Distraction Aids in Pediatric Dentistry: An Overview

Introduction

Pediatric dentistry is a specialty that provides oral health care for children through adolescence including those with special health care needs.¹ The foremost difficult aspect of dental care that practitioners face is the treatment of patient’s pain that encompasses a sturdy psychological part wherever conscious attention is required.² Success of treatment in pediatric dentistry not only depends on the technical skills of the operator, but also on his/her capability to gain and maintain a child's cooperation.³ Numerous strategies have been developed to manage the child’s behavior in a veritable dental setting. Distraction is one such method to reduce pain and anxiety during the dental procedures. The distraction process involves optimal patient attention and emotional participation. It is the method in which the individual or cluster attention is altered from the preferred vicinity of recognition through blockading or dwindling the event of favored information, which is salutary in the pain and anxiety management, caused by the dearth of heed, lack of interest in the object of attention or the great intensity, novelty, or attractiveness of entity than the object of attention.⁴

Distraction aids are the medium of distraction which indirectly influences positive behavior. It reduces fear of the patients during their dental visit, while treatment is imminent, thus making their dental treatment more efficient and anxiety free.⁵ Distraction techniques are a form of coping skills, tutored during cognitive behavioral therapy. They are of two types i.e. Active and Passive. An active technique involves children participating in activities like virtual reality, interactive toys, guided imagination, controlled breathing, and relaxation, while the passive techniques rely on the child's observation of an activity instead of direct participation in the activities like viewing television and hearing music.⁶ There are three key ‘distraction’ approaches:

1. Cognitive distraction

2. Behavioral distraction

3. Physiological distraction

In order to divert the focus and attention from the voices, a conscious effort is made by interacting with others in a behavioral distraction approach, whereas physiologic techniques encompass relaxation strategies, exercise, the use of an earplug inside the dominant ear, and engagement in hobbies. Cognitive distractions include reading aloud, humming, and voice mastery (e.g., responding solely to affable voices or describing hallucinations aloud).⁷ Methods We evolved a search strategy and systematic literature search to go through databases like PubMed, Google Scholar, Embase, and Medline between 1996 to 2022 booklet dates with a similar set of key phrases like distraction aids, distraction technique, virtual reality, AV distraction, and anxiety. Reference list of applicable articles and reviews had been hand-searched for extra reports.

Discussion

Preparation/education

This is intended in offering records concerning the medical intervention as it allows the child to have a greater sense of control and to map out coping strategies. Here, the sensory, visual, and aural interpretation of the procedure is performed in an age/developmentally suitable manner. The study reported that preparatory information provided by the nurses helped the children to cope with pain.⁸

Rest breaks

AAPD acknowledges that providing a brief break to the child patient during a disagreeable procedure could be an effective use of distraction prior to superior behavioral strategies.⁹

Mobile dental app

It is an interactive session where the children are virtually allowed to perform different dental treatments using the mobile dental app. The study concluded that the use of different dental instruments ought to reduce fear and additional cooperative behavior ought to be achieved.¹⁰

Videogame distraction

It is primarily based on the principle of cognitive behavioral remedy and neural feedback mechanisms for anxiety disorders. It is the commonly available media which helps in distraction by active participation of the child in the course of a dental procedure. The study concluded that videogame could better elicit a child’s cooperation when compared to different traditional methods.^11-14

Humor

It refers to a stimulus that is intended to provide a funny response (such as a humorous video), an intellectual process (perception of amusing incongruities), or a response (laughter, exhilaration). The most typical expression is laughter. Humor and laughter are also associated with an affable emotional state.¹⁵

Guided imagery or visual imagery

It is defined as a directed, deliberate daydream that uses all senses to make a targeted state of relaxation and a sense of physical and emotional welfare. It has proven its effectiveness as an alternative painkiller, particularly in dental procedures without the side effects of pharmacological analgesics. Three stages include Relaxation, Visualization, and Positive suggestion.^16,17

Magic tricks

This helps in dealing with strong-willed behavior patients. Here, the attention is drawn from the dental situation, and cooperation is achieved by distracting the mind and eye of the child, through guessing games, thumb and light tricks, book tricks, mystery prize boxes, and competition time.^18,19

Virtual reality

It is described as “a human-computer interface which permits the user to flexibly interact with a computer-generated environment” comprising of vital elements like virtual world, immersion, sensory feedback, and interactivity. Accordingly, the differentiating feature is that it offers the phantasm that the inanimate items are present inside a computer-generated virtual environment (VE). However, it is contraindicated in medically compromised children, particularly those with epilepsy, migraine, and vestibular tenderness. It is a secure, non-intrusive technique that does not need any prior schooling and training and leaves behind additional positive reminiscences of the treatment, leading to a greater temperament to return for treatment.^20,21

Niharika et al.²² and Pande et al.²³ found that virtual reality was efficacious in reducing dental anxiety in children, whereas Ran et al. reported that in addition to reducing the anxiety and pain in children, it improved the compliance of children who underwent short-term dental procedures without any adverse reaction.²⁴

Audio-visual distraction

The child will be able to control the unpleasant stimulus and feel as if being in an acquainted surrounding and additionally create a multi-sensory distraction provided by the TV screen. The child will also be able to tune out unpleasant dental sounds like the sound of the hand piece as the concentration will be on the TV screen.^25-27 Study reports that the AV distraction approach is more proficient when compared to the audio distraction approach alone.²⁸

Music therapy

It is a proven art-based health profession, which uses music in therapeutic relationship to handle clients’ physical, emotional, cognitive, and social requirements. It is a technique of pain relief available in two forms: Active and Passive. In active music therapy, there is involvement of a music therapist for active communication, whereas patients listen to music without a music therapist in passive music therapy.²⁹

It has been demonstrated that it makes children feel more at ease during dental work by lowering their heart and breathing rates. In addition to being more efficient when used in conjunction with other modalities than when presented alone, this may also result in requirement of lower amounts of pharmacological agents to manage pain and anxiety. For instance, combining music therapy with aromatherapy has shown better outcomes in the dental workplace of medical specialty patients in managing anxiety and improving their cooperation.^30-32 It also helps in reducing symptomatology, such as maladaptive behaviors and migraine frequency. White noise is another option to reduce stress. It offers something to concentrate on, whilst being present at the moment with the dentist.³³ Relaxation Involves numerous strategies that encourage stress reduction, the release of bodily tension, and the instillation of a peaceful and tranquil frame of mind. It could be achieved by holding younger children in a supportive, comfortable position, while tutoring older children on how to actively engage in progressive muscle relaxation.³⁴

Sucrose

It is a technique for treating pain that works by stimulating taste receptors in the brain, which are home to the endogenous opioid system, in order to lessen the impact of pain.³⁵ A study by Gaspardo et al., has substantiated the finding that oral sucrose with or without non-nutritive sucking is efficacious and safe for lowering pain responses. However, the knowledge on the continuous sucrose dosing remains inconclusive.³⁶

Massage therapy

Massage therapy involves manipulation of the body through tactile and kinaesthetic stimulation in a purposeful successional application. A study by Suresh et al., (2008) reveals a considerable improvement in their degree of distress, tension, pain, mood, and discomfort when compared to pre-massage ratings.³⁷

Acupuncture

It is a non-pharmacological pain relief method primarily based on the concept that energy travels through the body along meridians that are linked by acupuncture points. Pain results in case of obstructed flow. By inserting needles at the acupuncture points along the blocked meridians, the energy flow is regenerated, which eliminates or significantly lowers pain. A study on the acceptability and feasibility of acupuncture for the management of postoperative pain found that pain scores were significantly reduced four hours after the treatment.³⁸

Bio-feedback

It is a non-invasive, painless therapy that trains individuals to regulate voluntary functions including blood pressure, heart rate, skin temperature, and muscle tension. Electrodes are attached to the skin to measure these functions and the results are displayed on the screen. It is used to ease pain, promote relaxation, and reduce stress.³⁹

Transcutaneous electric nerve stimulation (TENS)

TENS is a pain-relieving technique that is non-invasive and secure, which partially or totally blocks pain sensations, and is primarily based on the gate control principle where nerves stimulate via electrodes on application to the skin. It reduces pain throughout the presynaptic nociceptors of the dorsal horn and limits its essential communication capabilities. A study by Kasat revealed TENS as an effective pain relief method during various dental procedures.⁴⁰

Positioning

Position modifications minimize acute pain as well as the subsequent development of discomfort by permitting appropriate blood flow and preventing muscle spasms and contractions. A study by Chng et al. (2015) found that almost half of parents used positioning to ease their child's pain and comfort.⁴¹

Others include

Animal-assisted therapy (AAT)

This might be a fundamental part of child's first dental visit, the provision of dental services to special needs children and orphanages, and conjointly in varied dental specialties, as well in different dental specialties. There is evidence that a 15-minute exposure to a dog in the workplace room will scale back the anxiety level. As a result, it is a favorable approach for reducing anxiety in dental settings. According to recent research, AAT can ameliorate pain throughout dental treatment, improve patients' opinions of their visits, and can lower heart rate in patients when administered between dental treatments. If more parents are made aware of this behavior management strategy, it might prove to be effective.^42,43

Sensory adapted dental environment (SADE)

This form of dental surrounding has the potential to enhance not only oral care for children with autism spectrum disorders and other impairments but also for children with dental fear and anxiety or sensory processing difficulties. It allows the child to better tolerate complementary holistic oral care procedures and improves overall health and quality of life as it reduces the perception of baneful smells, noises, and touch. By scheduling routine dental checkups, dwindling waiting time, and by averting exigency treatment, dental anxiety in children can be reduced.^42,44

It is counseled that a fidget spinner is an effective approach for reducing children's dental anxiety during Inferior alveolar nerve block (IANB) procedures.⁴⁵ This tool when utilized by autistic, anxiety, or attention deficit hyperactivity disorder children, provides them a pathway to channel their energy and might help to boost their executive functioning and memory skills while they engage in challenging tasks.⁴⁶ It additionally helps them to concentrate by helping them filter out extra sensory information that would otherwise be distracting. Some tools have smooth or soft surfaces that promote calmness and eliminate anxiety.⁴⁷

Sensory bottles or Calm down bottles provide a comforting sensory experience for children with autism and sensory requirements. They help calm any sort of meltdowns or tantrums when a child is feeling burdened with an excessive amount of sensory input.⁴⁸

Conclusion

A prospering treatment requires dentist–patient cooperation and should provide a less nerve-racking ambiance for the dental platoon. Better treatment outcomes can be achieved by identifying the source of fear and anxiety of the patient. Communication with the employment of self-reporting anxiety and fear scales help in identifying and modifying the behavior that is necessary for successful treatment.

Conflicts of Interest

Nil