Effectiveness of oral simulation games and ``tell-show-do'' behavioral management in alleviating dental fear in children: a randomized controlled study

Background: This study aimed to evaluate the efficacy of Oral Simulation Games and the “Tell-Show-Do” (TSD) behavioral management technique in reducing dental fear among children aged 4 to 6 years. Methods: Two hundred fifty-five children aged between 4 and 6 years, experiencing initial dental fear and scheduled for a single deep caries tooth treatment under local anesthesia, were randomly assigned to either the “Tell-Show-Do” group or the Oral Simulation Games group, and their physiological stress, fear intensity, pain and anxiety levels, and compliance were compared between the two groups. Physiological stress was assessed through heart rate, respiration, and blood oxygen saturation. Fear intensity was evaluated using the Child Fear Survey Schedule-Dental Subscale (CFSS-DS), while pain and anxiety levels were measured using the Wong-Baker FACES Pain Rating Scale and Venham’s Scale, respectively. Compliance was assessed using the Frankl Behavior Rating Scale. Between-group comparisons were conducted using the Wilcoxon signed-rank test. Results: Significant improvements were observed in pain reduction, fear alleviation, and enhanced compliance among children utilizing oral simulation games for behavior management. In addition, the oral simulation game group exhibited a lower Q value compared to the TSD (Tell-show-do) group (p < 0.01), with no significant differences observed in respiration and blood oxygen saturation. Conclusions: Both approaches were found to effectively alleviate children’s anxiety. Compared to the TSD method, oral simulation games were more effective in reducing dental fear in children undergoing treatment for deep caries under local anesthesia. Clinical Trial Registration: The trail was registered on Chinese Clinical Trial Registry, the identification number is ChiCTR2400089734.

Children dental fear; Pain; Oral simulation puzzle game; Tell-show-do

[1] Gizani S, Seremidi K, Katsouli K, Markouli A, Kloukos D. Basic behavioral management techniques in pediatric dentistry: a systematic review and meta-analysis. Journal of Dentistry. 2022; 126: 104303.

[2] Kakkar M, Wahi A, Thakkar R, Vohra I, Shukla AK. Prevalence of dental anxiety in 10–14 years old children and its implications. Journal of Dental Anesthesia and Pain Medicine. 2016; 16: 199–202.

[3] Cianetti S, Lombardo G, Lupatelli E, Pagano S, Abraha I, Montedori A, et al. Dental fear/anxiety among children and adolescents. A systematic review. European Journal of Paediatric Dentistry. 2017; 18: 121–130.

[4] Grisolia BM, dos Santos APP, Dhyppolito IM, Buchanan H, Hill K, Oliveira BH. Prevalence of dental anxiety in children and adolescents globally: a systematic review with meta‐analyses. International Journal of Paediatric Dentistry. 2021; 31: 168–183.

[5] Uziel N, Meyerson J, Winocur E, Nabriski O, Eli I. Management of the dentally anxious patient: the dentist’s perspective. Oral Health and Preventive Dentistry. 2019; 17: 35–41.

[6] Blomqvist M, Ek U, Fernell E, Holmberg K, Westerlund J, Dahllöf G. Cognitive ability and dental fear and anxiety. European Journal of Oral Sciences. 2013; 121: 117–120.

[7] Zhang Q, Deng X, Wang Y, Huang R, Yang R, Zou J. Postoperative complications in Chinese children following dental general anesthesia: a cross-sectional study. Medicine. 2020; 99: e23065.

[8] Shukla H, Kulkarni S, Wasnik MB, Rojekar N, Bhattad D, Kolekar P. Acceptance of parents for behavior management technique with reference to previous dental expertise and dental anxiety. International Journal of Clinical Pediatric Dentistry. 2021; 14: S193–S198.

[9] Kevadia MV, Sandhyarani B, Patil AT, Gunda SA. Comparative evaluation of effectiveness of tell-play-do, film modeling and use of smartphone dental application in the management of child behavior. International Journal of Clinical Pediatric Dentistry. 2020; 13: 682–687.

[10] Asokan S, Geetha Priya P, Natchiyar S, Elamathe M. Effectiveness of distraction techniques in the management of anxious children —a randomized controlled pilot trial. Journal of Indian Society of Pedodontics and Preventive Dentistry. 2020; 38: 407–412.

[11] Radhakrishna S, Srinivasan I, Setty JV, D R MK, Melwani A, Hegde KM. Comparison of three behavior modification techniques for management of anxious children aged 4–8 years. Journal of Dental Anesthesia and Pain Medicine. 2019; 19: 29–36.

[12] Lekhwani PS, Nigam AG, Marwah N, Jain S. Comparative evaluation of tell-show-do technique and its modifications in managing anxious pediatric dental patients among 4–8 years of age. Journal of the Indian Society of Pedodontics and Preventive Dentistry. 2023; 41: 141–148.

[13] Ying J, Tao H, He Q, Zhang Z, Hu W, Chen S, et al. Children’s dental fear: occurrence mechanism and prevention guidance. Journal of Multidisciplinary Healthcare. 2023; 16: 2013–2021.

[14] Home-Wong-Baker FACES®. Wong-Baker FACES foundation. 2019. Available at: http://www.WongBakerFACES.org (Accessed: 18 July 2024).

[15] Arapostathis KN, Coolidge T, Emmanouil D, Kotsanos N. Reliability and validity of the Greek version of the Children’s Fear Survey Schedule-Dental Subscale. International Journal of Paediatric Dentistry. 2008; 18: 374–379.

[16] Sahebalam R, Rafieinezhad R, Boskabad M. Comparison of the efficacy of Jilo animation approach versus conventional tell-show-do (TSD) technique on cooperation and anxiety levels of children during dental practice: a randomized controlled clinical trials. Journal of Dentistry. 2020; 21: 284–291.

[17] Belevcikli M, Altan H, Demir O. Effect of the new needle-free injection system on pain perception and dental anxiety during anesthesia: randomized controlled split-mouth study. Journal of Dental Anesthesia and Pain Medicine. 2023; 23: 1–8.

[18] Meshki R, Basir L, Alidadi F, Behbudi A, Rakhshan V. Effects of pretreatment exposure to dental practice using a smartphone dental simulation game on children’s pain and anxiety: a preliminary double-blind randomized clinical trial. Journal of Dentistry. 2018; 15: 250–258.

[19] Alkanan SAM, Alhaweri HS, Khalifa GA, Ata SMS. Dental pain perception and emotional changes: on the relationship between dental anxiety and olfaction. BMC Oral Health. 2023; 23: 175.

[20] Suleiman-Martos N, García-Lara RA, Membrive-Jiménez MJ, Pradas-Hernández L, Romero-Béjar JL, Dominguez-Vías G, et al. Effect of a game-based intervention on preoperative pain and anxiety in children: a systematic review and meta-analysis. Journal of Clinical Nursing. 2022; 31: 3350–3367.

[21] Meshki R, Basir L, Alidadi F, et al. Effects of Pretreatment Exposure to Dental Practice Using a Smartphone Dental Simulation Game on Children's Pain and Anxiety: A Preliminary Double-Blind Randomized Clinical Trial. Journal of Dental (Tehran). 2018;15:250-258.