Levels in Children

Chandana Krishna Shree CH¹ https://orcid.org/0000-0001-5508-7818, Priya Nagar², Pooja HR³ https://orcid.org/0000-0003-3349-6711, Andrea Natalia Mascarenhas⁴ https://orcid.org/0000-0002-5592-0969

^1-4Department of Pedodontics & Preventive Dentistry, Krishnadevaraya College of Dental Sciences & Hospital, Bengaluru, Karnataka, India

Corresponding Author: Chandana Krishna Shree CH, Department of Pedodontics & Preventive Dentistry, Krishnadevaraya College of Dental Sciences & Hospital, Bengaluru, Karnataka, India, Phone: +91 7204405350, e-mail: chandanachitturi1@gmail.com

Received on: 16 July 2022; Accepted on: 24 September 2022; Published on: 26 December 2022

ABSTRACT

Background: Anxiety in the dental setup is a most encountered problem associated with fear and stress, which has overemphasized its impact on the pediatric population. The lack of cooperativeness of children seen in the dental setup is mainly accredited to the behavioral expression of anxiety. There is a requirement for a constructive technique in dealing with children with obstinate attitudes. The magic technique is a new epoch in dentistry that can be used in strong-willed children. The magic technique helps in distracting the child and thus helps the child to relax and the dentist to perform the necessary treatment.

Aim: To evaluate the change in behavioral attitude during the first visit in children and adolescents using magic distraction and audio-video distraction aids.

Materials and methods: A total of 60 children of the age-group 4–13 years, who are recognized as strong-willed children, were chosen for the study. Children falling under the inclusion criteria were treated with endodontic and surgical procedures requiring local anesthesia administration and were assessed using three distraction aids (audio, audio-video, and magic group). Anxiety was assessed before and after the procedures using the Chotta Bheem and Chutki anxiety scale.

Results: Mean anxiety levels were observed to be significantly reduced with the magic group using the thumb and light trick, followed by the audio-video group and then with the audio group.

Conclusion: The use of distraction aids significantly reduced anxiety levels in children and adolescents.

How to cite this article: CH CKS, Nagar P, HR P, et al. Magic: A Modern Alleviating Constituent of Anxiety Levels in Children. J South Asian Assoc Pediatr Dent 2022;5(3):121-126.

Source of support: Nil

Conflict of interest: None

Keywords: Behavior guidance, Distraction tricks, Magic trick, Rubber light and thumb trick, Strong-willed children

INTRODUCTION

Dental anxiety and fear are accredited to the fear and stress associated with the dental setup, which is overexpressed in a pediatric population.¹ Lack of cooperative behavior in children is seen as a behavioral expression of dental anxiety.²

Authors like Forehand and long described children with obstinate attitudes who exhibit a lack of cooperative behavior in dental setup as being strong-willed children.² Children of such behavior can be impatient, obstinate, bickering, and intransigent. In the dental scenario, they may refuse to enter the dental clinic and even refuse to open their mouth for oral examination or push the dentist away with a continuous cry. Strong-willed children in dental setup generally manifest fear and anxiety, which deal with negative feelings associated with dental treatment.³

Dentists have estimated such uncooperative behavior in dental setup as being the trickiest challenge one can face on a dental chair.⁴ Sequelae of anxiety or lack of cooperative behavior depict delay or winding up of treatment before completion, which leads to a decrease in the quality of treatment given.⁵ Few pediatric patients depict uncooperative personalities beginning from the infantile period, which is expressed in several issues like nervousness, agitation, glumness, and faces difficulty in adapting to the surrounding setting.⁶

Management of strong-willed children in the dental setup is extremely labor-intensive, in addition to an increase in overprotective and overindulgent parental attitudes toward children, where aversion therapies are difficult to implement. Proper assessment of parents and children’s behavior by the dentist is essential in scheduling appointments and furnishing efficient and effective dental treatment. Appropriate use of management techniques on a dental chair can improve the child’s behavior in subsequent visits.

All behavior management techniques available to pediatric dentists must be used appropriately considering all ethnic, analytical, and legal requirements in dental practices. The requisite of an efficacious method to deal with stubborn children is noted. The present study was conducted to evaluate the change in behavioral attitude during the first visit in children and adolescents using magic distraction and audio-video and audio distraction aids.

MATERIALS AND METHODS

After taking approval from the Ethical Committee and Review Board of the institution, this study was conducted to evaluate the change in behavioral attitude during the first visit in children and adolescents using magic distraction and audio-video distraction aids with inclusion criteria with children requiring local anesthesia procedure and not requiring any emergency treatment. The study was conducted with the main objective to compare the mean anxiety scores between the pre and postintervention periods in each study group and to compare gender-wise differences in the mean anxiety scores in the pre and postintervention periods in each study group.

The sample size was estimated using GPower software v. 3.1.9.4 (Franz Faul, Universität Kiel, Kiel, Germany). With regard to the effect size measured (f) at 42% (based on the pilot study), the power of the study was kept at 80% and the α error at 5%, and the sample size needed is 60. Each study group comprises 20 samples (20 samples × three groups = 60 samples).

The present study was an in vivo study, where 60 patients aged 4–13 years were selected, showing Frankl’s behavior scale ratings of 3 and 4 with no previous dental experience. Children falling under inclusion criteria were observed directly by the observer, not by anyone else in the department, to avoid any bias in the preanxiety score. A prior appointment was made, and attention was given to standardization. Children requiring emergency treatment and those who did not have parental consent were excluded from the study. Informed consent from the parents/guardians of the pediatric patients and the child was obtained after thoroughly explaining the procedure details and treatment outcomes.

The study uses magic distraction using thumb and light aid, audio distraction using earphones, and video distraction using cartoons played on smartphones and the Chotta Bheem–Chutki scale for assessment of anxiety levels (Fig. 1). This scale utilizes two different cartoon characters, with images of the Chotta Bheem cartoon character for boys and the Chutki character for girls. Each character depicts six unique emotions, which vary from an extremely happy face to an extremely sad face, on the contrary, where fear can be correlated to a patient’s feelings.

Fig. 1: Aids used

Patients were then randomly allocated into three respective groups with closed white envelopes, which were then picked and grouped by two interns who were not involved in this study. The preoperative mean anxiety scale was recorded in the reception area to avoid any influence of anxiety created due to the dentist’s treatment or the dental setup (Fig. 2). Respective distraction aids were introduced to the patients allotted to the groups, after which the treatment involving the administration of local anesthesia was carried out.

Figs 2A and B: Recording preanxiety levels (A) in the reception area; and (B) Postanxiety levels in the clinical area

The postoperative mean anxiety scale was recorded after the procedure on the dental chair to obtain the accurate response of the distraction aids (Fig. 2). Results were assessed and tabulated for all the groups. Mean anxiety levels were recorded for all the groups. Comparison between pre and post-time intervals were assessed statistically and compared.

Group I: Audio distraction using earphones (Fig. 1).
Group II: Video distraction using cartoons played on a smartphone (Fig. 1).
Group III: Thumb and light aid, with rubber thumb tip with red flashing light which is similar to real finger developed by Mile’s retail. This magical aid emits light which could appear and disappear magically on the dentist’s will (Fig. 1).⁷

Male:female ratio for all three groups was maintained equal to avoid any gender. All the techniques included in the study were used on the child individually only for a period of 3–5 minutes for maintaining standardization. Treatment was performed on children after performing behavioral strategy, and dental anxiety on chair postoperatively was assessed using the scale by the trained intern.

The analysis of outcomes was carried out using Statistical Package for Social Sciences for Windows Version 22.0, released in 2013. Armonk, New York, IBM Corp. will be used to perform statistical analyses by the statistician, who was also blinded to the randomization process and the intervention received by the children.

The mean anxiety scores between the three groups during pre and postintervention periods were assessed using Kruskal–Wallis test. Wilcoxon signed-rank test was used to assess the mean anxiety scores between pre and postintervention periods in each study group. Mann–Whitney post hoc test was used to compare gender-wise differences in the mean anxiety scores in pre and postintervention periods in each study group. The level of significance was set at p < 0.05

RESULTS

Assignment, random allocation, and grouping of children were done into different groups in a systematic method. When the mean anxiety scores between the three groups during the preintervention and postintervention period were compared using Kruskal–Wallis test, it showed that the anxiety scores of the audio group with the mean difference of 1.10 in the audio group, the audio-video group with the mean differences of 1.05, and magic group with the mean difference of 1.90 with p < 0.001 which is statistically significant (Table 1 and Fig. 3). When the intergroup comparison was made, there was a statistically significant mean difference seen as a decrease in mean anxiety levels magic group followed by the audio group and least with the audio-video group with p < 0.001.

**Table 1:** Comparison of mean anxiety scores between pre- and postintervention period in each study group using Wilcoxon signed-rank test
Trick used	Period	N	Mean	Standard deviation (SD)	Mean difference	p-value
Audio	Preintervention	20	3.10	0.97	1.10	<0.001*
Audio	Postintervention	20	2.00	0.73	1.10	<0.001*
Audio and video	Preintervention	20	2.85	0.81	1.05	<0.001*
Audio and video	Postintervention	20	1.80	0.62	1.05	<0.001*
Magic	Preintervention	20	3.20	0.95	1.90	<0.001*
Magic	Postintervention	20	1.30	0.47	1.90	<0.001*

Fig. 3: Mean anxiety scores between pre- and postintervention period in each study group

When gender-wise distribution of anxiety scores was assessed using Mann–Whitney post hoc test during preintervention group and postintervention group, there was no statistical significance between the groups. It suggests that the anxiety score was more or less similar to both males and females when compared, whereas, in postintervention group, there was a statistical reduction in postanxiety scores in both genders, with the statistical reduction seen in females compared to males (Table 2A and B and Fig. 4).

**Table 2A:** Gender-wise comparison of mean anxiety scores during preintervention period in each group using Mann–Whitney U test
Trick used	Gender	N	Mean	SD	Mean difference	p-value
Audio	Males	10	3.00	0.82	−0.20	0.90
Audio	Females	10	3.20	1.14	−0.20	0.90
Audio and video	Males	10	2.80	0.79	−0.10	0.81
Audio and video	Females	10	2.90	0.88	−0.10	0.81
Magic	Males	10	3.20	1.03	0.00	1.00
Magic	Females	10	3.20	0.92	0.00	1.00

**Table 2B:** Gender-wise comparison of mean anxiety scores during postintervention period in each group using Mann–Whitney U test
Trick used	Gender	N	Mean	SD	Mean difference	p-value
Audio	Males	10	2.20	0.79	0.40	0.22
Audio	Females	10	1.80	0.63	0.40	0.22
Audio and video	Males	10	2.00	0.67	0.40	0.17
Audio and video	Females	10	1.60	0.52	0.40	0.17
Magic	Males	10	1.40	0.52	0.20	0.34
Magic	Females	10	1.20	0.42	0.20	0.34

Figs 4A and B: (A) Genderwise distribution of mean anxiety in preintervention period; (B) Genderwise distribution of mean anxiety in postintervention period

On multiple pairwise comparisons of mean difference in anxiety scores between the groups were assessed using Mann–Whitney post hoc test, children treated with magic trick behavior guidance showed better results when compared to the other two groups with p = 0.002* with the audio group and p = 0.03* with the audio-video group which was statistically significant (Table 3). The magic trick group showed a significant effect to lower anxiety levels when compared to audio and audio-video groups.

**Table 3:** Multiple pairwise comparison of mean difference in anxiety scores between groups using Mann–Whitney *post hoc* test
(I) Trick	(J) Trick	Mean difference (I-J)	95% Confidence interval for the difference		p-value
(I) Trick	(J) Trick	Mean difference (I-J)	Lower	Upper	p-value
Audio	Audio and video	0.20	−0.27	0.67	0.56
Audio	Magic	0.70	0.23	1.17	0.002*
Audio and video	Magic	0.50	0.03	0.97	0.03*

*Statistically significant

DISCUSSION

Dental anxiety in parents, as well as children, is the common reason for neglecting dental care in the pediatric population. It is the emotional and psychological condition that is generally seen before a dental appointment on a child’s first dental experience. Distress in dental visits occurs mostly in apprehensive and uncooperative children when compared to nonapprehensive children. Hence, apprehension and fear of the child should be addressed from the child’s first dental visit. This helps us in developing a positive attitude toward the success of the treatment and build confidence in treating doctors.⁷

The anxiety created in pediatric dental set up on the first visit can also lead to irregular follow-up in the dental setup, which affects the patient’s oral health and increases the overall cost of dental treatments, which can be avoided through early preventive care in dental setup.⁸ An effort should be made to tackle apprehensive behavior based on age and rational thinking using various behavioral techniques.⁹

The present study includes children belonging to 4–13 years of age who show disruptive behavior that is difficult to manage and have increased apprehensive levels in dental setup. The wide age-group was selected in the study as anxiety as a parameter should be noted for all age-groups as low as 4 to high as 13. These distraction strategies have a great impact on the brain waves of children, leading to tranquility, which in turn, helps in reducing pain and anxiety.¹⁰ Therefore, this study attempted to compare the efficacy of magic tricks in comparison to both audio and audiovisual distraction aids.

Various methods, including physiological and projective measures, have been utilized in most of the studies for assessing anxiety in the dental setup. Assessment of physiological methods was done using various parameters like assessing blood pressure and determining one’s pulse rate as well as muscle tension. Assessment of projective methods includes various surveys, including Corah’s dental anxiety survey and questionnaire surveys like Children’s Fear Survey Schedule-Dental Subscale.⁷

The representative scale used to record apprehensive levels must be ideal, which requires minimal skills and should be easy to assess and record. The picture test of all of the most used and the most suitable scales when used in children. The facial index scale and Venham’s pictorial test have been utilized in various studies.¹¹ The vague characteristics of the figures used on the scale may complicate the child’s decision to make a fair choice. The Chotta Bheem-Chutki scale utilized in this study was proposed by Sadana et al., which comprises animated characters from an anime series. The animated personality in the series fascinates the child’s focus as well as helps to increase interaction between the child and the dentist. This scale also helps in identifying oneself or depicting inner thoughts through the familiar cartoons to which they can relate to.¹²

The cognitive development or the ability to reason or think about scenarios played a key part in the techniques employed in the study. The cognitive development of an individual is based on the development of the human brain, which generally consists of two hemispheres that are associated with various skills. Verbal and voluntary processes of children are associated with the left hemisphere in right-handed people, whereas language, speech analysis, and problem-solving techniques are associated with the left side. The right half of the brain can be linked with the nonverbal skills and emotions of a child. Art and musical skills belong to the right hemisphere of the brain. Imagination is also thought to be associated with the right half of the brain.¹³ Thus, the right half of the brain plays a key crucial role in using the magic technique.

Isaac Bonewits defined magic as the use of magic for nonreligious purposes, an art and science of wonder-working.¹⁴ These skills are schemed for a certain age cluster of subjects who can respond effectively. Thumb and light aid utilizing magic remarkably reduced anxiety which can be observed due to increased development of the right half of the brain. They visualize on and off the phenomenon of light in the thumb as a magical phenomenon that helps in alleviating pain and preanxiety before any dental procedure, thereby instilling positive behavior in children. Magical aids, when used appropriately, proved to be an innovative behavior-shaping technique improving the results of the dental treatment in the dental setup.

In a study conducted by Asokan et al., a notable decrease in apprehension levels was noted in the magic group.⁷ The results were similar to Peretz and Gluck, who analyzed and compared the efficacy of magic tricks and the Tell-Show-Do technique in treating stubborn children in whom distraction by the magic trick was seen to be more effective.¹⁵

In a study conducted by Prabhakar et al., audio distraction aids did not have a significant effect in reducing anxiety levels¹⁶ which was also noticed in a study conducted by Aitken et al.¹⁷ Audio distraction, when compared to other methods, showed a reduction in anxiety which may be contributed to the relaxation effect of music. It may so be attributed to the elimination of dental distraction with noises such as the sound of handpieces, which are unpleasant to children.¹⁸

Among the three distraction skills utilized in the present study, all strategies were equally effective in alleviating the anxiety of children. Readiness to take treatment was superior with the thumb and light trick group compared to the audio and audiovisual group.

The limitation of the present study was the assessment of anxiety levels which could be a subjective response in children. All behavioral studies on younger children have this limitation. The situational anxiety levels of the child are best assessed by children rather than parents or caregivers. Utmost care has been taken to avoid this limitation by using the Chotta Bheem–Chutki scale, which is easily understood by children and thus helping us in assessing the correct response of anxiety levels.

CONCLUSION

All three distraction strategies used in the study are equally efficacious in decreasing anxiety levels, with the highest anxiety alleviation observed in the magic group. Magic can be an important tool to decrease the anxiety of children who were reluctant to even come closer to the chair. It’s a tool that can be easily mastered and used in daily practice too. Thus, this study concludes that magic could be a new era in dentistry if used properly to decrease the patient’s anxiety.

ORCID

Chandana Krishna Shree CH https://orcid.org/0000-0001-5508-7818

Pooja HR https://orcid.org/0000-0003-3349-6711

Andrea Natalia Mascarenhas https://orcid.org/0000-0002-5592-0969

REFERENCES

1. Konde S, Sumaiyya S, Agarwal M, et al. “Thaumaturgy”—a novel behavior-shaping technique. Int J Clin Pediatr Dent 2020;13(4):318. DOI: 10.5005/jp-journals-10005-1781.

2. Forehand R, Long N. Strong-willed children: a challenge to parents and pediatric dentists. Pediatr Dent 1999;21(7):463–468. PMID: 10633525.

3. Klingberg G, Broberg AG. Dental fear/anxiety and dental behaviour management problems in children and adolescents: a review of prevalence and concomitant psychological factors. Int J Paediatr Dent 2007;17(6):391–406. DOI: 10.1111/j.1365-263X.2007.00872.x.

4. Ingersoll TG, Ingersoll BD, Seine RJ, et al. A survey of patient and auxiliary problems as they relate to behavioral dentistry curricula. J Dent Educ 1978;42(5):260–263. DOI: 10.1002/j.0022-0337.1978.42.5.tb01189.x

5. Allen KD, Stark LJ, Rigney BA, et al. Reinforced practice of children’s cooperative behavior during restorative dental treatment. ASDC J Dent Child 1988;55(4):273–277. PMID: 3165985.

6. Thomas A, Chess S. Temperament and Development. New York, NY: Brunner/Mazel, 1977.

7. Asokan S, Geetha Priya PR, Natchiyar SN, et al. Effectiveness of distraction techniques in the management of anxious children–a randomized controlled pilot trial. J Indian Soc Pedod Prev Dent 2020;38(4):407. DOI: 10.4103/JISPPD.JISPPD_435_20

8. Shetty RM, Khandelwal M, Rath S. RMS Pictorial Scale (RMS-PS): an innovative scale for the assessment of child’s dental anxiety. J Indian Soc Pedod Prev Dent 2015;33(1):48–52. DOI: 10.4103/0970-4388.149006.

9. Seligman LD, Ollendick TH. Cognitive-behavioral therapy for anxiety disorders in youth. Child Adolesc Psychiatr Clin N Am 2011;20(2):217–238. DOI: 10.1016/j.chc.2011.01.003.

10. Appukuttan DP. Strategies to manage patients with dental anxiety and dental phobia: literature review. Clin Cosmet Investig Dent 2016;8:35–50. DOI: 10.2147/CCIDE.S63626.

11. Agarwal M, Das UM. Dental anxiety prediction using Venham Picture test: a preliminary cross-sectional study. J Indian Soc Pedod Prev Dent 2013;31(1):22. DOI: 10.4103/0970-4388.112397.

12. Allani S, Setty JV. Effectiveness of distraction techniques in the management of anxious children in the dental operatory. IOSR J Dent Med Sci 2016;15(10):69–73. DOI: 10.9790/0853-1510026973.

13. Waxman D. Hartland’s Medical and Dental Hypnosis. 3rd ed., London: Bailliere Tindall; 1989.

14. https://en.wikipedia.org/wiki/Isaac_Bonewits https://en.wikipedia.org/wiki/Isaac_Bonewits Accessed:2018/15/10.

15. Peretz B, Gluck G. Magic trick: a behavioural strategy for the management of strong-willed children. Int J Paediatr Dent 2005;15(6):429–436. DOI: 10.1111/j.1365-263X.2005.00668.x.

16. Prabhakar AR, Marwah N, Raju OS. A comparison between audio and audiovisual distraction techniques in managing anxious pediatric dental patients. J Indian Soc Pedod Prev Dent 2007;25(4):177. DOI: 10.4103/0970-4388.37014.

17. Aitken JC, Wilson S, Coury D, et al. The effect of music distraction on pain, anxiety and behavior in pediatric dental patients. Pediatr Dent 2002;24(2):114–118. PMID: 11991313.

18. Seyrek SK, Corah NL, Pace LF. Comparison of three distraction techniques in reducing stress in dental patients. J Am Dent Assoc 1984;108(3):327–329. DOI: 10.14219/jada.archive.1984.0034.

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