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Dental Research Journal

Systematic Review
Psychological behavior management techniques to alleviate dental
fear and anxiety in 4–14‑year‑old children in pediatric dentistry:
A systematic review and meta‑analysis
Neha Kohli, Shivayogi M. Hugar, Sanjana P. Soneta, Nivedita Saxena, Krishna S. Kadam, Niraj Gokhale
Department of Pediatric and Preventive Dentistry, KAHER’S KLE VK Institute of Dental Sciences, Belgaum, Karnataka, India

ABSTRACT
Child’s uncooperative behavior can impede the efficient delivery of dental care. Therefore, in
spite of exceeding availability of behavior management techniques there is a need to search
for a psychological behavior management technique that effectively reduces fear and anxiety
during dental treatment and instill a change in child’s attitude toward the treatment and is also
acceptable by the parents. The aim of our systematic review is to determine the efficacy of
various psychological behavior management techniques in managing a child’s behavior in pediatric
dentistry by assessing the fear and anxiety levels, ease of use by the clinician, application in
various operative procedures, and parental acceptance. A systematic search was conducted by
two reviewers in databases PubMed, Google Scholar, Scopus, Web of Science, and Cochrane for
the studies published from January 1, 2011, to December 31, 2020. Studies included were clinical
studies which evaluated the efficacy of various psychological behavior management techniques
by evaluating the fear and anxiety levels and the changes in behavior during dental treatment in
Received: 20-Aug-2021 children aged between 4 and 14 years. The studies selected were then assessed for quality with
Revised: 05-Dec-2021 the help of predetermined criteria which categorized the studies into high, medium, and low.
Accepted: 19-Jan-2022 Through search strategy, 7147 articles were yielded. After screening through titles and abstracts,
Published: 01-Jun-2022 60 nonduplicated articles were selected which were further screened for full text. At the end,
Address for correspondence:
15 articles were included in systematic review and 3 articles for meta‑analysis. It was concluded
Dr. Shivayogi M. Hugar, that all the psychological behavior management techniques aided in reduction of fear and anxiety.
Department of Pediatric In noninvasive procedures, conventional psychological behavior management techniques can be
and Preventive Dentistry, effective but in invasive procedures other newer psychological behavior management techniques
KAHER'S KLE VK Institute of
Dental Sciences, Belgaum,
showed better results. The aspect of parental acceptance regarding various techniques was not
Karnataka, India. discussed in any of the included studies.
E‑mail: dr.hugarsm@gmail.
com Key Words: Cooperative behaviors, dental anxieties, dental fear, pedodontics

INTRODUCTION importance of behavior management over technical

excellence in pediatric dentistry.[1]
“Although operative dentistry may be perfect, the
This is an open access journal, and articles are distributed under the terms
appointment is a failure if a child departs in tears,” of the Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0
this statement by McElory beautifully emphasizes the License, which allows others to remix, tweak, and build upon the work
non‑commercially, as long as appropriate credit is given and the new
Access this article online creations are licensed under the identical terms.

For reprints contact: [email protected]

Website: www.drj.ir
www.drjjournal.net How to cite this article: Kohli N, Hugar SM, Soneta SP, Saxena N,
www.ncbi.nlm.nih.gov/pmc/journals/1480 Kadam KS, Gokhale N. Psychological behavior management techniques
to alleviate dental fear and anxiety in 4–14‑year‑old children in pediatric
dentistry: A systematic review and meta‑analysis. Dent Res J 2022;19:47.

© 2022 Dental Research Journal | Published by Wolters Kluwer ‑ Medknow 1

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Kohli, et al.: Psychological behavior management techniques used to manage children in pediatric dentistry

Dentistry has an environment which can stimulate 2. To evaluate various psychological behavior
the natural fear responses even in adults. This is management techniques in terms of its ease of use
even more extensive in children because of lack of by the clinician, different operative procedures,
maturity, intellectual capacity, and communication and acceptance by parents.
deficits. Various studies reported the prevalence of
dental fear and anxiety in children to be as high as METHODS
30%–40%.[1,2]
Protocol and registration
Children often try all means to avoid dental treatment
The systematic review followed preferred reporting
resulting in failed or missed appointments. They are
items for systematic reviews and meta‑analyses
difficult to treat leading to prolonged appointment
guidelines and was registered at PROSPERO
durations. Their uncooperative nature also creates
(CRD42020211883) and can be accessed at http://
occupational stress on dentist. All these results in
www.crd.york.ac.uk/prospero/index.php.
neglected dental care.
Eligibility criteria
Delay in seeking treatment leaves conservative
treatment options unviable. They may require more Inclusion criteria
complex treatment with the aid of pharmacological 1. Study setting should be clinical
interventions.[3] Psychological behavior management 2. Study design should be randomized control
techniques are meant to reduce need for excessive trial, quasi‑randomized, control clinical trial and
and potentially unsafe use of medications. Moreover, retrospective or a cohort study
behavior management technique should focus on 3. Study population should be between 4 and
decreasing fear and anxiety toward a dental procedure 14 years of age
and on increasing children’s coping abilities. The 4. Study evaluating the fear and anxiety levels and
use of pharmacological techniques does not fulfill the changes in behavior using standard parameters
these purposes. This highlights the need for using 5. Study published between January 1, 2011, and
psychological behavior management techniques over December 31, 2020
pharmacological ones. 6. Studies written in English language or any other
language than can be translated into English.
A literature search was carried out but no systematic
reviews were found which highlighted this aspect, Exclusion criteria
hence this study is planned to discuss in detail, the 1. Articles reported as letter to editor, case reports,
plethora of psychological behavior management and review
techniques and emphasizing the one which is the most 2. Studies conducted on special children or children
effective in reducing dental fear and anxiety. with medical condition that could potentially
influence their behavior.
Population exposure comparison outcome
format Search strategies and data extraction
• Population (P): Children between 4 and 14 years Literature search strategy was developed using
of age keywords related to psychological behavior
• Exposure (E): To assess fear and anxiety using management techniques in Pediatric Dentistry.
different psychological behavior management The search strategy used for searching articles
techniques was psychological behavior management/
• Comparison (C): Comparison of different nonpharmacological behavior management AND
psychological behavior management techniques dental fear and anxiety AND Pediatric dentistry. Data
• Outcome (O): To establish communication, were searched through PubMed, Google Scholar,
alleviate fear, diminish anxiety, deliver quality Scopus, Web of Science, and Cochrane from January
dental care, and promote child’s positive attitude 1, 2011, to December 31, 2020. Cross‑references were
toward dental health. checked, gray literature and hand searching of articles
were done when full texts of the relevant studies were
Objectives
unavailable through electronic database.
1. To evaluate various psychological behavior
management techniques by assessing the fear and Two review authors (NK, SMH) screened the titles,
anxiety levels and change in behavior abstracts, full text, and included them if they met

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Kohli, et al.: Psychological behavior management techniques used to manage children in pediatric dentistry

inclusion criteria. All the excluded studies were were at low risk of bias in the seven domains that we
recorded with their reason for exclusion [Figure 1]. assessed. The assessment of each article was done on
the basis of Random sequence generation, allocation
RESULTS concealment, blinding of participants and outcome
assessments, incompletion of outcome data, and
The total articles yielded after the search were 7149. selective reporting. A summary of the risk of bias for
After screening through duplicates, titles, abstracts, individual study as well as the judgments of the risk of
and full text 15 studies were included in the systematic bias for each domain is mentioned [Figures 2 and 3].
review which were then qualitatively analyzed. Data
Meta‑analysis
extraction was performed using a standardized outline.
For quantitative measures, 15 articles were reviewed
Study characteristics were tabulated for the selected
and three of them were selected for meta‑analysis.
studies [Table 1]. Summary of the effectiveness of
These three articles were statistically evaluated
psychological behavior management techniques is
using statistics and data software STATA (Statistical
compiled in Table 2.
Software: College Station, TX: StataCorp LLC).
Risk of bias Forest graph was plotted while comparing the
The studies were categorized into high‑, medium‑, Audio‑visual distraction as the experimental group
and low‑risk bias according to Cochrane handbook for and conventional tell show do like the control group.
systematic review using RevMan 5.3.[4] Most studies Heart rate was taken for assessing the change in

Figure 1: Flow diagram depicting the process of selection and exclusion of articles at each step.

Dental Research Journal / 2022 3

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Table 1: Qualitative analysis of the studies selected for the systematic review
Author Sample Age Study T/t given Behavior management Objective assessment Subjective assessment Assessment of Effectiveness of
and year of size (n) (years) design technique used of anxiety of anxiety behavior technique
publication
Shah et al. 50 4‑7 Randomized Restorative Group A: Tell Play Do Heart rate (bpm) Facial Image Scale Venham Picture Scale Tell play do was
2018 controlled treatment Group B: Audio‑visual Mean difference Mean difference Mean difference equally effective
trial distraction between (A) and (B) between (A) and (B) between (A) and (B) as audio‑visual
Before=‑0.179 Before=0.0513 Before=0.0897 distraction
After=0.1153 After=−0.1699 After=0.2852
P=0.133 P=0.39 P=0.525
Vishwakarma 98 5-7 Randomized Oral prophylaxis+ Group A: Live modeling Heart rate (bpm) Facial Image Scale Venham 6‑point index Tell play do was
et al. 2017 controlled restorative Group B: Tell play do a. Before=102.49±7.90 a. Before=16.22 a. Before=17.28 more effective
trial treatment After=95.20±7.60 After=20.00 After=20.00 than live modeling
b. b. Before=16.78 b. Before=15.72
Before=100.14±8.88) After=13.00 After=13.00
After=90.06±7.09) P=0.007** P=0.010*
P=0.001**
Kharouba 69 5-12 Randomized Restorative Group A: Tell show do Heart rate (bpm) Facial Image Scale FBRS Television
et al. 2020 controlled treatment Group B: Audio‑visual a. Before=104 a. Before=3.06 a. Before=2.5 distraction was
trial distraction (television) After=102 After=2.74 After=2.74 more effective
b. Before=97 b. Before=1.52 b. Before=2.9 than tell show do
After=95 After=1.32 After=3.8
P=0.008** P=0.036* P=0.001**
Sridhar et al. 66 7-11 Randomized Local anesthesia Group A: Control Heart rate (bpm) Facial Image Scale Wong Baker Faces Relaxation
2019 controlled Group B: Relaxation a. Before=96.00±10.27 a. Before=1.76±0.61 Pain Rating Scale Training reduced
trial training After=94.7±8.73 After=1.84±0.61 a. 2.45±0.56 the pain perceived
b. Before=93.30±8.52 b. Before=1.60±0.5 b. 1.51±0.67 but no significant
After=92.5±8.03 After=1.57±0.56 P=0.001** difference found in
P=0.319 P=0.073 FBRS (A) and (B) anxiety
Negative=18%
Positive=72.7%
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Definitely
positive=9.1%
P=0.001**
Radhakrishna 66 4-8 Randomized Restorative Group A: Tell play do Heart rate (bpm) Facial Image Scale FBRS Tell play do and
et al. 2019 controlled treatment Group B: smartphone a. Before=108.5 a. Before=2.40 a. Definitely Smartphone
trial dentist game After=91.75 After=1.00 positive=85% dentist game are
Group C: tell show do P=0.002** P=0.005** b. Definitely more effective
b. Before=108.35 b. Before=2.55 positive=85% than tell show do
After=92.65 After=1.10 c. Definitely
P=0.007** P=0.01* positive=55%
C. Before=109.60 c. Before=2.35 P=0.04*
After=100.10 After=1.15
P=0.5 P=0.5
Kohli, et al.: Psychological behavior management techniques used to manage children in pediatric dentistry

Dental Research Journal / 2022

Contd...
 Table 1: Contd...
Author Sample Age Study T/t given Behavior management Objective assessment Subjective assessment Assessment of Effectiveness of
and year of size (n) (years) design technique used of anxiety of anxiety behavior technique
publication
Ghadimi et al. 28 4-5 Randomized Pulpotomy Group A: Visual Heart rate (bpm) Venham picture test Frankl Behavior rating Visual Distraction
2018 clinical trial distraction in I and tell I visit I visit scale by playing cartons
show do in II visit a. 83.85±2.41 a. 1.86±1.29 I visit was more effect
Group B: Tell show b. 81.43±3.18 b. 1.71±1.33 a. 3.14±0.66
do in I and visual II visit II visit b. 3.07±0.62
distraction in II visit a. 81.14±2.32 a. 1.00±1.04 II visit
b. 81.29±2.79 b. 1.07±1.21 a. 3.43±0.51
P=0.001** P=0.001** b. 3.64±0.50

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P=0.24
Al‑Khotani 56 7-9 Randomized Restorative Group A : Control Heart rate (bpm) MVARS MVARS Audio‑visual
et al. 2016 Controlled Treatment Group B : Audio‑visual a. Before=94.3 a. Before=0.64 a. 0.75±0.52 distraction was
Trial distraction After=93.4 After=0.75 b. 0.14±0.36 more effective
B. Before=95.5 b. Before=0.71 P=0.03*
After=95.3 After=0.25
P=0.04* P=0.04*
Facial Image Scale
a. 1.68±0.86
B. 1.93±1.15
P=0.570
Mitrakaul et al. 42 5-8 Randomized Restorative Group A: Tell show Heart rate (bpm) Faces Pain FLACC Scale Audio‑visual
2015 Controlled treatment/ Do in I visit and I visit Scale‑ Revised I visit distraction was
Trial pulpectomy/ audio‑visual distraction a. Before=94.5±15.9 I visit a. Before=0.57±0.98 more effective
extraction in II visit After=96.96±1 a. 1.62±2.94 After=0.57±0.9 than tell show do
Group B: Audio‑visual b. Before=88.06±12.74 b. 1.9±2.93 b. Before=0.1±0.3
distraction in I visit and After=95.24±12 II visit After=0.95±1.63
tell show do in II Visit II visit a. 0.86±1.49 II visit
a. Before=88.14±10.07 b. 1.9±3.32 a. Before=0.1±0.3
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After=93.51±9.8 P=0.032* After=0.33±0.7

b. Before=89.86±12.11 b. Before=0.4±0.8
After=91.96±10 After=0.7±1.1
P=0.043* P=0.047*
Kaur et al. 60 4-6 Randomized II visit: restorative Group A: Control Heart rate (bpm) DSCFSS Scale Clinical Anxiety Rating Audio‑visual
2015 clinical trial treatment without Group B: Audio II visit II visit Scale and cooperative distraction was
LA distraction a. Before=122.70 a. Before=23.50 behavior rating scale more effective
III visit endodontic/ Group C: Audio‑visual After=128.90 After=22.00 II Visit
extraction distraction b. Before=115.10 b. Before=21.60 a. 2.50
procedure with LA After=110.00 After=19.30 b. 1.00
c. Before=115.90 c. Before=19.5 c. 0.20
After=101.50 After=15.8 III visit
P=0.001 a. 3.40
b. 1.80
c. 1.00
Kohli, et al.: Psychological behavior management techniques used to manage children in pediatric dentistry

P=0.018*

5
Contd...
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Table 1: Contd...
Author Sample Age Study T/t given Behavior management Objective assessment Subjective assessment Assessment of Effectiveness of
and year of size (n) (years) design technique used of anxiety of anxiety behavior technique
publication
III visit III visit
a. Before=113 a. Before=27.50
After=130.20 After=25.70
b. Before=109.4 b. Before=25.10
After=111.40 After=22.30
c. Before=103.3 c. Before=22.20
After=91.80 After=18.90
P=0.047* P=0.001**
Nuvvula et al. 90 7-10 Randomized Local anesthesia Group A: Control Heart Rate (bpm) MCDAS Frankl’s Behavior Audio‑visual
2015 clinical trial Group B: Audio a. Before=95.4±5.6 a. Before=20.6±2.4 rating scale distraction using
distraction After=119±13.1 After=20.9±7.2 a. Before rating 3D glasses was
Group C: Audio‑visual b. Before=89.3±3 b. Before=21.5±2.5 2=30% more effective
distraction After=104.6±2.9 After=14.1±4.4 Rating 3=70% after than Audio
c. Before=102.4±8 c. Before=22.2±4 rating 3=36.6% rating Distraction
After=109.4±5 After=8.3±2.5 4=10%
P=0.001** P=0.001** b. Before rating
2=40%
Rating 3=60% after
rating 3=53.3% rating
4=30%
c. Before rating
2=63%. rating
3=36.6% after rating
3=20% rating 4=73%
P=0.001**
Dixit et al. 120 4-6 Randomized Oral Group A: Bach flower Heart Rate (bpm) Facial Image Scale North Carolina Both Bach flower
2020 controlled prophylaxis+fluoride therapy a. Before=109.2±11.6 a. After very happy=70% Behavior Rating Scale therapy and music
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trial treatment Group B: Music therapy After=103.9±12 happy=17.5% a. 0.5±0.5 therapy were
Group C: Control b. Before=105.5±13.6 b. After very happy=47% b. 1.88±0.9 equally effective
After=102.9±13 happy=40% c. 5.98±2.4
c. Before=108±12.6 c. After very happy=60% P=0.014*
After=108.3±11 happy=25%
P=0.243 P=0.001**
Rajeswari 45 6-10 Randomized Not specified Group A: Cognitive Heart Rate (bpm) Facial Image Scale FIS Active distraction
et al. 2019 Clinical Trial Behavioral Play a. Before=93.33±4 a. Very happy=80% a. Very happy=80% using CBT was
Therapy After=73.00±4 happy=20% happy=20% more effective
Group B: Audio‑visual b. Before=94.8±5 b. Very happy=26% b. Very happy=26% than Passive form
Distraction After=80.93±5 happy=46.7% happy=46.7% using Audio‑visual
Group C: Tell Show Do c. Before=94.13±4.2 c. Very happy=0% c. Very happy=0% distraction
After=83.93±3.8 happy=53.3% happy=53.3%
P=0.001** P=0.001** P=0.001**
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Contd...
 Table 1: Contd...
Author Sample Age Study T/t given Behavior management Objective assessment Subjective assessment Assessment of Effectiveness of

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and year of size (n) (years) design technique used of anxiety of anxiety behavior technique
publication
Azher et al. 48 6-8 Pilot study Restorative Group A: Relaxation Heart rate (bpm)Venham’s Interval Venham Scale Tell show do is
2020 treatment training a. Rating Scale a. Relaxed=4.2% more effective
Group B: Tell show do Before=106.95±11.16
a. After=4.2% total b. Relaxed=25% than bubble
After=103.50±13.52
cooperation 87% mild P=0.004* breath play
b. Before=102.25±7.95
protest therapy
After=93.58±8.18b. After=16.7% total
P=0.014* cooperation 75% mild
protest
P=0.003*
Paryab 2014 46 4-6 Randomized Pulpotomy Group A: Tell Show Do Heart rate (bpm) Venham Scale Frankl’s Behavior Filmed Modeling
Clinical Trial Group B: Filmed a. Before=98.89±10.1 a. 0.96±0.72 rating scale is equally effective
Modeling After=111.17±11.93 b. 1.09±0.99 a. 3.02±0.57 as tell SHOW Do
b. Before=102.8±12.91 P=0.61 b. 3.03±0.62
After=113.90±14.70 P=0.95
P=0.6
Pani et al. 150 6-8 Controlled Restorative Group A: Presence of Heart rate (bpm) Venham anxiety rating Venham Behavior Presence of
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2016 Clinical Trial Treatment father a. Before=85.06±13 scale Rating Scale parents in
Group B: Presence of After=87.57±12 a. 2.64 a. 1.74 operatory reduces
mother b. Before=87.74±8.9 b. 2.26 b. 1.49 anxiety
Group C: Parent outside After=94.88±12 c. 1.34 C. 1.44
operatory c. Before=95.91±8.9 P=0.05* P=0.05*
After=100.1±10
P=0.001**
*Statistically significant, **Highly statistically significant. P value=Probability value, FIS: Facial image scale, MCDAS: Modified child dental anxiety scale, DSCFS: Dental subscale of children's fear survey schedule,
FLACC: Face, legs, activity, cry, consolabilty scale, MVARS: Modified venham's clinical rating of anxiety and cooperative behaviour scale, FBRS: Frankl behaviour rating scale
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Table 2: Table showing effectiveness of various psychological behavior management techniques in the
reduction of anxiety and change in behavior of children
Author Technique Outcomes Conclusion
Reduction in physiological Reduction in Change in
parameters of anxiety anxiety rating scales behavior
Shah et al. Audio‑visual distraction ↓↓ ↓↓ ++ Audio‑visual distraction and
Tell play do ↓↓ ↓↓ ++ tell play do equally effective
Vishwakarma et al. Tell play do ↓↓ ↓↓ ++ Tell play do more effective that
Live modeling ↓ − − audio‑visual distraction
Kharouba et al. Audio‑visual distraction ↓↓ ↓↓ ++ Audio‑visual distraction more
Tell show do ↓ ↓ + effective than tell show do
Sridhar et al. Relaxation therapy − ↓ + Relaxation therapy show no
Control − − + significant effect on dental
anxiety and behavior
Radhakrishna et al. Tell play do ↓↓ ↓↓ ++ Tell play do and smartphone
Smartphone game ↓↓ ↓↓ ++ game are more effective than
Tell show do ↓ ↓ − tell show do
Ghadimi et al. Audio‑visual distraction ↓↓ ↓↓ − Audio‑visual distraction is
Tell show do ↓ ↓ − more effective
Khotani et al. Audio‑visual distraction ↓↓ ↓↓ + Audio‑visual distraction more
Control − − − effective
Mitrakaul et al. Audio‑visual distraction ↓↓ ↓↓ + Audio‑visual distraction more
Control ↓ ↓ − effective
Kaur et al. Audio‑visual distraction ↓↓ ↓↓ ++ Audio‑visual distraction more
Audio distraction ↓ ↓ + effective
Nuvvula et al. Audio‑visual distraction ↓↓ ↓↓ ++ Audio‑visual distraction more
Audio distraction ↓ ↓ + effective
Dixit et al. Audio distraction ↓↓ ↓ + Bach flower therapy and audio
Bach flower therapy ↓↓ ↓ ++ distraction are equally effective
Control − ↓ −
Rajeswari et al. Active Distraction ↓↓↓ ↓↓↓ +++ Active distraction more
Audio‑visual distraction ↓↓ ↓↓ ++ effective
Tell Show Do ↓ ↓ +
Azher et al. Relaxation Therapy ↓ ↓ + Tell Show Do is more effective
Tell Show Do ↓↓ ↓↓ ++
Paryab et al. Filmed Modeling ↓↓ ↓↓ ++ Filmed modeling and tell show
Tell Show Do ↓↓ ↓↓ ++ do are equally effective
Pani et al. Presence of father ↓↓ ↓↓ ++ Presence of father is effective
Presence of mother ↓ ↓↓ + in reduction of anxiety
Parents absent − ↓ +
↓: Effective in anxiety reduction, ↓↓: More effective in anxiety reduction, +: Effective in changing the behavior positively, ++: More effective in changing the behavior
positively,−: No effect

anxiety due to its unswerving association with the CI is below “0.” These findings suggest that the
anxiety levels. difference between experimental group and the control
group is statistically significant. The overall results
Meta‑analysis was carried out using studies conducted
are also depicted by the diamond which sits on the
by Al‑Khotani et al. (Study 1), Mitrakul et al.
value of overall effect estimate and the width depicts
(Study 2), and Nuvvula et al. (Study 3) and all three
the overall CI. The diamond is merely crossing the
were given equal weightage as indicated by the size
line of no effect and is lying on the left side of the
of the boxes.[5‑7] Horizontal lines across the squares
line which suggests that the difference between both
depict the length of confidence intervals (CIs).
groups is statistically significant [Figure 4].
Smaller lines indicate that the study results were more
precise. The horizontal lines of each study lie in the The funnel plot was also plotted and it was observed
“favors experimental” territory. The values of 95% CI that most of the literature search was seen inside the
for each study are negative, indicating that the entire funnel indicating the proper standardization followed

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Kohli, et al.: Psychological behavior management techniques used to manage children in pediatric dentistry

Figure 4: Forest plot showing pooled data obtained from meta

analysis of tell show do and Audio‑visual distraction.

Figure 5: Funnel plot showing pooled data obtained from

meta‑analysis of tell show do and Audio‑visual distraction.

DISCUSSION

The criteria used for the evaluation of effectiveness

covers all aspects by which anxiety levels can be
determined. Heart rate, blood pressure, oxygen
Figure 2: Summary of Risk of bias: Review authors’ judgements saturation, and salivary cortisol levels were the
about each risk of bias item for each included study. physiological parameters and psychological
determination was done using anxiety rating scales.
The assessment of change in behavior was done using
various behavior rating scales.
Tell show do
Paryab and Arab evaluated the effect of Tell Show
Do and Filmed modeling in children between
4 and 6 years. Tell show do was as efficient as filmed
modeling in reduction of anxiety and making the
Figure 3: Summary of Risk of bias: Review authors’ judgements
patients cooperative during treatment.[8] The results
about each risk of bias item presented as percentages across
all included studies. were in accordance with a study conducted by
Virupaxi Both studies involved the usage of airotor
during study selection. However, it is difficult to draw whose sight, sound, and sensation is rated as one of
conclusions from a funnel plot when the number of the most fear‑eliciting stimuli in children. Despite this,
studies is small (<10). This also calls for the need a conventional behavior management technique like
of conducting more studies in the future with proper tell show do was effective in plummeting the anxiety
standardization [Figure 5]. levels.[9]

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Azher et al. compared tell show do with relaxation Distraction

therapy and 25% children in former group appeared Audio distraction
more relaxed when compared to 4.2% in the latter Studies conducted by Navit et al., Singh et al.,
group.[10] Al‑Halabi et al. evaluated the effect of and Tshiswaka and Pinheiro concluded that audio
virtual reality glasses and tell show do during LA distraction decreases anxiety to a significant extent.
administration. They had similar results in anxiety However, in these studies comparison was done with
reduction. It was difficult for practitioner to perform a control group in which no other technique was
the procedure as the use of VR box was blocking the used.[20‑22]
vision. Thus, tell show do is comparatively operator
Studies done by Khandelwal et al., Naithani and
friendly and cost‑effective.[11]
Viswanath, Nuvvula et al., and Kaur et al. also stated
However, in other studies where it is compared with that the efficacy of audio distraction is better when
more advanced techniques, it has been proven to be compared to the control group.[7,23‑25] Kaur et al. stated
less effective. that this might be due to the fact that music helps
cutting down unpleasant noise of handpieces or other
Tell play do
anxiety‑inducing stimuli.[25] Furthermore, playing
Shah and Bhatia compared audio‑visual distraction
familiar songs gave them feeling of being in a familiar
with tell play do and both techniques were found to
environment. However, when comparison was done
be equally effective. The author stated that the use
with audio‑visual distraction in these studies, it was
of dental imitating toys makes children understand seen that audio‑visual distraction was more effective.
the dentist’s frame of reference instilling a sense of
confidence.[12] Audio‑visual distraction
Various studies conducted on audio‑visual distraction
Radhakrishna et al. compared tell play do,
using virtual reality by Asl Aminabadi et al.,
smartphone dentist game, and tell show do in
Shetty et al., Niharika et al., Nunna et al., Rao et al.,
4–8‑year‑old children.[13] Tell play do and active
Koticha et al., Pande et al., and Khanapurkar et al.
distraction technique were equally effective.
prove the efficacy of this technique in reducing
Vishwakarma et al. compared it with live modeling
anxiety. Virtual Reality combines audio, visual, and
and concluded that tell play do was more effective in
kinesthetic sensory modalities which makes it the
reducing anxiety.[14] most immersive of all other distraction techniques,
Modeling and thus the child’s attention is greatly “drained”
A study by Tiwari et al. observed that children who from the surrounding fear‑provoking environment.
received live modeling with parents as model had It also reduces the amount of pain‑related brain
lower heart rates than those who received it with activity.[26‑33]
siblings as model.[15] Among parents, children whose In a study by Nuvvula et al., 83.3% children showed
behavior shaping was done taking mother as a model positive behavior in audio‑visual distraction group as
showed a greater reduction in anxiety. Similar findings compared to 60% in audio distraction group during
were obtained in studies conducted by Alrshah et al. LA administration. However, certain limitations
and Sharma and Tyagi [16,17] Walimbe et al. attributed were reported with the usage of eyeglasses such
this to the fact that modeling familiarizes children to as unavailability in small size, high cost, need for
procedures they will be subjected to, thus eliminating sterilization, and hindrance during communication.[7]
the threat of the unknown.[18]
Similar limitations were reported by Khandelwal
Modeling can be performed in two forms, live or et al. In addition, the author did not recommend
filmed. When compared, it was observed that anxiety it in children with disruptive behavior who insist
scores in filmed modeling group were least, reason on controlling the situation.[23] In another study by
being the consistency in the message. The author also Mitrakul et al., children also reported reduced pain
stated that in routine dental practice a cooperative while wearing audio‑visual glasses during treatment.
live model may not always be available.[18] Virupaxi, However, it was also seen that children who
Paryab and Arab, and Sahebalam et al. also advocated presented with high anxiety did not respond well as
the use of filmed modeling due to lesser consumption they felt a lack of control due to blockage of their
of dentist’s time.[8,9,19] visual field.[6]

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Kohli, et al.: Psychological behavior management techniques used to manage children in pediatric dentistry

In Adel Zakhary et al.’s study, virtual reality sickness Patil et al.[42‑44] However, Patil et al. reported that these
was observed in two children who suffered from applications are available mostly in English and hence
nausea, sweating, and blurred vision.[34] Shetty et al. a big chunk of population was unable to use them.[44]
also reported the incidence of headaches in few
Parental presence
children.[27]
Results of the study conducted by Shindova
Al‑Halabi et al. reported that audio‑visual et al. showed that parental presence or absence
distraction using a tablet device was more effective has no impact on the anxiety levels of children
than virtual reality eyeglasses.[11] Sahu et al. aged 6–12 years.[45] Cox et al., Vasiliki et al.,
compared virtual reality distraction with television and Ahuja et al. obtained similar results in their
distraction. Television was more effective in studies.[46‑48] Cox et al. also reported that 4–5 years
managing the anxiety as reported on self‑reporting old children showed more disruptive behavior when
anxiety rating scales.[35] The studies conducted by parent was present in the operatory.[46]
Al‑Khotani et al. and Kharouba et al. had similar
However, a study done by Pani et al. in 6–8‑year‑old
results.[5,36] Al‑Khotani et al. stated that television
children showed contrasting results. It was observed
requires low maintenance and many pediatric dental
that children accompanied by their father had the
offices are equipped with it. In contrast, virtual reality
lowest anxiety scores and greatest rate of completion
devices are costly, can break easily, and have to be
of treatment.[49]
disinfected between patients. Moreover, they limit the
ability of the child to hear the clinician’s instructions. Hypnosis
The use of television distraction, on the other hand, A study was done by Carrasco et al. to evaluate
enables quick disengagement of the child when the efficacy of hypnosis during the administering of
needed.[5] anesthesia. Results showed that hypnosis, combined
with conventional behavior management techniques,
Active distraction is a more effective tool to help children relax than
A study was done by Allani and Setty to determine conventional behavior management techniques
the effectiveness of distraction using video game and alone.[50]
it was found to be effective.[37] Varun et al. evaluated
its effectiveness in the form of stimulation games and Parental acceptance of behavior management
40% children showed positive behaviour during the techniques
treatment as compared to merely 3.3% in the control An integral aspect of child dental care is to provide
group.[38] parents with information of the treatment. This also
helps in reducing parental anxiety. Hence, one of the
Rajeswari et al. compared the effectiveness of objectives of our systematic review was the parental
cognitive behavioral play therapy and audio‑visual acceptance of these techniques. However, it was
distraction wherein 100% children showed positive surprising to see that none of the articles obtained
response for the former as compared to 73.4% in through our literature search discussed this aspect.
the latter.[39] Tirupathi et al. conducted a study on This calls for a need of inclusion of parents in treating
eye movement distraction in which children who their children.
exhibited negative behavior or were needle‑phobic
were included. They were less anxious than children Evaluation of psychological behavior management
in the control group. The author advocated the use techniques during different dental procedures
of this technique as it does not require any additional Oral prophylaxis + fluoride varnish
equipment and can be easily performed.[40] In a study by Dixit et al., a significant reduction
in anxiety was seen after intervention with audio
Dental apps
distraction.[51] Rajeswari et al. also reported a
In a study by Shah et al., behavior modification was
decrease in anxiety scores with active distraction and
done by allowing children to use dental apps which
audio‑visual distraction.[39]
demonstrated the use of common dental equipment in
form of animated pictures with sound. The reduction In studies conducted by Sharma et al. and Alrshah
in anxiety parameters was double as compared to et al. in 5–11‑year‑old children, it was seen that live
conventional techniques.[41] Similar results were modeling using mother as a model was effective.[16,17]
obtained by Coutinho et al., Elicherla et al., and Sahebalam et al. and Walimbe et al. reported the

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Kohli, et al.: Psychological behavior management techniques used to manage children in pediatric dentistry

effectiveness of filmed modeling in 4–9‑year‑old in 8–13‑year‑old children. However, more studies

children.[18,19] However, these studies did not use are needed to establish its effect on anxiety rates in
any behavior rating scales to evaluate the effect on children.[40]
cooperation of children.
Pulp therapy
The importance of subjecting children to a simple, Niharika et al. and Khanapurkar et al. reported the
painless procedure in the first visit has also been efficacy of virtual reality in 4–8‑year‑old children.
highlighted in these studies as this makes them These studies reported a significant decrease in pain
accustomed to the dental setting. In Sahebalam et al.’s perception and anxiety scores.[28,33] Shetty et al.
study, children exhibited less anxiety in their second and Zakhary et al. also observed that virtual reality
dental visit where they underwent restoration along distraction led to decrease in pain perception, salivary
with LA administration. Here, both the treatment cortisol levels and state anxiety in 5–8‑year‑old
modalities are fear‑provoking but despite this, children children.[27,34] However, Rangel et al. concluded that
were less anxious during the procedures.[19] there was no significant difference between the control
Restorative procedures group and the virtual reality group in 5–8‑year‑old
Shah et al. demarcated that the efficacy of tell play children.[52]
do in 4–7‑year‑old children. Reduction in anxiety was Limitations
seen using both self‑reported anxiety rating scales Athough several studies were conducted between
and operator‑rated anxiety rating scale.[12] Similar the span of 2011 and 2020, majority of studies did
results were obtained by Vishwakarma et al. and not assess all the factors which can evaluate dental
Radhakrishna et al.[13,14] fear and anxiety. Another major drawback was that
Another efficient technique highlighted in several very few studies were conducted on newer behavior
studies is audio‑visual distraction technique. In a study management techniques such as relaxation therapy
by Khandelwal et al., 5–8‑year‑old children showed and hypnosis. Thus, more meticulous research is
decrease in heart rate and blood pressure along with needed to be carried out in this direction.
lower self‑rated anxiety scores.[23] Kharouba et al.
also advocated the use of audio‑visual distraction CONCLUSION
technique.[36]
• Based on the critical evaluation of dental literature,
The efficacy of virtual reality has also been all the psychological behavior management
highlighted in studies conducted by Rao et al., techniques aided in reduction of fear and anxiety
Aminabadi et al. and Pande et al.[26,30,32] Aminabadi • It was observed that in noninvasive procedures
et al. also reported decrease in pain perception in which do not include the use of airotor or needles,
4–6‑year‑old children.[26] Pande et al. reported similar conventional behavior management techniques alone
results in 5–8‑year‑old children.[32] can be effective in reduction of dental fear and
anxiety. However, in terms of ease of use by the
Local anesthesia administration/extraction procedure
clinician, live modeling technique was less preferred.
Various authors have reported the efficiency
In restorative procedures and invasive procedures
of distraction techniques in managing children
like extraction or pulp therapy, more advanced
undergoing LA administration or extraction.
techniques like various forms of distraction have
Khandelwal et al., Allani and Setty, Naithani et al.,
proven to be efficient in reduction of dental fear and
and Sahu et al. reported the efficacy of audio‑visual
anxiety. Among them, clinicians found it difficult to
distraction in 4–12 year children.[23,24,35,37] Allani and
operate with virtual reality eyeglasses
Setty reported that the efficacy of active distraction
• Aspect of parental acceptance regarding various
in the form of video games was even better than
techniques was not discussed in any of the
audio‑visual distraction.[37]
included studies.
In a study by Nunna et al. and Koticha et al., virtual
reality distraction caused a decrease in anxiety in
Financial support and sponsorship
Nil.
7–11‑year‑old children.[29,31] However, both the studies
did not assess the change in behavior. Tirupathi et al. Conflicts of interest
reported the efficacy of eye movement distraction The authors of this manuscript declare that they have

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Kohli, et al.: Psychological behavior management techniques used to manage children in pediatric dentistry

no conflicts of interest, real or perceived, financial or between live modelling and tell show do. Sch J Dent Sci
nonfinancial in this article. 2016;3:160‑3.
16. Alrshah SA, Kalla IH, Abdellatif AM. Live modelling vs.
tell‑show‑do technique for behaviour management of children
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