ORIGINAL RESEARCH

https://doi.org/10.5005/jp-journals-10077-3289
Journal of South Asian Association of Pediatric Dentistry
Volume 7 | Issue 1 | Year 2024

Process Drama as a Tool in the Management of Dental Fear and Anxiety

Kalyani Boorela1, Aron AK Vasa2, Suzan Sahana3

1–3Department of Pediatric & Preventive Dentistry, St Joseph Dental College, Eluru, Andhra Pradesh, India

Corresponding Author: Suzan Sahana, Department of Pediatric & Preventive Dentistry, St Joseph Dental College, Eluru, Andhra Pradesh, India, Phone: +91 9886231079, e-mail: drsuzansahana@gmail.com

Received: 03 November 2023; Accepted: 28 November 2023; Published on: 27 April 2024

ABSTRACT

Background: Fear of a dental visit leads to avoidance or delay in seeking treatment, which adversely affects a child’s oral and psychological health. Children who are worried about going to the dentist may benefit from preliminary knowledge and coping mechanisms created through dramatic framing.

Objectives: The aim was to identify children’s actual causes of dental fear and anxiety (DFA) and to develop anxiety-minimizing strategies outside a dental setting through process drama.

Materials and methods: A total of 60 children between the ages of 8 and 11 were chosen to take part in the process drama workshop. A classroom depicting the scenario of a pediatric dental clinic and a child anxiously waiting for her first dental visit was dramatized in sequence. Through roleplay activity, causes of dental anxiety were identified, and strategies for minimizing it were developed by children. The levels of anxiety were measured using three different rating scales at various intervals.

Statistical analysis: The data analysis was done using Statistical Package for the Social Sciences (SPSS) v22 software, analysis of variance (ANOVA), repeated ANOVA, and post hoc Tukey’s tests were used for comparative analysis of scores.

Results: A statistically significant difference was found in the anxiety scores of children, which were higher at the beginning of the workshop compared to levels after the session.

Conclusion: Process drama was found to be effective both in identifying the causes as well as developing strategies to minimize DFA; hence, it can be recommended as a tool to sensitize children awaiting dental visits.

How to cite this article: Boorela K, Vasa AAK, Sahana S. Process Drama as a Tool in the Management of Dental Fear and Anxiety. J South Asian Assoc Pediatr Dent 2024;7(1):16–20.

Source of support: Nil

Conflict of interest: None

Keywords: Dental anxiety, Dramatic framing, Process drama

INTRODUCTION

The term ”dental fear and anxiety” (DFA) is used to refer to a variety of fears that people experience when they are around dentists. It is a ”unique phobia with special psychosomatic components that impacts the oral health of the persons with odontophobia.” This leads to either avoidance or delay in seeking dental care.1

Anxiety is the most likely response to any dental stimuli, especially experienced during an individual’s first dental visit.2 Though anxiety affects people of all ages, it appears to be more prevalent in young children and adolescents. These individuals avoid dental care, which may subsequently impact their oral health-related quality of life. Little is known as to how dental anxiety develops in children and what might be done to prevent it in its early stages.1 Despite the evolving trends, anxiety and feelings of dental fear persist, especially in pediatric patients.2 Exploring new ways to understand the complex psychology of dental fear is crucial to the development of interventions appropriately designed for children.1

It is prudent for clinicians to identify anxious children and formulate acceptable evidence-based therapies specific to every child. In order to make the dental visit more child-friendly, evaluating the levels of anxiety before commencing dental treatment can help reduce the behavior management problems associated with it.3 Overcoming the fear of dental visits is important because children can have a progressive familiarization with dental care if they visit the dentist regularly and are more likely to have a positive attitude as well. This way, future anxiety can be prevented at an early age.4

Depending on the level of anxiety, the patient’s behavior, and the clinical circumstances, various methods are recommended for the therapy, including psychological, pharmaceutical, or a combination of the two. Interventions in psychotherapy are behaviorally focused and work to reorganize the content of negative cognitions. Cognitive therapy is currently considered the most accepted psychological treatment for anxiety and phobia.5

Process drama, a teaching strategy created in the 1980s, has been applied in a variety of artistic and scientific fields, mostly to encourage students’ empathy. This instructional approach involves both students and the teacher working in and out of roles to explore a problem, situation, or issue.

It has been reported that process drama has also been used in the medical field to train medical students’ empathy. Participants are encouraged to roleplay real-world scenarios using various improvisational techniques. The same approach might be used in other contexts when young children are concerned about their health. Accordingly, a recent qualitative study advocated the use of Process drama as a novel approach to oral health research among children, focusing mainly on dramatic framing and critical distancing.1 However, very little is known about its usage in dentistry, and literature underlines the need for greater research in this area. Therefore, the purpose of the current study was to identify factors that contribute to dental anxiety outside of a dentist’s office and encourage the children to participate in roleplaying exercises. This information could be crucial since it would allow dentists to better modify their procedures to children’s preferences.

MATERIALS AND METHODS

Determination of sample size was done using G*power 3.1.9.4 software. From the reference article,2 calculations were done based on an effect size of 0.167, an α-level of 0.05, and the desired power of 80%. The estimated sample size through power analysis was found to be 60.

The Institutional Review Board examined the study procedure, and ethical approval was granted. Serial number CEC/S.S/2021–22.

In total, 60 primary school students from the Eluru district of Andhra Pradesh, India, participated in the study. Children between the ages of 8 and 11 who were enrolled in the participating school and who had informed written agreement from their parents met the inclusion criteria. Children with any speech difficulties, sensory impairments, and intellectual disabilities were excluded from the study.

The workshop started out with the young participants seated in a classroom that would serve as a mock pediatric dental clinic. A lead investigator (teacher), a patient (helper), and two other people (parents) made up the process drama team. With the aid of an audiovisual aid, the instructor provided a quick introduction to a child’s first dentist appointment to kick off the interactive session.

The facial image scale (FIS), Chotta Bheem Chutki scale (CCS), and modified child dental anxiety scale (MCDAS) were used to assess each child’s anxiety levels at the beginning of the workshop.

The FIS scorecard (Fig. 1) features a row of five faces that range from extremely joyful to extremely miserable. The participants were instructed to point at the face that, at that precise moment, seemed most likely. Scoring was done by giving a value of one that illustrates the most positive and five being the most negatively affected face.6

Fig. 1: Facial image scale (FIS)

Two cards that were specifically created for boys and girls were used to rate anxiety using the CCS. These animated cartoon characters, Chutki for women and Chotta Bheem for men, stood in for various emojis. Each card has a collection of six figures that depict the cartoon character in a range of moods, such as happy, sad, and running away (Fig. 2). The cards were displayed to the kids, and they were told to pick the one that best captured their current mood. In accordance with this, one point was given for a pleased face and six points for an unpleasant face and a running away image.2

Fig. 2: Interpretation of CCS

Children’s state of anxiety was assessed using the MCDAS (f) faces version. An eight-item self-report questionnaire with five visual responses to each topic is used to measure anxiety. The scores range from 8 to 40, with scores below 19 showing the lack of state anxiety, beyond 19 indicating the presence of state anxiety, and above 31 suggesting a severe phobic disorder.7

All the scores were tabulated for further statistical comparison.

Following this, the children were randomly divided into four groups: A, B, C, and D, assigning 15 to each for further group activities. They were instructed to assume the roles of pediatric psychologists, with the assistant taking on the role of a patient who was awaiting her first visit to the pediatric dentistry clinic. The assistant acted as Chutki, a patient who was anxiously waiting outside the clinic while biting her nails and dodging her parents’ unwanted attention while wearing a terrified expression on her face. When acting as child psychologists, the participating kids were questioned about what they saw and given instructions to conduct a preliminary study of the possible explanations for the patient’s behavior.

The focus of the workshop’s second session switched from character development to character acting. To emphasize this, the kids were given a blank template of Chutki’s face and asked to draw a still image of what they thought she was feeling. By adding color and an appropriate facial expression, they finished the sketches. Later, each student in the class was given the chance to speak out on their own and demonstrate what their pictures represented. Following that, the images were assessed using Chutki’s character ratings on the CCS.2

Due to the immersive simulation of the real-world events made possible by dramatic framing, participants were able to further examine the issue and place a greater emphasis on the process rather than the result. As part of this, the kids were urged to develop their own methods for anxiety reduction. They were given the option to select which other characters could assist Chutki throughout the therapy to minimize fear and anxiety before being told to assume their roles as child psychologists. In order to learn coping techniques for dental anxiety, we invited the kids in each group to come up with their own set of suggestions for Chutki to try and help her worries associated with obtaining dental care. At all stages of the workshop, each group’s responses were compiled on large sheets of paper so that the results could be debated, recorded, and analyzed. The common responses provided by the children were compiled for statistical analysis using a mixed-method analysis.

The assessment of anxiety levels was conducted once again at the end of the process play workshop, and all the results were recorded for statistical comparison.

RESULTS

The Statistical Package for the Social Sciences (SPSS) v22 program was used to analyze the data. For the purpose of comparing different scores within each group, analysis of variance (ANOVA), repeated ANOVA, and post hoc Tukey’s tests were performed. There was a statistically significant difference between the process drama participants’ pre- and post-session anxiety assessments.

DISCUSSION

Dental anxiety is one of the main problems influencing children’s dental health and clinical care.8 The purpose of the current study was to compare the anxiety levels of kids before, during, and after a Process drama session that was used to treat DFA.

The assessment of DFA is quite complex. There are three major ways to gauge children’s dental anxiety such as ”physiological response analysis,” ”behavior assessment,” and ”psychometric assessment.” In the current study, dental anxiety levels were evaluated using a psychometric approach. Before starting treatment, the children or one of their parents must complete a questionnaire as part of the psychometric exam in order to gauge how anxious they are about typical dental scenarios.

Three variations of validated anxiety rating scales were employed to determine if there were any significant differences. When the results of the FIS were considered, it was discovered that most kids had given higher anxiety levels on the scale before the session started, while very few of them had given lower scores. However, the majority of the kids who had been initially quite anxious at the workshop showed a considerable reduction in anxiety levels at the end of the session. Similar substantial differences were seen between the CCS and MCDAS (f) anxiety rating scales, with the latter showing relatively lower anxiety scores at the conclusion of the workshop (Table 1).

Table 1: Intercomparison of anxiety scores using three rating scales at various intervals
Characteristic Time intervals Mean Standard deviation p-value
FIS Before 2.2333 1.43050 0.000*
During 1.4667 0.81233
After 1.3667 0.80183
CCS Before 2.2833 1.60604 0.003*
During 2.0167 1.30827
After 1.5833 1.27946
MCDAS Before 21.7000 6.64678 0.000*
During 18.6167 6.58990
After 16.8667 7.11043
Factor 1 (I) Factor 1 (J) Mean difference (I − J) Standard error p-value 95% confidence interval
Lower bound Upper bound
FIS Before During 0.767** 0.213 0.002 0.242 1.292
Before After 0.867** 0.185 0.000 0.411 1.322
During After 0.100 0.123 1.000 −0.203 0.403
CCS Before During 0.267 0.200 0.563 −0.226 0.760
Before After 0.700** 0.225 0.008 0.147 1.253
During After 0.433** 0.137 0.008 0.095 0.772
MCDAS Before During 3.083** 0.839 0.002 1.016 5.151
Before After 4.833** 0.968 0.000 2.449 7.218
During After 1.750** 0.420 0.000 0.716 2.784

*Statistically significant, repeated measures of ANOVA; **statistically significant, post hoc analysis using Tukey’s test

The causes of dental fear, as identified by the participant children in the current study, varied, and each of them gave one or more reasons. The reasons cited by most of them included injections, doctors, and drilling machines. On the other hand, some of them also mentioned about fear of taking out the tooth, light, and the operating room as the causative factors (Table 2). The results show that a process drama model presented the workshop as a platform for research rather than an educational session for conveying health messages as the particular causes of dental fear were uncovered.

Table 2: Possible causes of dental fear as assessed by children
S. no. Reason Percentage
1. Injection 78.3%
2. Doctor 66.7%
3. Drilling machine 41.6%
4. Taking out the tooth 35%
5. Operation 31.6%
6. Light 25.0%
7. Room 23.3%
8. Straw 16.6%
9. Blade 16.6%
10. Cement 15%
11. Pain 11.7%
12. Saline 1.3%
13. Screwdriver 0.2%

Four major themes were reported by Tahmassebi et al., who used Process Drama to investigate the causes of dental fear in primary school children, and their findings concur with those of the present study. The cited causes included unpleasant sensory experiences, dread of the unknown, and others.9 Additionally, a qualitative study (Morgan et al.) backed up the idea that a fear of the unknown is one of the primary causes of dental anxiety.10

In the current study, the workshop’s major goal was to inspire the kids to come up with original solutions for handling dental fear in young patients. As a result, the kids recommended having their parents, grandparents, siblings, and friends around to help them deal with their worries (Table 3). Similar to this, earlier research has shown that children’s physiological signs of fear during their first dentist visit are lessened when parents are present.11

Table 3: One or more characters suggested by children whose presence helps to overcome anxiety
S. no. Character Percentage
1. Parents 75%
2. Siblings 37.1%
3. Grandparents 41.6%
4. Friends 41.6%

Children who attended the session were instructed to draw a still representation of how they thought Chutki, the patient who was awaiting a dentist visit, was experiencing. Working with ”still images” thus gave them a chance to explore ideas and emotions that could be difficult to put into words. The youngsters finally provided the most perceptive answers to the underlying causes of Chutki’s worry during this phase, which allowed them to express their more imaginative and creative sides. The majority of participants drew a joyful face, but a few also drew sad faces, angry faces, shouting faces, and sobbing faces, depending on Chutki’s character scores on the CCS (Table 4 and Fig. 3).

Table 4: Scores assigned using the CCS for the pictures drawn by children
Score ​ Number ​ Percentage ​
1.​ 45​ 75.0​
2.​ 10​ 16.7
3. 2 3.3
4. 2 3.3
5. 1 1.7

Fig. 3: Sample images of children depicting various expressions

Every child was able to project his or her own narratives into fiction as a result of the drama workshop’s openness throughout the process, which let students approach the problem of dental anxiety from the viewpoint of an ”expert” and develop a set of tactics to reduce it. The majority of the kids advised that the list of approved modes includes toys, televisions, and colorful operating rooms. Some of them also thought that using audiovisual aids, cartoons, papers or charts, pictures or drawings of their favorite characters would help them to relax (Table 5).

Table 5: Set of suggestions given by children to overcome anxiety during dental treatment
S. no. Strategy suggested Percentage
1. Toys 56.6%
2. Television 53.3%
3. Colors 33.3%
4. Cartoons 25.0%
5. Audiovisual aids 13.3%
6. Color papers/charts 1.16%
7. Pictures/drawings 1.16%

CONCLUSION

The conclusions drawn from the study are as follows:

Dental anxiety affects a sizable section of the pediatric population, potentially negatively affecting their quality of life. Therefore, focusing on psychological factors with the adjuvant use of self-reporting anxiety and fear measures and utilizing strategies that could shield individuals from dental dread should be a crucial component of therapeutic practice.

REFERENCES

1. Carter AE, Carter G, Boschen M, et al. Pathways of fear and anxiety in dentistry: a review. World J Clin Cases 2014;2(11):642–653. DOI: 10.12998/wjcc.v2.i11.642

2. Sadana G, Grover R, Mehra M, et al. A novel Chotta Bheem-Chutki scale for dental anxiety determination in children. J Int Soc Prev Community Dent 2016;6(3):200–205. DOI: 10.4103/2231-0762.183108

3. Ummat A, Dey S, Nayak PA, et al. Association between dental fear and anxiety and behavior amongst children during their dental visit. Biomed Pharmacol J 2019;12(2):907–913. DOI: 10.13005/bpj/1716

4. Carrillo-Díaz M, Migueláñez-Medrán BC, Nieto-Moraleda C, et al. How can we reduce dental fear in children? the importance of the first dental visit. Children (Basel) 2021;8(12): DOI: 10.3390/children8121167

5. 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

6. Buchanan H, Niven N. Validation of a facial image scale to assess child dental anxiety. Int J Paediatr Dent 2002;12(1):47–52. DOI: 10.1046/j.0960-7439.2001.00322

7. Asl Aminabadi N, Erfanparast L, Sohrabi A, et al. The impact of virtual reality distraction on pain and anxiety during dental treatment in 4-6 year-old children: a randomized controlled clinical trial. J Dent Res Dent Clin Dent Prospects 2012;6(4):117–124. DOI: 10.5681/joddd.2012.025

8. Wu L, Gao X. Children’s dental fear and anxiety: exploring family related factors. BMC Oral Health 2018;18(1):100. DOI: 10.1186/s12903-018-0553-z

9. Tahmassebi JF, Malik M, Berg N, et al. Using process drama to explore the causes of dental anxiety in primary-school children. Eur Arch Paediatr Dent 2021;22(5):869–877. DOI: 10.1007/s40368-021-00623-4

10. Morgan AG, Rodd HD, Porritt JM, et al. Children’s experiences of dental anxiety. Int J Paediatr Dent 2017;27(2):87–97. DOI: 10.1111/ipd.12238

11. Pani SC, AlAnazi GS, AlBaragash A, et al. Objective assessment of the influence of the parental presence on the fear and behavior of anxious children during their first restorative dental visit. J Int Soc Prev Community Dent 2016;6(Suppl 2):S148–S152. DOI: 10.4103/2231-0762.189750

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