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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 31  |  Issue : 2  |  Page : 147-151

Audiovisual modeling: An efficient, time-saving, radiation-specified method of reducing dental anxiety in children undergoing panoramic radiographic imaging and IOPA radiographic imaging


1 Department of Oral Medicine and Radiology, CSMSS Dental College and Hospital Aurangabad, Maharashtra, India
2 Department of Periodontology, MGV's KBH Dental College, Nashik, Maharashtra, India
3 Department of Orthodontics, CSMSS Dental College and Hospital Aurangabad, Maharashtra, India

Date of Submission01-Jul-2019
Date of Acceptance28-Feb-2019
Date of Web Publication24-Jun-2019

Correspondence Address:
Dr. Rupali V Mhaske
Department of Oral Medicine and Radiology, CSMSS Dental College and Hospital, Kanchanwadi, Aurangabad, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaomr.jiaomr_5_19

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   Abstract 


Background: Children undergoing panoramic radiographic imaging (PRI) and intraoral periapical (IOPA) radiographic imaging show anxiety due to the presence of a revolving PRI machine and IOPA X-ray unit and a different environment which can pose behavioral concerns. Staying still for 15–20 s is not possible for young children. This could lead to distortions and require repetitions, leading to more radiation exposure. Aim: The aim of the study was to reduce the dental anxiety and reduce the increased radiation exposure and saving time in PRI and IOPA radiographic imaging by audiovisual modeling. Methodology: Forty children age 2–12 years indicated for PRI and IOPA radiographic imaging were subjected and observed before and after audiovisual modeling. The patients were modeled by audiovisual modeling before imaging in the oral radiology department. The anxious and disruptive behavior was assessed using the anxious and disruptive behavior code by a single blinded observer. Statistical Analysis Used: Statistical Software SPSS 13.0. Results: There was significant difference in the occurrence of body movement and complaining and restraint before and after audiovisual modeling in the same patients. There were statistically significant differences in the overall events before and after audiovisual modeling. Conclusion: The basic behavior management technique and use of audiovisual modeling can reduce the anxiety and disruptive behavior in children undergoing PRI and IOPA radiographic imaging and also reduces increased radiation exposure, saving time for the process thus reducing the cost of repeated imaging.

Keywords: Audiovisual modeling, behavior management, IOPA radiograph imaging, PRI


How to cite this article:
Mhaske RV, Kale LM, Kadam VD, Kale AM, Ingle VM, Vispute SS. Audiovisual modeling: An efficient, time-saving, radiation-specified method of reducing dental anxiety in children undergoing panoramic radiographic imaging and IOPA radiographic imaging. J Indian Acad Oral Med Radiol 2019;31:147-51

How to cite this URL:
Mhaske RV, Kale LM, Kadam VD, Kale AM, Ingle VM, Vispute SS. Audiovisual modeling: An efficient, time-saving, radiation-specified method of reducing dental anxiety in children undergoing panoramic radiographic imaging and IOPA radiographic imaging. J Indian Acad Oral Med Radiol [serial online] 2019 [cited 2019 Sep 18];31:147-51. Available from: http://www.jiaomr.in/text.asp?2019/31/2/147/261093




   Introduction Top


Fear is an unpleasant emotional state consisting of psychological and psychophysiological changes in response to real external threat or danger. Anxiety is an emotion similar to fear but arising without any objective source of danger. The fear and anxiety in children during the dental visit affects not only the quality of the outcome of treatment but also the attitude of a child toward the dental profession.[1] It has been observed in the oral radiology department that patients between 2 and 12 years show anxiety undergoing intraoral periapical (IOPA) radiographic imaging or panoramic radiographic imaging (PRI) which leads to distortions of images and may require repetitions leading to multiple radiation exposure. Such patients when taken to the imaging room start crying or showing temper tantrums, nervousness, shouting, and creating havoc in the department, thus consuming more time of the dental assistants and radiographers. One psychometric scale that is widely used in pediatric dentistry research is the Children's Fear Survey Schedule – Dental Subscale (CFSS-DS), presented by Cuthbert and Melamed. The scale helps in identification of specific stimuli which provoke fear in children with regard to the dental situation.[2] If such patients are assessed using the above CFSS-DS thus evaluating their fear before imaging, the radiology team can be prepared for behavior management of the child thus saving a lot of time at the moment of imaging.

Behavior management and reducing anxiety is the key for success of treatment. Hence, apart from pharmacological management, such as conscious sedation, nonpharmacological interventions, such as audiovisual modeling, play an important role. Many parents feel that pharmacological methods of managing their child are undesirable due to perceived medical risks.[3] Thus, audiovisual modeling can be an effective behavioral management technique in radiology department to incorporate positive reinforcement right from the first visit because the patient undergoes the initial check up, diagnosis, and imaging procedures in the oral diagnosis and radiology department.

If audiovisual modeling and the fear evaluation is done initially in the oral medicine and radiology department, the patient will be mentally prepared for further dental treatment with a positive attitude, thus saving the time of other departments during the actual treatment. The use of audiovisual modeling in a child before referring them to the PRI or IOPA X-ray imaging or any dental treatment can reduce anxiety in children and elicit a favorable positive behavior, thus reducing multiple radiation exposure due to distortions, saving the radiographer's time and thus saving the extra cost of repeated X-rays.[4] With this background, this study was planned to evaluate anxious and disruptive behavior in children undergoing PRI and intraoral X-ray imaging and the effect of audiovisual modeling on such patients.

Aim

The aim of this study was to ascertain whether audiovisual modeling is an effective means of managing anxious pediatric dental patients.

Objective

The objective of this study was ascertain whether audiovisual modeling is an effective means in saving time, cost, and reducing multiple radiation exposure due to repeated imaging.

Settings and design

Informed consent was taken from parents of all participants prior to starting the study [Table 1].
Table 1: Parent's consent form

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Inclusion criteria

Children from 2 to 12 years of age were selected for the study if they presented for the first visit to the dental college with no medical history of any systemic disease indicated for IOPA radiographic imaging and PRI.

Exclusion criteria

Children were excluded if they had acute pain, abscess, and any dental emergency. Children with mental subnormality, physical disabilities, systemic illnesses, intraoral or extraoral swellings, and acute dental symptoms and those not accompanied by parents or whose parents were unable to understand and complete the CFSS-DS were excluded from the study.


   Methodology Top


This clinical study was conducted in the Department of Oral Medicine and Radiology. After obtaining ethical clearance, the study was conducted for a period of 5 months from June 2018 to November 2018. Forty children between 2 and 12 years of age from both the genders indicated for PRI and IOPA X-ray imaging were included in the study. Below are the indications and age criteria for the IOPA radiographic imaging and PRI.

Indications for IOPA imaging in study subjects 2-12 years of age of both genders for

  1. Dental caries,
  2. Reversible pulpitis,
  3. Irreversible pulpitis,
  4. Eruption of permanent tooth.


Indications for panoramic radiographic imaging in study subjects 7-12 years of age of both genders for

  1. Mixed dentition status (7-12 years)
  2. Skeletal development (7-12 years)
  3. Orthodontic treatment (above 10 years)
  4. Unerupted permanent teeth.


The PRI was done using VATECH PAX-isc model PCH-2500 and X-ray machine Trident 1070-D with proper radiation protection protocols as lead aprons. Children dental fear was assessed by the parents using the parental version of the 15-item CFSS-DS[2] [Table 2].
Table 2: Children's Fear Survey Schedule - Dental subscale (CFSS-DS)

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Questionnaire

The psychometric scale used to assess dental fear in this study was CFSS-DS, which is a modification of the CFSS by Cuthbert and Melamed to include specific dental fear items as one of its subscales. The scale consists of 15 items related to various aspects of dental treatment, such as drilling or injections. Each item can be scored on a 5-point Likert scale from 1 (not afraid at all) to 5 (very afraid). Total scores thus range from minimal 15 to maximal 75. Scores above 38 indicate significant dental fear.[2]

The patients were randomly subjected to before audiovisual modeling [Table 3] and after audiovisual modeling [Table 4]. The patients were taken to the imaging room to evaluate the anxiety and to assess their behavior and cooperation toward all the imaging procedures. Most of the patients were not anxious outside the imaging room, but as soon as they entered the imaging room and sat on the dental chair for intraoral X-ray imaging or PRI they started showing anxiety which was immediately measured by the anxious and disruptive behavior code (ADBC)[4] [Table 5] and were sent for audiovisual modeling to another room. The audiovisual modeling was done in the presence of their parents or guardians or relatives. An audiovisual clip was shown to them for 3–6 min of PRI or IOPA X-ray imaging whichever imaging the patient was indicated respectively. The audiovisual modeling clip contained the role model children undergoing PRI and intraoral X-ray imaging effectively with the instructions of how to undergo these imaging procedures. Then the patients were counseled to behave like the role models in the imaging rooms and they were assured to be appreciated after the imaging procedures, by giving them token of appreciation or reward. Then the patients were taken to the imaging room after audiovisual modeling for the imaging and their anxious and disruptive behavior was assessed again using ADBC by the observer. The total number of events observed, namely, body movements, crying, restraint, and radiographer interference were recorded. The data collected were statistically analyzed using SPSS Software 13.0.
Table 3: Before audiovisual modeling

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Table 4: After audiovisual modeling

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Table 5: ADBC criteria for coding

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   Results Top


A total of 40 patients between 2 and 12 years of age were subjected randomly to before and after audiovisual modeling. The total number of events such as body movement, crying, complaining, vocalization, and radiographer's interference in the patients before audiovisual modeling was 163 [Table 6], of which body movement and complaining and restraint by the dental assistant to control the patient occurred the most, and the total number of events in the same patients after audiovisual modeling was 53 [Table 6]. There was statistically significant difference in the overall events in the same patients before and after audiovisual modeling (P > 0.05) [Table 6], [Graph 1].
Table 6: Distribution of anxious and disruptive behaviors between before and after audiovisual modeling

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   Discussion Top


The fear of the unknown provokes anxiety in the radiographic room. In children with no past radiographic experience, fear may be due to uncertainty they feel about what awaits them after the initial appointment. Although previous studies have reported successful use of audiovisual modeling in reduction of anxiety and other behavior management problems, there are no reports about the influence of audiovisual modeling with respect to PRI and IOPA X-ray imaging. Hence, this study was designed to assess and compare the anxious and disruptive behavior exhibited by children undergoing PRI and IOPA X-ray imaging before and after audiovisual modeling. Audiovisual modeling is a nonpharmacological behavior management technique. It is a process of acquiring behavior through observation of a model. Observing a peer (live or filmed) successfully undergoing the procedure is effective in reducing children's fear and anxiety. In this approach, the ability of a child to imitate others is used and by imitating, the child learns complex behavior patterns. Several techniques for managing children have been developed to modify child's behavior. Nonpharmacological “Tell Show Do” (TSD) technique consists of verbal explanation of the procedure to the patient, demonstration of the visual auditory, and tactile aspects of the procedure which remain the most commonly used technique in pediatric dentistry. The use of modeling and TSD technique can easily be learned and adapted by radiographic technicians to enable cooperative behavior from children. In our study, the anxious and disruptive behavior was assessed using ADBC.[4] This is the objective method of assessing the children behavior.

This study found that the children after audiovisual modeling experienced less anxious disruptive behavior than before audiovisual modeling during imaging.

In this study, there was statistically significant difference before and after audiovisual modeling [Graph 1] and [Graph 2]. About 75% of body movement occurred before audiovisual modeling and only 25% body movement occurred after audiovisual modeling. Around 57.50% of crying occurred before audiovisual modeling and 17.50% of crying occurred after audiovisual modeling. About 80% of complaining occurred before audiovisual modeling and only 28% of complaining occurred after audiovisual modeling. Approximately 48% of vocalization occurred before audiovisual modeling and 25% of vocalization occurred after audiovisual modeling. About 82.50% restraint by dental assistant occurred before audiovisual modeling and significant decrease of 22.50% of restraint by dental assistant occurred after audiovisual modeling. A total of 65% radiographer interference occurred before audiovisual modeling and only 15% of radiographer interference occurred after audiovisual modeling.



This may be due to the fact that the exposure of these children to film modeling may familiarize the child to sights, sounds, and procedure that they will be subjected to. Hence, the threat of unknown was reduced or eliminated among these children who might have reduced the anxiety and negative responses toward the unfamiliar situations by fear extinction. Furthermore, familiarizing the radiographers with euphemisms for lead apron, the PRI machine, and X-ray unit also made a difference in our study. Since the radiographic examination is mostly performed in the first dental appointment, it is important that a positive dental attitude is attained, which increases the probability of a child to exhibit further positive behavior in successive appointments too. Behavior management is an important and effective aid in PRI and IOPA X-ray imaging for the radiographers.


   Conclusion Top


Hence, to conclude, the basic behavior management techniques and use of audiovisual modeling can reduce the anxiety and disruptive behavior in children undergoing PRI and IOPA X-ray imaging, thus saving time and cost and reducing the multiple radiation exposure due to repeated imaging.

Acknowledgement

The authors would like to thank Mr. Arvind Sardar for all the cooperation and support needed for this article.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Tiwari N, Tiwari S, Thakur R, Agrawal N, Shashikiran ND, Singla S. Evaluation of treatment related fear using a newly developed fear scale for children: “Fear assessment picture scale” and its association with physiological response. Contemp Clin Dent 2015;6:327-31.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Mungara J, Injeti M, Joseph E, Elangovan A, Sakthivel R, Selvaraju G. Child's dental fear: Cause related factors and the influence of audiovisual modeling. J Indian Soc Pedodont Prevent Dent 2013;31:215-20.  Back to cited text no. 2
    
3.
Gupta N, Gupta H, Gupta P, Gupta N. Evaluation of the role of music as a nonpharmacological technique in management of child patients. J Contemp Dent Pract 2017;18:194-7.  Back to cited text no. 3
    
4.
Sakthivel R, Poornima V, Jayanthi M, Reddy VN, Selvaraju G, Sakthivel MR. Evaluation of anxiety and the effect of modeling in children undergoing orthopantomographic examination. J Indian Acad Oral Med Radiol 2013;25:274-7.  Back to cited text no. 4
  [Full text]  



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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