International Journal of Contemporary Pediatrics

Krishnadasan A et al. Int J Contemp Pediatr. 2024 Jun;11(6):722-727

http://www.ijpediatrics.com pISSN 2349-3283 | eISSN 2349-3291

DOI: https://dx.doi.org/10.18203/2349-3291.ijcp20241354
Original Research Article

Storytelling using self-designed image-based storybook as

tools for reducing dental anxiety in 5 to12-years-old children:
a narrative therapy
Amritha Krishnadasan1*, Jyothsna V. Setty2, Ashwani Mohan3,
Aparna Jai Krishna1, Ila Srinivasan1

1
Department of Pedodontics and Preventive Dentistry, Mathrushri Ramabai Ambedkar Dental College and Hospital,
Bangalore, Karnataka, India
2
Department of Pedodontics and Preventive Dentistry, Sri Siddhartha Dental College, Tumakuru, Karnataka, India
3
Department of Pedodontics, Karuna, Kakkad, Kannur, Kerala, India

Received: 01 April 2024

Revised: 04 May 2024
Accepted: 09 May 2024

*Correspondence:
Dr. Amritha Krishnadasan,
E-mail: [email protected]

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: Children commonly experience dental anxiety, marked by a general feeling of fear when they have not
encountered the situation before. By incorporating positive dental information through storytelling or engaging dental
activity books, children can be effectively reassured and mentally prepared for their initial dental appointments.
Storytelling and storybooks in healthcare serves multiple functions such as educating patients and their families,
promoting specific qualities, and enhancing behaviors.
Methods: A randomized clinical study involving 240 children aged 5 to 12 years was conducted. The children were
randomly assigned to three groups of 80 each: group 1 (received storytelling with image-based storybook), group 2
(received only storytelling), and the control group (received neither). Pulse rate and anxiety assessment using
animated emoji scale measurements were taken at the start of the appointment, after the intervention before treatment,
and after dental treatment.
Results: The interventional groups 1 and 2 showed a significant difference compared to the control group for pulse
rate and animated emoji scale. Group 1 exhibited the highest reduction in anxiety as measured using the animated
emoji scale and pulse rate.
Conclusions: In conclusion, providing children with a dental storybook before dental treatment can decrease dental
anxiety and improve their behavior during the dental treatment.

Keywords: Dental anxiety, Child behavior, Story book, Story telling

INTRODUCTION dental care. The fear of unfamiliar aspects of dental

procedures, combined with the sensory elements of the
Dental anxiety is a prevalent issue that influences people dental environment, contributes to heightened anxiety for
across diverse age brackets. It is marked by an intense many individuals. Impact of dental anxiety' extends
fear or anxiety related to dental visits and procedures that beyond emotional stress, potentially resulting in
goes beyond typical nervousness.1 This heightened level postponed or overlooked dental care, ultimately
of distress can result in increased stress or avoidance of jeopardizing oral health.2 Delaying routine dental check-

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ups and essential treatments may worsen dental issues, reference, fostering a more straightforward correlation
establishing a pattern of avoidance, and further between them. The American academy of pediatric
compromising oral health. Furthermore, an individual's dentistry recommends placing greater emphasis on
dental anxiety is significantly influenced by cultural nonpharmacological interventions and behaviour
attitudes toward dentistry and personal experiences. It is modification techniques. Limited research exists on
crucial to address dental anxiety to support overall well- preoperative behaviour modification utilizing storytelling
being and prevent complications associated with oral and storybooks in the available literature. There is a
health. Comprehending the source of this anxiety, scarcity of studies that have evaluated the effectiveness of
employing empathetic communication among dental a dental storybook in reducing dental anxiety. Hence this
professionals, and incorporating relaxation techniques study aims to compare verbal storytelling and a self-
can contribute to establishing a dental environment that is designed image-based storybook as tools for reducing
more comfortable and supportive.1 Through dental anxiety in 5-12-years-old children.
acknowledgment and proactive management of dental
anxiety, individuals can actively break the cycle of fear, METHODS
advocate for enhanced oral health, and cultivate a more
positive dental experience. The initial dental encounter Study design
plays a crucial role in shaping a child's perception of
dentistry and influencing the outcome of their dental This is a randomised control trial conducted in the
treatment. department of paediatric and preventive dentistry
Mathrusri Ramabai Ambedkar dental college and
The first dental visit experience is pivotal in shaping a hospital, by a single operator. Written informed consent
child's perspective on dentistry and impacting the was obtained from patient’s parents, with assent from
outcome of their dental treatment.3 Altering an patient. Study was under for a period of 6 months i.e.,
individual's pre-existing notions about dental care or June 2023 to November 2023. Total sample of 240
specific treatment procedures is essential to achieve a children aged between 5-12 years, visiting the department
more favourable outcome. Patients across different age for first dental visit requiring oral prophylaxis or
groups display differing degrees of cognitive and/or restorations were randomly selected.
perceptual functioning, along with varying skills in verbal
and nonverbal communication, as well as social
interaction. Therefore, various non-pharmacological A B
techniques are employed based on individual needs.
These may include methods like "tell-show-do,"
relaxation, distraction, systemic desensitization,
modelling, and more. Patients possessing extensive
knowledge about their oral condition or treatment
procedures tend to experience superior outcomes
compared to those lacking such understanding. C D
Consequently, the provision of comprehensive
information to patients typically enhances compliance. In
the field of health education, various media are at our
disposal, including demonstration models, leaflets, video
films, and computers. Patients from rural areas in
developing countries may lack awareness of dental
procedures. Therefore, it is recommended to offer them a
book that explains dental procedures, facilitating better
understanding on their part. Various communication-
assisted approaches, including applied behavioural Figure 1: A) Story book and pulse oximeter, B)
analyses, visual pedagogies, pictorial or iconic images, animated emoji scale, C) group A-story book and D)
and audio-visual aids, have been suggested to facilitate measurement of animated emoji scale.
behavioural changes among individuals. Recent studies
have explored various behavioural interventions, Inclusion criteria
including social stories, visual pedagogy, and comic
strips.2 These tools are frequently employed to encourage Patients who fulfil below criteria were included in study.
a desired behaviour or prepare a child for a new Children between the ages of 5 and 12, who are in good
experience. Like other behaviour management general health, possess the ability to understand and
techniques, they prove effective, cost-efficient, and easy communicate effectively, and have parental or guardian
to implement. It is of utmost importance to craft stories consent, are sought for participation in this study.
from the child's perspective and present them in a print Candidates must not be currently involved in similar
size tailored to the child. This approach aims to enhance research on dental anxiety, and they should not have
the child's understanding of the dentist's frame of severe mental health disorders that could significantly

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 Krishnadasan A et al. Int J Contemp Pediatr. 2024 Jun;11(6):722-727

affect study outcomes. Additionally, they should reside in Statistical analysis

stable living environments, free from recent traumatic
experiences likely to impact anxiety levels. Statistical Package for Social Sciences (SPSS) for
Windows Version 22.0 Released 2013. Armonk, NY:
Exclusion criteria IBM Corp., will be used to perform statistical analyses.
Chi Square Test was used to compare the gender
Patients were excluded from the study if they had distribution between 4 groups. One-way ANOVA Test
significant medical conditions posing risks to safe followed by Tukey's post hoc Test was used to compare
participation, severe anxiety or mental health disorders the mean heart rate between 3 groups at different time
unrelated to needle anxiety, cognitive impairments intervals. Repeated measures of ANOVA Test followed
affecting comprehension and communication, did not fall by Bonferroni's post hoc Test was used to compare the
within the specified age range, lacked parental consent, mean heart rate between different time intervals in each
experienced recent trauma, or failed to adhere to study group. Kruskal Wallis Test followed by Dunn's post hoc
protocols. test was used to compare the mean Animated Emoji Scale
scores between 3 groups at different time intervals.
In this study where anxiety was assessed using heart rate Friedman's Test was used to compare the mean Animated
and anxiety scores using animated emoji scale in children Emoji Scale scores between different time intervals in
aged 5-12 years for first dental visit requiring oral each group. The level of significance was set at p<0.05.
prophylaxis or restorations. Patients were divided into 3
groups of 80 each: group 1 (received story telling using RESULTS
image-based storybook), group 2 (received storytelling)
and the control group (did not receive either). Evaluation No significant difference existed in mean heart rate
of all parameters was carried out at three levels, i.e., pre- among the three groups pre-operatively. Post-
operative, post-intervention (In control group after they intervention, significant differences emerged (p=0.009),
were seated comfortably for 10 minutes) and after with the control group displaying higher mean heart rate
treatment completion. The animated emoji scale (AES) compared to the storybook and storytelling groups
utilizes five animated emoji faces representing various (p=0.02 and p=0.03 respectively). Post-operatively,
emotions, spanning from extreme happiness and laughter similar findings were observed (p=0.005), with the
to deep sadness and crying, illustrating a spectrum from control group having significantly higher mean heart rate
the most positive to the most negative feelings. The child than the storybook and storytelling groups (p=0.006 and
was requested to select the animated emoji displayed on p=0.03 respectively). However, there was no significant
the electronic screen that most accurately reflected their difference between the storybook and storytelling groups
current emotions. The scale ranged from a score of 1, post-operatively (Table 1).
corresponding to the happiest emoji, to a score of 5,
indicating the saddest emoji, as depicted in (Figure 1).4-6

Table 1: Comparison of mean heart rate (BPM) between 3 groups at different time intervals using one-way
ANOVA test followed by Tukey's post hoc test.

Time Groups N Mean SD P valuea P valueb

Group 1-storybook 80 96.05 9.19 -
Pre-operative Group 2-storytelling 80 96.55 10.09 0.94 -
Group 3-control 80 95.35 12.31 -
Group 1-storybook 80 90.40 7.65 0.94
Post intervention Group 2-storytelling 80 91.00 8.22 0.009* 0.02*
Group 3-control 80 98.05 9.21 0.03*
Group 1-storybook 80 88.85 8.31 0.82
Post-operative Group 2-storytelling 80 90.55 8.05 0.005* 0.006*
Group 3-control 80 97.80 10.11 0.03*
*Statistically significant, aOne-way ANOVA test and bTukey’s post hoc test

No significant differences were noted in mean animated respectively). However, there was no disparity between
emoji scale (AES) scores among the three groups pre- storybook and storytelling groups pre-operatively.
operatively. Similarly, post-operatively, significant differences were
observed (p=0.005), with the control group scoring
Post-intervention, a significant difference emerged higher than the storybook and storytelling groups
(p=0.009), with the control group scoring higher than the (p<0.001). Yet again, there was no difference between
storybook and storytelling groups (p<0.001 and p=0.002 the storybook and storytelling groups (Table 2).

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Table 2: Comparison of mean animated emoji scale between 3 groups at different time intervals using Kruskal
Wallis test followed by Dunn's post hoc test.

Time Groups N Mean SD P valuea P valueb

Group 1-storybook 80 2.45 1.00 -
Pre-operative Group 2-storytelling 80 2.75 0.79 0.47 -
Group 3-control 80 2.85 0.99 -
Group 1-storybook 80 1.45 0.76 0.22
Post intervention Group 2-storytelling 80 1.85 0.59 <0.001* <0.001*
Group 3-control 80 2.70 0.87 0.002*
Group 1-storybook 80 1.35 0.59 0.48
Post-operative Group 2-storytelling 80 1.60 0.68 <0.001* <0.001*
Group 3-control 80 2.80 0.77 <0.001*
*Statistically significant, aKruskal Wallis test and bDunn’s post hoc test

Table 3: Comparison of mean heart rate (BPM) between different time intervals in each group using repeated
measures of ANOVA test followed by Bonferroni's post hoc test.

Groups Time N Mean SD P valuea P valueb

T0 80 96.05 9.19 0.07
Group 1-storybook T1 80 90.40 7.65 0.01* 0.03*
T2 80 88.85 8.31 <0.001*
T0 80 96.55 10.09 0.04*
Group 2-storytelling T1 80 91.00 8.22 0.04* 0.04*
T2 80 90.55 8.05 0.81
T0 80 95.35 12.31 -
Group 3-control T1 80 98.05 9.21 0.19 -
T2 80 97.80 10.11 -
*Statistically significant, aRepeated measures ANOVA test and bBonferroni’s post hoc test, T0-pre-operative period; T1-post-
intervention period & T2-post-operative period.

Significant differences were found in mean heart rate DISCUSSION

within Storybook Group between time intervals (p=0.01).
Specifically, T2 displayed significantly lower mean heart Anxiety is an emotional state often described as the fear
rate compared to T0 and T1 (p=0.03 and p<0.001 of the unknown. It is commonly expressed as an
respectively), while no significant difference was noted unpleasant feeling preceding the actual interaction with
between T0 and T1. threatening stimuli. As per Agras et al anxiety linked to
dental appointments and procedures ranks as the fifth
In Storytelling Group, a significant difference was most prevalent cause of anxiety, particularly among
observed between time intervals (p=0.04), with T2 children.7-10 Children who have not had prior dental
showing significantly lower mean heart rate compared to experiences frequently convey anxiety, driven by the
T0 and T1 (p=0.04), yet no difference was found between uncertainty of what lies ahead. It is crucial to alleviate a
T0 and T1. Control group exhibited no significant child's anxiety about dental treatment, not only to address
difference in mean heart rate between time intervals immediate fears but also to prevent lingering
(Table 3). apprehension that may persist into adulthood. Filewich
reported that patients with extreme fear required roughly
Significant differences were observed in mean animated 20% more chair side time than those with less fear. This
emoji scale scores within the Storybook group between highlights the importance for dentists to acquire and
time intervals (p<0.001). Specifically, T0 displayed utilize diverse management techniques to alleviate
significantly higher scores compared to T1 and T2 patients' fear and anxiety.11 Behaviour management must
(p<0.001 and p=0.002 respectively), while no significant be adaptable and tailored to each child. Comprehensive
difference was found between T1 and T2. Similarly, understanding of the cognitive, emotional, and social
within the Storytelling group, significant differences were development of the child is essential for most behaviour
found between time intervals (p<0.001), with T0 showing management techniques. It is crucial that any approach to
higher scores compared to T1 and T2 (p=0.002 and behavioural management be implemented with empathy
p=0.001 respectively), but no difference between T1 and and a genuine concern for the child's well-being.
T2. However, no significant difference was observed Paediatric dentists commonly employ non-
within the Control group between time intervals (Table pharmacological behaviour management techniques,
4). including tell-show-do, distraction, modelling,

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 Krishnadasan A et al. Int J Contemp Pediatr. 2024 Jun;11(6):722-727

desensitization, and verbal communication, to address self-designed dental storybook and storytelling as a
children's anxiety during pre-treatment visits. Among behaviour management technique to alleviate dental
various approaches available, this research aimed to anxiety in 5-12-year-old children.
explore a psychological approach employing a

Table 4: Comparison of mean animated emoji scale scores between different time intervals in each group using
Friedman’s test followed by Wilcoxon signed rank post hoc test.

Groups Time N Mean SD P valuea P valueb

T0 80 2.45 1.00 <0.001*
Group 1-storybook T1 80 1.45 0.76 <0.001* 0.002*
T2 80 1.35 0.59 0.56
T0 80 2.75 0.79 0.002*
Group 2-storytelling T1 80 1.85 0.59 <0.001* 0.001*
T2 80 1.60 0.68 0.16
T0 80 2.85 0.99 -
Group 3-control T1 80 2.70 0.87 0.58 -
T2 80 2.80 0.77 -
*Statistically significant, aFriedman’s test and bWilcoxon signed rank post hoc test.

The story was designed to explain various oral conditions emojis on social networking applications, AES becomes
and their associated treatment modalities, assisting particularly appealing to young children as it includes
children in becoming more comfortable with the dental animated emoticons.6 The findings of this study suggest
procedure and provide introductory information before that utilizing a dental storybook has a favourable
dental procedure. The storybook provided an image- influence on children, serving as an efficient strategy for
based approach to understand this information prior to behaviour management to alleviate dental anxiety.
dental treatment.
Limitations
Deshpande et al concluded that a self-designed dental
storybook used as an adjuvant was found to be promising The sample size was limited and could be expanded to
behaviour modification technique for 5-7-year-old encompass a larger population. Additionally, storytelling
children as compared to behaviour modification without using self-designed storybook, originally printed only in
storybook. However, in the study we conducted we English, has the potential to be translated into multiple
compared image-based storybook with verbal storytelling languages to enhance comprehension.
and found that verbal story telling also aids in reducing
anxiety.1 In our current study, a notable distinction in the CONCLUSION
pulse rate of children was elicited between the
storytelling intervention group and the control group. The self-designed storybook can function as a simple yet
This finding aligns with the research conducted by effective tool when employed before dental procedures. It
Aminabadi et al where they concluded that storytelling contributes to enhancing patient awareness and
can effectively contribute to children’s cognitive motivation to initiate dental care, ultimately ensuring a
development and progress, resulting in a significant future free from cavities in children.
decrease in situational anxiety and the perception of pain
during dental procedures.3 In the present clinical study, Funding: No funding sources
the evaluation of dental anxiety comprised an Conflict of interest: None declared
examination of physiological and behavioural measuring Ethical approval: The study was approved by the
scales/parameters. Sympathetic stimulation, reflecting Institutional Ethics Committee
anxiety or fear in children, manifests as an elevated pulse
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https://ieeexplore.ieee.org/ document/8942384.
Accessed on 20 November 2023.

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