Acta Odontologica Scandinavica

ISSN: 0001-6357 (Print) 1502-3850 (Online) Journal homepage: www.tandfonline.com/journals/iode20

Effects of audiovisual distraction on children’s

behaviour during dental treatment: a randomized
controlled clinical trial

Amal Al-Khotani, Lanre A'aziz Bello & Nikolaos Christidis

To cite this article: Amal Al-Khotani, Lanre A'aziz Bello & Nikolaos Christidis (2016)
Effects of audiovisual distraction on children’s behaviour during dental treatment: a
randomized controlled clinical trial, Acta Odontologica Scandinavica, 74:6, 494-501, DOI:
10.1080/00016357.2016.1206211

To link to this article: https://doi.org/10.1080/00016357.2016.1206211

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Published online: 13 Jul 2016.

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ACTA ODONTOLOGICA SCANDINAVICA, 2016
VOL. 74, NO. 6, 494–501
http://dx.doi.org/10.1080/00016357.2016.1206211

ORIGINAL ARTICLE

Effects of audiovisual distraction on children’s behaviour during dental

treatment: a randomized controlled clinical trial
Amal Al-Khotania,b,c , Lanre A’aziz Belloc and Nikolaos Christidisa,b
a
Section for Orofacial Pain and Jaw Function, Department of Dental Medicine, Karolinska Institutet, Huddinge, Sweden; bScandinavian Center
for Orofacial Neurosciences, Huddinge, Sweden; cPediatric Dentistry and Orthodontics Department, College of Dentistry, King Saud University,
Riyadh, Saudi Arabia

ABSTRACT ARTICLE HISTORY

Aim: Dental anxiety leads to undesirable distresses such as avoidance of dental treatment and increase Received 3 March 2016
stress among caregivers that consequently affect the treatment quality. The aim of this study was there- Revised 9 June 2016
fore to evaluate the effectiveness of viewing videotaped cartoons using an eyeglass system (i-theatreTM) Accepted 21 June 2016
as an audiovisual (AV) distraction technique on behaviour and anxiety in children receiving dental
KEYWORDS
restorative treatment. Children; anxiety; behaviour;
Methods: Fifty-six consecutive children patients who presented for treatment and met inclusion criteria dental fear; restorative
were included and randomly divided into two groups; a control group without distraction (CTR-group) treatment
and a distraction-group (AV-group). Three dental treatment visits were provided for each patient.
Anxiety and cooperative behaviour were assessed with the Facial Image Scale (FIS) and the Modified
Venham’s clinical ratings of anxiety and cooperative behaviour scale (MVARS). The vital signs, blood
pressure and pulse were also taken.
Results: The AV-group showed significantly lower MVARS scores than the CTR-group (p ¼ 0.029), and
the scores decreased significantly during treatment in the AV-group (p ¼ 0.04). Further, the pulse rate
was significantly increased in the CTR-group during injection with local anaesthesia (p ¼ 0.02), but not
in the AV-group.
Conclusion: AV distraction seems to be an effective method in reducing fear and anxiety in children
during dental treatment. Further, children who used eyeglass goggle display as a distraction tool during
dental treatment reported not only less anxiety than control groups but also showed more positive
responses after injection with local anaesthesia. Hence, AV-distraction seems to be a useful tool to
decrease the distress and dental anxiety during dental treatment.

Introduction adverse dental experiences,[6,7] while a continuing behaviour

of avoidance may aggravate dental anxiety. Hence, anxiety
One of the primary desires for dental professionals is to treat
and fear are closely related. Dental anxiety is therefore
their patients in an anxiety-free environment along with a
defined as the distressed expectation of a visit to a dentist to
high quality of the dental care. To achieve this, dentists have
the extent where a child might avoid treatment,[6,8] while
to implement their learned skills and experience. Previous dental fear/phobia is defined as when the distressed expect-
studies have shown that the level of fear that children per- ation interferes with normal functioning.[9]
ceive before or during dental treatment is not only associated Distraction, one of the psycho-behavioural approaches
with the degree of disruptive behaviour,[1] but also with an used in medical and dental treatment situations, is defined as
increase of pain perception, which consequently may result in a non-aversive approach used to modify a child’s discomfort
nervousness, anxiety and sensitization for future appoint- by disrupting his/her attention away from the main task to
ments.[2] Based on the theory by McCaul and Mallot, a accomplish successful treatment with high quality.[10]
patient’s perception of pain is decreased when the patient is Previous studies have suggested that the use of distraction
distracted from an unpleasant stimulus.[3] One can under- during dental treatment is beneficial to patients by reducing
stand that the perception of pain is directly associated with their distress and in turn decrease their perception of pain
the amount of attention a patient pays to an unpleasant sensation, especially during injections with local anaesthe-
stimulus. Several neurophysiological studies have confirmed sia.[11] It has been stated, however, that the ideal distractor
this theory pointing out the importance of distraction con- ought to possess various abilities such as visual, auditory and
cerning lower levels of pain and anxiety.[4,5]. Previous kinaesthetic modalities (i.e. physical movements) to provide
research indicates that dental fear seems to rise from past the full capacity to harness the child’s concentration and

CONTACT Amal Al-Khotani aalkhotani@yahoo.com Section for Orofacial Pain and Jaw Function, Department of Dental Medicine, Karolinska Institutet, Box
4064, SE-141 04 Huddinge, Sweden
ß 2016 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License (http://creativecommons.org/licenses/by-nc-nd/4.0/),
which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or built upon in any
way.
 ACTA ODONTOLOGICA SCANDINAVICA 495

attention and in turn minimizing the child’s anxiety.[12] and one control group (CTR-group). The inclusion of 26
Furthermore, it has also been shown that the use of audiovi- patients in each group would be sufficient to detect a statis-
sual (AV) distraction not only leads to full involvement of tically significant difference between interventions at a signifi-
scenes (visual and auditory), but it also induces a positive cance level of 5% with a power of 80.[22] To compensate for
emotional reaction resulting in a relaxed experience.[13,14] dropouts two additional patients were included in each group
Several studies have shown that AV distraction in medical leading to a total of 56 included boys and girls.
practice is commonly used in short invasive procedures to The inclusion criteria for the patients were: (1) general
reduce the patients’ pain and anxiety.[15,16] Nevertheless, good health, (2) no previous dental experience involving local
there is still a controversy regarding the effectiveness of dis- anaesthetic administration for the last 2 years and (3) restora-
traction during dental treatment procedures. Some studies tive treatment required under local anaesthesia.
concluded that the use of AV distraction is successful in The exclusion criteria were: (1) previous unpleasant experi-
decreasing not only anxiety,[11,17,18] but also pain percep- ence in medical setting or known dental phobia as reported
tion.[19] However, other studies found that distraction by dis- in the medical records, (2) need for pharmacological manage-
playing a videotaped cartoon did not reduce uncooperative ment to cooperate or (3) medical disability such as the history
behaviour during dental treatment.[20] On the other hand, of seizures or convulsion disorders, nystagmus, vertigo or
Sullivan et al. (2000) showed that AV distraction significantly equilibrium disorders, eye problems and autism. Further, the
reduced the pulse but did not have an effect on anxiety or participating children were excluded if their parents did not
behaviour.[21] give consent.
With this in mind, the aim of this study was to evaluate
the effectiveness of viewing videotaped cartoons using an Study design
eyeglass system (i-theatreTM) as an AV distraction technique
on behaviour and anxiety in children receiving restorative This prospective randomized controlled parallel arm trial was
dental treatment. carried out during September 2007 to May 2008. The patients
were divided randomly into two groups that received either
Materials and methods AV distraction or no distraction. The randomization was per-
formed by a dental assistant not participating in the study by
The local ethics committee at the College of Dentistry assigning the first patient to either group by the toss of a
Research Center at King Saud University, Riyadh, Saudi Arabia, coin, after that the next patient went to the other group.
approved the current study. The study was carried out in The study comprised three visits: V1) dental examination
compliance with the Declaration of Helsinki as well as the and inclusion, V2), acclimatization (including oral hygiene
International Conference on Harmonization Guideline for information and prophylaxis) and V3) restorative visit. The
Good Clinical Practice. All participants and their parents patients were treated by the same dentist (AA-K), specialist in
received both written, and verbal information about the pro- paediatric dentistry, and the same dental assistant, at all three
cedure before inclusion. Both the children and their parents visits. If further appointments were necessary for dental treat-
gave their verbal and written consent. ment of their restorative needs, the patients booked with the
same dentist and dental assistant after the end of the study.
Participating patients A pilot study was conducted consisting of six participants
meeting the inclusion criteria to get acquainted with the
The participants were selected from consecutive patients that
measurement technique and the AV distraction (i-theatreTM).
presented for treatment at the paediatric dentistry clinic at
These participants were, however, not included in the main
the College of Dentistry, King Saud University, Riyadh, Saudi
study. Findings from the pilot study suggested the protocol
Arabia. These were uncooperative patients referred from
worked well, and subsequently, no changes were made.
undergraduate clinic to the postgraduate clinic for behaviour
management. The children were aged between 7 and 9 years,
with a mean (SD) age of 8.2 (0.8) years, (Table 1). The sample Audio-visual distraction
size was calculated on a two-sample comparison of propor- The Merlin i-theatreTM (i-theatrepro, Merlin, Soft Magic Systems
tions of behaviours; one group with AV distraction (AV-group) LLC, Al Ain Center, Dubai, UAE) was used for the AV distrac-
tion (Figure 1). It is an eyeglass system (16.9 cm wide) placed
Table 1. Participant characteristics, sub-grouped by type of distraction. in front of the eyes and can be connected to several devices
CTR-group AV-group Total such as DVD Players, gaming systems like Sony Play Station
Individuals 28 (50%) 28 (50%) 56 (100%) Pro, Microsoft X-BOX, Nintendo WII, etc., or a satellite box.
Sex
Female 17 (60.7%) 17 (60.7%) 34 (60.7%) According to the manufacturer, it is equivalent to watching a
Male 11 (39.3%) 11 (39.3%) 22 (39.3%) 60 inches (1.53 m) LCD-screen from a distance of 2.0 m.
Age
Mean (SD) 8.1 (0.9) 8.3 (0.8) 8.2 (0.8)
Min–max 7–9.8 7–9.6 7–9.6
7 years 12 (43%) 10 (35.7%) 22 (39.3%) Dental operatory procedures
8 years 9 (32%) 12 (43%) 21 (37.5%)
9 years 7 (25%) 6 (21.4%) 13 (23.2%) The dental clinic used for this study was fully equipped with
SD: standard deviation; AV-group, with audiovisual distraction; CTR-group, with- a dental unit, pulse oximeter and blood pressure (BP) moni-
out distraction. tor. A video camera was attached to an adjustable tripod and
496 A. AL-KHOTANI ET AL.

placed in a position that allowed complete viewing of the regarding the topical fluoride was then given to both the
child during the entire dental procedures, i.e. before, during child and parent/guardian. At the end of the acclimatization
and after the prophylaxis process in visit 2 and the restorative visit the child rated his/her anxiety on the FIS.
procedure in visit 3. The accompanying parent/guardian was
allowed to attend during the entire procedure, however, only Visit 3: restorative visit Before the visit, the participating
as a passive observer and was seated on a chair that placed patients were randomly divided into two groups: (a) the dis-
behind the child and the operator (the child was aware of traction group (AV-group) or (b) the control/non-distraction
the parent/guardian presence). The amount of time for each group (CTR-group).
visit was 30 min or less. Three visits for each patient were as In both groups, the following procedures were carried out:
follows. (1) preoperative and postoperative anxiety was rated with FIS
at the beginning and the end of treatment respectively, (2)
the Modified Venham’s clinical ratings of anxiety and
Visit 1: dental examination and inclusion visit cooperative behaviour scale (MVARS).[24,25] BP and PR have
Before the clinical dental examination, including radiographs registered preoperatively and also for the following period:
when necessary, the parent/guardian was asked about the (a) intraoral examination, (b) injection with local anaesthesia,
child’s medical and dental history. After the examination, a (c) application of rubber dam, (d) cavity preparation and (e)
treatment plan was done and discussed with the parent/ tooth restoration. During all the procedures the same behav-
guardian. In order to introduce the child to the dental proce- iour management techniques were used including verbal
dures, the psychological behaviour management technique communication and positive reinforcement.
tell-show-do was used during this visit. This method includes; However, in the AV-group, before the start of the restora-
a verbal description by ‘tell’, demonstration by ‘show’ and tive procedure, the child was introduced to the AV-system
completion of the show by ‘do’ to introduce the child with (i-theatreTM) and allowed to choose his/her favourite cartoon,
dental settings. appropriate for the age-group, out of four funny movies with
similar characteristics. The cartoon film was in the Arabic lan-
Visit 2: acclimatization visit including oral hygiene guage to involve full auditory and visual engagement.
information and prophylaxis
This visit started by using the tell-show-do technique to Patient assessment
explain the procedure. After that the Facial Image Scale (FIS),
validated to assess dental anxiety,[23] was explained to the The child’s response to dental stress was assessed using a
child, and the dentist asked the child to choose one of the combination of five measures: (1) the FIS for dental anxiety.
five faces that best represented his/her current emotional This scale consists of five faces ranging from ‘very happy’ (1)
state. A BP cuff (DURA-CUF, Critikon, Tampa, FL) and a pulse to ‘very unhappy’ (5). The first two faces; response number 1
oximeter sensor were then placed on the left biceps muscle and 2 are positive, i.e. without signs of anxiety.[23] Each
and the big toe of the right foot respectively; baseline values patient was asked to choose one of these faces that best rep-
for BP, and pulse rate (PR) were obtained. resent his/her feeling at the beginning, and at the end of
The acclimatization started with the instruction of oral each visit. However, the response number (1) accounts for
hygiene by explaining the technique to brush the teeth the most positive affect face (approval and no discomfort)
(toothpaste and toothbrush were used). After that, dental and the response number (5) represents the most negative
prophylaxis was performed using a slow-speed hand piece affect face (disapproval and extreme discomfort); (2)
with a rubber cup and prophylaxis paste, followed by applica- MVARS.[25] This scale consists of six categories, (range from
tion of topical fluoride using disposable trays. Information 0 to 5), where; 0 ¼ Relaxed, 1 ¼ Uneasy, 2 ¼ Tense,
3 ¼ Reluctant, 4 ¼ Interference, 5 ¼ Out of contact. Each cat-
egory describes the patient status in the dental chair when a
particular dental procedure is performed; (3) the systolic BP
(s-BP); (4) the diastolic BP (d-BP); (5) the PR. The values
obtained for FIS, MVARS, BP and PR were averaged to pro-
duce mean value for the visit.

Observer training
Two observers (NCh and LB) who did not have any contact
with the patients, were trained as observers through using
video recordings from the pilot study. Scores were assigned
using MVARS to determine the clinical ratings of anxiety and
cooperative behaviour at intervals when a specific dental pro-
cedure is performed. The videotapes were scored and
Figure 1. Illustration of the AV distraction eyeglass goggle Merlin i-theatreTM
repeated until a sufficient reliability level was reached
in a clinical setting. (Cohen’s Kappa ¼ 0.85). Inter-observer agreement was also
 ACTA ODONTOLOGICA SCANDINAVICA 497

achieved by scoring the videotapes individually; where there the included patients reported any anxiety at baseline; 57%
was disagreement; joint decision made the final score. The said they were ‘very happy’ and 43% said they were ‘happy’ in
two observers were blinded, and the tapes were coded dur- the CTR-group. While 43% said they were ‘very happy’, and
ing the main study. 57% stated that they were ‘happy’ in the AV-group.

Statistical analysis Behavioural and anxiety measurements

The statistical analyses were performed using IBM SPSS When the cooperative behaviour was analyzed (MVARS), there
Statistics 22 (IBM Corp., Armonk, NY). Normality of the data was a significant difference between groups with lower mean
was tested with the Shapiro–Wilk test. Descriptive data are (SD) MVARS scores in the AV-group (0.14 ± 0.36) compared to
reported as frequencies, means and standard deviation (SD). the CTR-group (0.75 ± 0.52) (p ¼ 0.03). When the clinical anx-
For analyses of group differences in frequencies, v2-test was iety was analyzed with MVARS there was a significant reduc-
used. For analyses of group differences in variables on a nom- tion in clinical anxiety throughout the restorative procedure,
inal scale t-test was used, while the Mann–Whitney U-test was including injection with local anaesthesia, in the AV-group
used for variables on an ordinal scale. The two-way repeated (p ¼ 0.04), where it was 0.71 before the restorative procedure
measures ANOVA with Holm–Sidak as post hoc test (ANOVA) and 0.25 at the end of the procedure. This significant reduc-
for analyses of changes between data at baseline and during tion was not found in the CTR-group (p > 0.05), where it was
the restorative procedure for each group (AV-group and CTR- 0.64 before and 0.75 at the end of the restorative procedure,
group). The significance level was set at p < 0.05. as shown in Figure 2. Although girls tended to show more
anxiety than boys in MVARS in the AV-group, there were no
significant differences in any aspect between sexes.
Results
However, as illustrated in Figure 3, there were no signifi-
There were no differences between the AV-group and CTR- cant differences in mean (SD) FIS scores between the AV-
group regarding background data such as age and sex, as group; 1.93 (1.15) and CTR-group (1.68 ± 0.86) (p ¼ 0.570).
shown in Table 1. Further, there were no drop-outs or missing Although the mean (SD) value of the AV-group tended to be
data from the participants. According to the FIS scale, none of lower after restoration (1.32 ± 0.67) (p ¼ 0.057). Further, there

Figure 2. The proportions of clinical anxiety and cooperative behaviour (MVARS) with either audiovisual distraction (AV-group; A) or no distraction (CTR-group; B).
*Significant decrease in clinical anxiety throughout the restorative procedure in visit 3.
498 A. AL-KHOTANI ET AL.

were no significant differences regarding situational anxiety patient/child-rated anxiety using the FIS scale. However, there
according to the FIS scores between the visits in any of the was a difference in the overall disruptive behaviour between
groups (p ¼ 0.34). the CTR-group and the AV-group where children in the AV-
group showed improved behaviour with a positive response.
This improved behaviour was significantly evident after injec-
Vital signs tion with local anaesthesia in the AV-group, and this was not
Table 2 presents the vital signs, including PRs, s-BP and d-BP.
Within the CTR-group, there was a significant elevation of the
Table 2. Vital signs (mean, SD) for each sub-group at different sections of the
PR during injection with local anaesthesia (p ¼ 0.04) during dental restoration process, from the 56 children undergoing restorative dental
the restorative procedure, but this elevation was not found treatment.
after the procedure. The PR did not increase in the AV-group CTR-group Mean (SD) AV-group Mean (SD)
(p ¼ 0.27) either during or after the restorative procedure. Prophylaxis visit
However, there were no significant differences in the overall Systolic blood pressure 111.7 (10.8) 113.6 (9)
Diastolic blood pressure 67.9 (9) 69.0 (7.0)
mean PRs between the CTR-group and the AV-group Pulse rate 94.3 (17.6) 95.5 (13.3)
(p ¼ 0.564). Restorative visit
Further, there were no significant changes in s-BP through- Examination
Systolic blood pressure 112 (10) 111.7 (10.7)
out the restorative procedure in any of the groups Diastolic blood pressure 67.8 (9) 65.2 (7.5)
(p ¼ 0.131). Although s-BP seemed to be higher during injec- Pulse rate 94.3 (14.4) 95.9 (10.3)
After LA
tions with local anaesthesia in both groups, there were nei- Systolic blood pressure 110.9 (9.6) 115 (6.3)
ther any differences in s-BP between the groups (p ¼ 0.854). Diastolic blood pressure 64.5 (5.8) 66.8 (6.3)
As for s-BP, there were no significant changes in d-BP Pulse rate 99.4 (14.5)a 98.6 (12.2)
After RD
throughout the restorative procedure in any of the groups Systolic blood pressure 112 (10.2) 114.6 (7.5)
(p ¼ 0.21), and there were no significant differences between Diastolic blood pressure 64.9 (6.7) 67 (6.8)
the groups (p ¼ 0.147). Pulse rate 95.2 (12.3) 98.5 (11.6)
During cavity preparation
Systolic blood pressure 111 (11.6) 114.9 (5.6)
Diastolic blood pressure 65.4 (6) 66 (7.1)
Discussion Pulse rate 97.1 (14.1) 98.2 (12.7)
After tooth restoration
The present study showed that AV distraction using the eye- Systolic blood pressure 111.6 (7.6) 110.6 (5.5)
glass system i-theatreTM seems to be effective in reducing Diastolic blood pressure 67.6 (5.6) 63.7 (5.1)
Pulse rate 93.4 (14.7) 95.3 (11.1)
observer-rated dental anxiety and keeping good cooperative
SD: standard deviation; LA: injection of local anaesthesia; RD: rubber dam appli-
behaviour in children during restorative dental treatment. On cation; AV-group, with audiovisual distraction; CTR-group, without distraction.
a
the other hand, this study could not show any effect on the Significant increase in pulse rate after injection of LA (p ¼ 0.04).

Figure 3. The proportions of self-reported measures of anxiety (FIS), ranging from ‘very happy’ (1) to ‘very unhappy’ (5), before and after each visit with either audio-
visual distraction (AV-group; A) or no distraction (CTR-group; B).
 ACTA ODONTOLOGICA SCANDINAVICA 499

the case in the CTR-group. Further, there was a marginal dif- Dental anxiety is a multi-dimensional concept that consists
ference in the observed mean cooperative behaviour and of behavioural, cognitive and physiological components. The
anxiety between those who used AV distraction and those strength of this study can be the use of a combination of
who did not. However, the AV-group showed more positive more than one measurement technique, which is crucial to
responses after injection with local anaesthesia. As observed successfully assess children who have limited cognitive/lin-
in this present study, Filcheck et al. (2004) reported that the guistic skills and little ability to remember.[31] For instance,
display of attention-grabbing videotaped material had an FIS was used as a self-report measure that, appropriately used
effect in distracting the children from the feared stimuli and with children, provides an immediate state of emotional feel-
that it was considered as one of the most attractive methods ing towards dental treatment. It has been reported as a valid
for modifying children’s behaviour during dental treat- indicator of a child’s pain experience.[23] MVARS precisely
ment.[26] Also, a study by Prabhakar et al. (2007) reported determine the children’s behaviour during the dental treat-
results coinciding with the present study. They found that the ment procedure. This system has been used in previous stud-
use of AV distraction during dental treatment was more ies and found to have good validity.[32] On the other hand,
effective in managing the children than using audio distrac- s-BP and d-BP, as well as PRs are commonly used as indirect
tion solely.[14] measures of dental anxiety in children.[33] The present study
In a study by Ram et al. (2010), the use of AV eyeglass sys- showed that s-BP and d-BP were increased during injections
tem was shown to be more efficient than a regular television with local anaesthesia in both in the CTR-group and the AV-
screen and that it also could be used instead of nitrous oxide group. However, this change was not significant between
gas.[27] When compared to similar behaviour management these groups. In agreement with previous studies that
techniques, such as music relaxation, storytelling, listening to reported a small increase in arterial BP, but not significant, in
the audio by headphones, playing video games and watching children undergoing dental treatment following administra-
television. The AV eyeglass system has been shown to minim- tion of local anaesthesia.[33] Furthermore, the PR within the
ize not only the children’s anxiety towards dental treatment, CTR-group in this study was significantly elevated during
but in turn also, enhance the children’s cooperative behav- injection with local anaesthesia when compared to the pre-
iour,[14,18] which is consistent with the results of this study. operative baseline value during the restorative treatment pro-
Previous studies have also reported that parents/guardians cedure. However, this was not observed in the AV-group. This
and the practicing paediatric dentists were relaxed and satis- result complements other studies that reported less increase
fied about the treatment situation.[27] in PR in a group of children undergoing dental treatment
Patel et al. (2006) showed that children who enjoyed play- with AV distraction methods.[14,26,28]
ing hand-held video games had less anxiety during anaesthe- Pre-school age groups have shown to have a higher level
sia induction compared with the children who had only their of fear and anxiety than school age children.[14] For that rea-
parental presence.[28] Also, another study showed that the son, school age children were chosen for the current study,
use of an iPad, where a kinaesthetic component is involved, since the use of distraction requires a low level of dental fear
is more effective than an AV eyeglass system in reducing not and anxiety.[14] Further, different age groups possess differ-
only fear and disruptive behaviour but also in decreasing the ent cognitive and behavioural actions towards AV distraction.
treatment duration.[29] The AV distraction used in the present Therefore, it has been suggested that distraction is more
study had no kinaesthetic components and did therefore not effective in an older age group.[34] Another reason for choos-
involve any participation of the patient except viewing the ing school age children is that younger age groups exhibit
cartoon movies. Nevertheless, the individual choice of distrac- more uncooperative and disruptive behaviour that’s hard to
tion can provide the sense of a familiar situation during den- control.[35]
tal treatment in order to increase the child’s control over the One limitation of the current study might be that the
unpleasant stimulus and in turn reduce the chance of unco- design of the eyeglass system (i-theatreTM). This design does
operative behaviour.[26,29] Thus, since the children in the not eliminate visual access to the surrounding environment.
present study had the opportunity of choosing their preferred Hence, the patients might not have been completely dis-
movie cartoon (one out of four movies), one can believe that tracted from the procedures performed in the oral cavity.
this can compensate for the lack of kinaesthetic components Although previous research has shown that distraction in chil-
in the used AV eyeglass system. dren as being a highly acceptable technique in helping divert
Further, it has been shown that children showed more dis- their attention, anxiety and helping them relax,[36] this study
tress and uncooperative behaviour when the dental proced- did not take these qualitative aspects regarding the child
ure went beyond 30 min.[29] However, to prevent these patients’ opinions into consideration, which is another limita-
behaviour changes of the children during dental procedures, tion of the study. Also, the sample size could be considered
the length of the visits in the present study were no longer as a limitation. A larger sample size and in a general clinical
than 30 min. For further control of unexpected influence on setting might have elucidated the differences in the use of
the study outcomes, the dental appointments were scheduled AV distraction as indicated by anxiety and behaviour meas-
in the afternoon. This arrangement was made not only to ures. This study excluded children with previous bad experi-
standardize the visit time for all children but also to eliminate ence which might have affected the results and could hence
the chance of misbehaviour due to missing the school time if be considered a limitation. However, this was chosen in order
the appointments were given in the morning since the school to achieve as a homogeneous group as possible to be able to
is crucial for this age group.[30] draw any conclusions.
500 A. AL-KHOTANI ET AL.

In conclusion, children using AV distraction with the eye- [9] Simpson HB, Neria Y, Lewis-Fernandez R, et al. Anxiety disorders:
glass-goggle display during restorative dental treatment do theory, research and clinical perspectives. New York (NY):
Cambridge University Press; 2010.
not only report less distress during the procedure than those [10] Pinkham JR. Behavior management of children in the dental office.
without, but they also show a more positive response after Dent Clin North Am. 2000;44:471–486.
injection with local anaesthesia. Hence, AV-distraction seems [11] Al-Namankany A, Petrie A, Ashley P. Video modelling and reducing
to be a useful tool to decrease the distress and anxiety dur- anxiety related to dental injections – a randomised clinical trial. Br
Dent J. 2014;216:675–679.
ing dental treatment.
[12] Slifer KJ, Tucker CL, Dahlquist LM. Helping children and caregivers
cope with repeated invasive procedures: how are we doing? J Clin
Acknowldgements Psychol Med Settings. 2002;9:131–152.
[13] Hubert W, de Jong-Meyer R. Psychophysiological response pat-
The authors acknowledge the support of College of Dentistry, King terns to positive and negative film stimuli. Biol Psychol.
Saud University, Riyadh, Saudi Arabia for providing clinical facilities for 1991;31:73–93.
the study. [14] Prabhakar AR, Marwah N, Raju OS. A comparison between audio
and audiovisual distraction techniques in managing anxious pedi-
Disclosure statement atric dental patients. J Indian Soc Pedod Prev Dent.
2007;25:177–182.
The authors declare no conflicts of interest. The authors alone are respon- [15] Wang ZX, Sun LH, Chen AP. The efficacy of non-pharmacological
sible for the content and writing of the paper. All authors have read and methods of pain management in school-age children receiving
approved the final version of the manuscript. venepuncture in a paediatric department: a randomized controlled
trial of audiovisual distraction and routine psychological interven-
tion. Swiss Med Wkly. 2008;138:579–584.
Notes on contributors [16] Sinha M, Christopher NC, Fenn R, et al. Evaluation of nonpharma-
Dr. Amal Al-Khotani, BDS, MSc, PhD, is a senior pediatric dentist special- cologic methods of pain and anxiety management for laceration
ist. Her research interest include child’s oral health and behavior manage- repair in the pediatric emergency department. Pediatrics.
ment subjects, orofacial pain and jaw function in children and 2006;117:1162–1168.
adolescents. Her research focus is centered on orofacial pain and jaw [17] El-Sharkawi HF, El-Housseiny AA, Aly AM. Effectiveness of new dis-
function, child’s behavior management and child’s psychology. traction technique on pain associated with injection of local anes-
thesia for children. Pediatr Dent. 2012;34:e35–e38.
[18] Hoge MA, Howard MR, Wallace DP, et al. Use of video eyewear to
Dr. Lanre A’aziz Bello, BDS, MS, POSTDOC, is an Associate Professor,
manage distress in children during restorative dental treatment.
pediatric dentist consultant. His research interest pharmacological man-
Pediatr Dent. 2012;34:378–382.
agement of patient behavior, cariology & prevention, pulp therapy, dental [19] Asl Aminabadi N, Erfanparast L, Sohrabi A, et al. The impact of vir-
anomalies, preventive & therapeutic uses of fluoride. tual reality distraction on pain and anxiety during dental treat-
ment in 4-6 year-old children: a randomized controlled clinical
Dr. Nikolaos Christidis, DDS, PhD, is an Assistant Professor, Senior Dental trial. J Dent Res Dent Clin Dent Prospects. 2012;6:117–124.
Officer (specialist in orofacial pain and jaw function), his research interest [20] Ingersoll BD, Nash DA, Blount RL, et al. Distraction and contingent
is myofascial pain, orofacial pain, TMD in children and adolescents. reinforcement with pediatric dental patients. ASDC J Dent Child.
1984;51:203–207.
[21] Sullivan C, Schneider PE, Musselman RJ, et al. The effect of virtual
ORCID reality during dental treatment on child anxiety and behavior.
ASDC J Dent Child. 2000;67:193.
Amal Al-Khotani http://orcid.org/0000-0001-7168-9835 [22] Kenny DA. Statistics for the social and behavioral sciences. Toledo
Nikolaos Christidis http://orcid.org/0000-0002-8199-7863 (OH): Little, Brown; 1987.
[23] Buchanan H, Niven N. Validation of a Facial Image Scale to assess
child dental anxiety. Int J Paediatr Dent. 2002;12:47–52.
[24] Venham L, Bengston D, Cipes M. Children’s response to sequential
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