Effect of visual distraction on children's anxiety during dental treatment: a crossover randomized clinical trial

Cartoon-assisted visual/auditory distraction usage in paediatric dental care, assessment of effects on patient anxiety, pain, and behaviour: a randomised crossover clinical trial

OBJECTIVES

This randomized crossover clinical trial designed to evaluate the impact of visual and auditory distraction techniques on pediatric patients' anxiety, pain perception, and behavior during dental treatment. The study specifically focuses on children, aiming to determine whether distraction methods can effectively reduce anxiety levels, alleviate pain experiences, and improve cooperative behavior in a clinical setting.

METHOD AND MATERIALS

Children aged 4 to 9 years receiving routine dental care at the Pediatric Dentistry Clinic, Istanbul Medipol University, were randomly assigned to Group 1 (distraction first, then tell-show-do) or Group 2 (tell-show-do first, then distraction), with a two-week washout period before switching interventions. Anxiety was assessed using the Venham Picture Test and pulse rate, pain perception with the Sounds, Eyes, and Motor Scale during local anesthesia and the Wong-Baker FACES Pain Rating Scale during treatment, while cooperation and behavior were evaluated using the Houpt Scale. Statistical analysis was conducted using Mann-Whitney U, Student's t-test, Paired t-test, and Wilcoxon test, with the significance level set at 0.025 using the Bonferroni correction.

RESULTS

Sixty-eight patients (37 female, 31 male) with a mean age of 6.69 ± 1.08 years completed the study (Group 1: n = 32, Group 2: n = 36). The cartoon-assisted distraction technique did not significantly reduce anxiety compared to the tell-show-do method. A non-significant reduction in pain perception was observed during local anesthesia with distraction. However, this technique significantly reduced self-reported pain during treatment (p < 0.025) and improved child cooperation and behavior.

CONCLUSION

Cartoon-assisted visual and auditory distraction can alleviate pain perception and improve behavior during pediatric dental procedures. However, it does not appear to reduce dental anxiety or pain perception during local anesthesia. Integrating this technique with the traditional tell-show-do approach may enhance the pediatric dental experience.

TRIAL REGISTRATION

The trial was registered at ClinicalTrials.gov, number NCT04927754, 06/01/2021.

The evaluation of different information methods on behaviour and anxiety levels of children aged 6 to 9 years: a randomised controlled trial

PURPOSE

To evaluate the alteration of pre-post informing anxiety levels and behavioural scores of the children in the groups between those who were shown the multimedia-application and verbally explained.

METHODS

In this randomized controlled study, healthy children, who applied to a paediatric-dental-clinic who never had a dental visit or dental procedure rather than oral examination were included. In the waiting room evaluation of children with a behaviour-control-list and Frankl's-Behaviour-Rating-Scale were performed, Venham-Picture-Test (VPT) was shown to the children. Then, the random information method (with a multimedia-application or verbally) was used for giving information. Finally, the child was observed whilst sitting in the dental chair and meeting with dentist, the behaviour-control-list was filled out again, and child's behaviour were re-scored.

RESULTS

A total of 56 children [mean (± sd) age of 7.3 (± 1.1)] participated. There was no statistically significant difference between the median values of the change in Frankl and VPT-scores after the information (p = 0.261 and p = 0.651, respectively). The percentage change of pre-post informing in definitively negative children according to Frankl's score was higher in the multimedia application group (25%). Besides, the percentage change in children scored with score 5-6 according to VPT was also higher in multimedia-application group (25%-28.6%, respectively, for scores 5-6).

CONCLUSION

Although the score changes after the information procedure were more pronounced in the multimedia-application group for both VPT and Frankl-scores, the difference was not statistically significant. Multimedia applications seem to offer a promising modern tool for patient education before dental examination in 6- to 9-year-old children.

Impact of Virtual Reality Intervention on Anxiety and Level of Cooperation in Children and Adolescents with Autism Spectrum Disorder during the Dental Examination

Background: Individuals with Autism Spectrum Disorder (ASD) frequently encounter increased levels of anxiety and display resistant behaviors during dental examinations, which negatively affects their oral care and maintenance. This study employed a cross-sectional design to evaluate the impact of virtual reality (VR) intervention on the anxiety and level of cooperation in children and adolescents with ASD during dental examinations. Methods: A total of 140 participants diagnosed with ASD, aged from 4- to 18-years-old, were selected from two specialized ASD management centers in Riyadh/Saudi Arabia. The participants were randomly allocated into either the control group or the VR group. Control group participants were subjected to a conventional dental examination, while the VR group utilized VR intervention to immerse themselves in a simulated natural and soothing environment. The Venham anxiety and behavior scale (VABS) was utilized to measure anxiety levels, while the Frankl behavior rating scale (FBRS) was employed to assess the level of cooperation. Data were analyzed using a Mann-Whitney U test with a significance level of p < 0.05. Results: The baseline anxiety and level of cooperation between the groups were comparable (p > 0.05). During the dental examination, the VR group had significantly reduced anxiety scores (2.48 ± 1.76) compared to the control group (1.50 ± 1.74) (p < 0.001). Regarding the level of cooperation, the VR group exhibited significantly greater levels of cooperation (3.41 ± 0.96) than the control group (2.86 ± 1.03) (p = 0.002). Conclusions: These findings suggest that VR intervention is a successful technique for decreasing anxiety and enhancing cooperation among children with ASD during dental examination. Integrating VR technology in dental environments can potentially improve the dental experience and results for children diagnosed with ASD.

Hypnosis and nitrous oxide impact on the school aged patients' anxiety and cooperation candidate for tooth extraction: A randomized clinical trial

Background

This randomized clinical trial (RCT) investigated whether hypnosis would lead to favorable outcomes in reducing anxiety, enhancing cooperation, and improving physiological responses in school-aged children undergoing tooth extraction compared to nitrous oxide/oxygen (N2O/O2) and conventional behavior guidance (CBG).

Methods

Sixty-six school-aged children (mean age: 7.87 ± 1.18 years) who needed one posterior primary tooth extraction were included. Children with low-to-moderate anxiety were randomly divided into three groups (n = 22 each): hypnosis, N2O/O2, and CBG. Anxiety levels during and after anesthetic injection and tooth extraction were assessed using the Venham Clinical Anxiety Scale (VCAS) and the Venham Picture Test (VPT). Changes in heart rate (HR) and oxygen saturation (SpO2) were monitored. Children's cooperation levels were measured using the Venham Clinical Cooperation Scale (VCCS).

Results

The VPT scores were significantly higher in the CBG group than in the N2O/O2 and hypnosis groups (p < 0.001). The VCAS scores in the N2O/O2 group were lower than those in the CBG group (p < 0.05) and were comparable to those in the hypnosis group. The VCCS scores were significantly higher in the CBG group than in the N2O/O2 and hypnosis groups (p < 0.05). HR changes in the N2O/O2 group were significantly lower than in the hypnosis and CBG groups (p < 0.05). No significant difference in pain was observed between the groups the day after the intervention.

Conclusion

N2O/O2 inhalation and hypnosis are effective in reducing self-reported and observed anxiety and improving cooperation levels in pediatric patients during dental extraction. Moreover, the frequency of reported pain was lower in the hypnosis group compared to the other groups.

Effectiveness of Nonpharmacological Behavioural Interventions in Managing Dental Fear and Anxiety among Children: A Systematic Review and Meta-Analysis

BACKGROUND

Non-pharmacological behavioural interventions (NPBIs) have been employed by dentists to alleviate dental fear and anxiety (DFA) among preschool and school children. The aim of this systematic review and meta-analysis was to investigate the effectiveness of different NPBIs in reducing DFA among children aged below 12.

METHOD

A comprehensive search was conducted using four electronic databases to identify randomised controlled trials that assess the effectiveness of NPBIs among preschool and school children. Two reviewers independently screened and selected the relevant studies, evaluated the risk of bias, and extracted relevant data for qualitative and quantitative syntheses.

RESULT

A total of 66 articles were included in the study. Except during more invasive dental procedures, the use of distraction techniques was found to result in significantly lower self-rated anxiety, better cooperation, and lower pulse rate compared to the tell-show-do method. However, inconsistent results were reported regarding the efficacy of virtual reality, modelling, visual pedagogies, tell-show-do and other NPBIs in reducing DFA among children.

CONCLUSIONS

The studies exhibited substantial heterogeneity due to varying age groups, methods of implementing NPBIs, dental treatments performed, and measurement scales employed in the evaluation of DFA.

Effectiveness of sensory adaptive dental environments to reduce psychophysiology responses of dental anxiety and support positive behaviours in children and young adults with intellectual and developmental disabilities: a systematic review and meta-analyses

BACKGROUND

People with Intellectual and developmental disabilities (IDDs) experience oral health inequality due to myriad of risk factors and complex needs. Sensory processing difficulties, maladaptive behaviours and dental anxiety contribute to difficulties in receiving preventive and routine dental treatments. This study aimed to systematically review the evidence on the effectiveness of sensory adaptive dental environments (SADE) for children and young adults (up to the ages 24 years) with IDD to address cooperation and dental anxiety.

METHODS

This review was reported according to The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. MEDLINE (Ovid), The Cochrane Library, Embase, Google Scholar, Web of Science and OT Seeker were searched using appropriate terms to identify Randomised Control Trails (RCTs) that matched inclusion criteria. Screening was conducted by two reviewers after de-duplication based on titles and abstracts followed by full text retrieval. Quality of the included studies was assessed using Cochrane Risk of Bias (ROB)-2 for crossover trials and data extracted by two reviewers. The details of the interventions and effectiveness were compared and discussed narratively, and comparable outcomes were included to meta-analyses using R software.

RESULTS

A total of 622 articles were identified and five articles met eligibility for inclusion. Three studies used multi-sensory adaptations and one used single sensory adaptation of music. Narrative synthesis showed some evidence of SADE reducing magnitude and duration, although, questionable for reducing the number of maladaptive behaviours. Two studies demonstrated conflicting evidence of the effect of SADE on cooperation. Three studies demonstrated significant positive impact of SADE on psychophysiological outcomes. Despite an overall tendency to favour SADE, no statistically significant difference of maladaptive behaviours was found between SADE and regular dental environment (RDE) (Standardised mean change (SMC) = 0.51; 95% Confidence Interval (CI) -0.20 to 1.22; p = 0.161). SADE was superior to RDE (SMC -0.66; 95% CI -1.01 to -0.30; p =  < 0.001) in reducing psychophysiological responses of dental anxiety.

CONCLUSION

Current evidence suggests that adapting visual, tactile, and auditory aspects of the dental environment in a single or multi-sensory approach demonstrates small positive effects on psychophysiological responses and maladaptive behaviours of dental anxiety for people with IDD.

TRIAL REGISTRATION

The title of this review was registered with PROSPERO (CRD42022322083).

The Efficacy of Little Lovely Dentist and Tell Show Do in Alleviating Dental Anxiety in Iraqi Children: A Randomized Clinical Trial

Aim

Behavior management approaches in treating children are generally viewed as techniques to enhance communication with patients to promote positive attitudes. Patients, particularly children, consider visiting a dental clinic to be a difficult and painful experience, so a dentist who treats children should have a variety of behavior management techniques. This study aimed to evaluate and compare the efficacy of Tell Show Do (TSD) and a mobile app in reducing dental anxiety among children patients.

Materials and Methods

A clinical trial study with 66 children aged 6-8 years was divided into three groups by the randomization method, which was performed in two steps: the first step used a random group generator template for excel to distribute the 66 children into three groups (each group 22), and the second step by excel function (RAND) to make the sequence for children. The sample was divided into three groups; each group has 22 children: Group I (TSD), Group II mobile app (Little Lovely Dentist), and Group III control. ClI fillings of the primary molars were provided to all participants. Anxiety levels were measured using physiological methods (heart rate and oxygen saturation by pulse oximeter) and psychological methods (Venham picture test) before treatment, during the education stage, and after treatment. The statistical tests were the paired t test for intragroup comparison and one-way analysis of variance (ANOVA) for intercomparison.

Results

One-way ANOVA showed a significantly lower pulse rate in the mobile app group after treatment, significantly higher SPO2 saturation in the mobile app group than in the TSD and control groups, and significantly lower Venham scores in the mobile app group than in the control group.

Conclusion

The use of the Little Lovely Dentist mobile app decreased dental anxiety levels in children's first dental visit more than both the TSD technique and control groups when compared.

Children's Dental Fear: Occurrence Mechanism and Prevention Guidance

Children's dental fear (CDF) has become one of the main reasons affecting the quality of dental treatment. In order to reduce the incidence of CDF in China before and after children's dental visits, this review applies literature analysis and empirical summary methods to analyze and summarize academic discussions on this topic, including occurrence mechanism, prevention guidance, and the conclusion that the occurrence and prevention of CDF is closely related with children's internal characteristics and external influences. In the end, we propose a breakthrough of combining the CFSS-DS scale and three-grade prevention theory together in the future to provide new ideas and hypotheses for the prevention of CDF.

Assessment of Different Distraction Behavioral Methods in Pediatric Dental Clinic: A Systematic Review

Dental anxiety is one of the main problems dentists may face during the treatment of pediatric dental patients; therefore, clinicians tend to perform different behavior management techniques to reduce dental anxiety in children. This review aimed to systematically compare and evaluate the published literature regarding the effects of distraction techniques on anxiety, pain perception, and patient experience during dental practice. A detailed electronic search was conducted on 3 databases including PubMed, Google Scholar, and Cochrane Library. The databases were searched for articles published in the English language between 2015 and 2022. Among 102 studies, 27 studies fulfilled the criteria of eligibility and were included in this study to be analyzed. Numerous approaches have been proposed for the reduction of dental anxiety, out of which the use of audio-visual aids and instruments, active distraction such as tablets, smartphones, and virtual reality glasses showed governance in decreasing the children's anxiety followed by cognitive and behavioral methods.

Which audio distraction technique is more effective for reduction the pain and anxiety of pediatric dental patients; "music" or "kids-story"? A randomized split-mouth crossover clinical trial

OBJECTIVE

Control of pain, fear, and anxiety of children during dental procedures is a major challenge in pediatrics. This study aimed to compare the effect of audio distraction by music and audio-story on pain and anxiety of children during dental treatment.

METHODS

This randomized crossover clinical trial evaluated 60 systemically healthy children between 4 and 8 years, who were candidates for pulpotomy and steel crown of bilateral primary maxillary first or second molars. The patients were randomly divided into two groups of music-story (M first), and story-music (S first) according to the sequence of receipt of the distraction techniques with a split-mouth design. The level of pain and anxiety of patients was measured using physiological scales such as pulse rate (PR), sound-eye-motor (SEM) and faces pain rating (FPR). The pkcross package in Stata software version 14 was used to assess the treatment effect, period effect, sequence effect and carryover effect.

RESULTS

In each group, 28 cases were included in the analysis. The difference in PR was not significant at the onset and termination of each treatment session between two distraction techniques and also, the mean FPR (P = 0.55) and SEM (P > 0.99) scores were not significantly different between the two groups.

CONCLUSIONS

The "audio-story" and "music" distraction techniques were not significantly different for pediatrics relieving during LA administration. Thus, considering the equal efficacy of the two techniques, dental clinicians can use any of the two to distract children.

REGISTRATION INFORMATION

The study registered in the Iranian Registry of Clinical Trials (IRCT20190702044077N1).

Effect of the Case for Carpule as a Visual Passive Distraction Tool on Dental Fear and Anxiety: A Pilot Study

The present cross-over study aimed to evaluate the effect of a visual passive distraction tool, a case for carpule, in the management of fear and anxiety during invasive dental treatment. Children between the ages of 4 and 8 years that need at least two treatments with inferior alveolar nerve block were selected. All the included children received two treatments at different moments: in one treatment, local anesthesia was performed with a visual passive distraction tool, the crocodile case, for carpule (experimental); in the other treatment, local anesthesia was performed without the device (control). An evaluation of the anxiety levels was performed by measuring the heart rate and salivary cortisol levels. Wilcoxon's nonparametric test was used for a data analysis (p < 0.05). The mean heart rate with the visual passive distraction device fell from 81.8 to 78.1, while the control rose from 91.4 to 100 (p < 0.05). The mean salivary cortisol levels with the visual passive distraction device fell from 2.0 to 1.6, while in the control, they rose from 2.1 to 2.4 (p < 0.05). In conclusion, the crocodile case for carpule as a visual passive distraction device contributed positively to the management of fear and anxiety during inferior alveolar nerve block in children.

Basic behavioral management techniques in paediatric dentistry: A systematic review and meta-analysis

OBJECTIVE

To systematically retrieve and assess studies regarding the effectiveness of basic behavioral management techniques (BMTs) in paediatric patients.

DATA SOURCES

Electronic and hand searches were conducted to locate Randomized Controlled Trials (RCTs) reporting on objective and subjective evaluation of anxiety and behavior of children up to 12 years of age. Data extraction and risk of bias evaluation, using the Cochrane risk of bias tool (RoB 2.0 Tool), were performed independently and in duplicate for all included studies. Mean differences and standard deviations were used to summarize the data from each study and meta-analyses were conducted with studies of limited heterogeneity.

STUDY SELECTION

A total of 708 papers were identified and screened, 122 retrieved for full text appraisal and 62 finally included. Results suggested that all basic BMTs have acceptable effectiveness on paediatric patients' anxiety, fear and behavior during dental treatment. Meta-analysis showed a statistically significant difference in favor of distraction for subjective anxiety using facial scale (Mean diff.: 2.78; 95% CI: -3.08, -0.53; p=0.005) and Modified Child Dental Anxiety Scale (Mean diff.: 12.76; 95% CI: -6.09, -4.47; p=0.001) and a non-significant difference for heart rate (Mean diff.: 1.70; 95% CI: -6.54, 0.46; p=0.09). Music significantly reduced heart rate when compared to a control comparator, underlining the superiority of the BMT (Mean diff.: 2.71; 95% CI: -3.70, -0.59; p=0.007).

CONCLUSIONS

Limited evidence about efficacy of one technique over another raises important issues on the topic for future research regarding the management of the child patient in the dental setting of the 21^st century.

CLINICAL SIGNIFICANCE

Behavioral management comprises a challenge for clinicians, who need to be familiar with a range of techniques to meet patients' needs at individual level and be flexible in their implementation. Appropriate technique should incorporate patients' personality and parents' active involvement, within the contents of the changes in modern societies.

Dental anxiety and the effectiveness of local anesthesia

Aim: The successful anesthesia is an essential factor for dental treatment. This study aimed at determining the effectiveness of local anesthesia and it’s relationship with dental Anxiety. Methods: This cross-sectional study was carried out on 256 dental patients, in 2017. Dental Anesthesia was administered after completing the Modified Dental Anxiety Scale by the patients. The level of anesthesia was recorded in one of three states (successful, difficult, and failed). Collected data was analyzed using SPSS version 22 and tests of, Chi-square, independent t-test, analysis of variance, and logistic regression model.  Results: About 60.5% subjects had moderate-severe dental anxiety. The mean of dental anxiety significantly was lower in the successful anesthesia group (P<0.01). Patients with elementary education had a significantly higher level of dental anxiety (P<0.01). Dental anxiety was significantly higher in the age group of ≥59 years, compared to the other age groups, except for 49-58 years (P<0.05). Subjects with a significantly higher level of dental anxiety more delayed their visits to the dentist. The logistic regression model showed that the dental anxiety (high anxiety) and literacy level (elementary) were the most important predictors of failed or difficult anesthesia. Conclusion: Informing patients about dental treatment procedures, regular and periodic visits to the dentist, using psychotherapeutic techniques to reduce dental anxiety before anesthesia, could play an important role in the success of anesthesia.

Robotic approach to the reduction of dental anxiety in children

OBJECTIVE

We introduced a humanoid robot for the use of techno-psychological distraction techniques in children aged 4-10 to reduce their anxiety and improve their behaviour during dental treatment.

MATERIALS AND METHODS

Two hundred children (98 boys, 102 girls; mean age: 6.5 ± 1.66 years) appointed for first time for dental caries were included and randomly divided into two groups [N = 100 for each group; RG: Robot Group (accompanied by the robot), CG: Control Group (without robot accompaniment)]. Half of the children were treated under local anaesthesia (infiltration anaesthesia) (n = 50 within each group) and half of the children were treated without any local anaesthesia (n = 50 within each group) within each group. The success rate of the new robotic distraction technique was evaluated by using Parental Corah Dental Anxiety Scale, Facial Image Scale (FIS), physiological pulse rate and Frankl Behaviour Rating Scale (FBRS).

RESULT

Pulse rates, which measured during treatment and after treatment, were statistically higher in CG than in RG (p < .05). After dental treatment, the FIS score was significantly higher in CG than RG (p < .05). 88.3% of the children in RG stated that they wanted the robot to be with them at the next treatment session.

CONCLUSIONS

Robotic technology can successfully help in coping with dental anxiety and stress, and helps children to behave better in dental office.

Stimuli involved in dental anxiety: What are patients afraid of?: A descriptive study

BACKGROUND

Dental anxiety is a psychological response inducing aversion following a dental ill-defined stimulus, non-imminent and perceived as potentially dangerous. It is better to intervene during childhood than to resolve in adulthood when dental anxiety is more settled.

AIM

The purpose of this study is to determine the nature of dental anxiety-provoking stimuli in young patients.

DESIGN

A questionnaire was submitted to 566 children between 3 to 18 years in health institutions and schools in Brussels, Belgium. The items were divided into 3 groups: environment (ENV), local anaesthesia (LA), and intervention (INT) and summarized through averaging per group. Descriptive analysis and non-parametric testing were combined with logistic regression after discretization, above mild, for the group averages.

RESULTS

About 7.2% of the respondents expressed high to severe dental anxiety. Several items presented a clear bimodal distribution dividing the population in fearless and fearing patients, for example, sight and feel of the syringe, sight and taste of blood and extraction. Others presented with a gradually lower incidence with increasing fear level. Fear for the environment was generally low. Gender and ethnic origin contribute significantly to the prediction of fear caused by LA. For fear caused by INT, first the place of questioning enters the models, thereafter follow: negative experience, frequency of dental visit, and gender (P < .05).

CONCLUSIONS

While the dental environment is in general not causing fear, the invasive part of the anaesthesia and the invasive dental procedures are involved. Fear seems to be related to culture, previous experience, and gender.

Digital Technology Distraction for Acute Pain in Children: A Meta-analysis

CONTEXT

Digital distraction is being integrated into pediatric pain care, but its efficacy is currently unknown.

OBJECTIVE

To determine the effect of digital technology distraction on pain and distress in children experiencing acutely painful conditions or procedures.

DATA SOURCES

Medline, Embase, Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, Institute of Electrical and Electronics Engineers Xplore, Ei Compendex, Web of Science, and gray literature sources.

STUDY SELECTION

Quantitative studies of digital technology distraction for acutely painful conditions or procedures in children.

DATA EXTRACTION

Performed by 1 reviewer with verification. Outcomes were child pain and distress.

RESULTS

There were 106 studies (n = 7820) that reported on digital technology distractors (eg, virtual reality and video games) used during common procedures (eg, venipuncture, dental, and burn treatments). No studies reported on painful conditions. For painful procedures, digital distraction resulted in a modest but clinically important reduction in self-reported pain (standardized mean difference [SMD] -0.48; 95% confidence interval [CI] -0.66 to -0.29; 46 randomized controlled trials [RCTs]; n = 3200), observer-reported pain (SMD -0.68; 95% CI -0.91 to -0.45; 17 RCTs; n = 1199), behavioral pain (SMD -0.57; 95% CI -0.94 to -0.19; 19 RCTs; n = 1173), self-reported distress (SMD -0.49; 95% CI -0.70 to -0.27; 19 RCTs; n = 1818), observer-reported distress (SMD -0.47; 95% CI -0.77 to -0.17; 10 RCTs; n = 826), and behavioral distress (SMD -0.35; 95% CI -0.59 to -0.12; 17 RCTs; n = 1264) compared with usual care.

LIMITATIONS

Few studies directly compared different distractors or provided subgroup data to inform applicability.

CONCLUSIONS

Digital distraction provides modest pain and distress reduction for children undergoing painful procedures; its superiority over nondigital distractors is not established. Context, preferences, and availability should inform the choice of distractor.

Use of distraction techniques for the management of anxiety and fear in paediatric dental practice: A systematic review of randomized controlled trials

OBJECTIVE

To determine whether distraction techniques (DT) reduce children's/adolescent's anxiety and fear during dental treatment.

METHODS

Randomized controlled trials (RCTs) in which any type of DT were used to manage dental anxiety and dental fear in children/adolescents were included. A systematic search of PubMed, Web of Science, Scopus, Cochrane Library, Lilacs, and Google Scholar was conducted. Two independent reviewers selected studies, extracted data, assessed methodological quality of studies using the Cochrane Collaboration's Risk of Bias tool (CCRBT), and approached certainty of evidence using GRADE (Grading of Recommendations, Assessment, Development and Evaluation). Data were analysed descriptively.

RESULTS

Twenty studies covering several types of DT (audio, audiovisual, instruments camouflage, biofeedback, dental operating microscope, toys) were included. Qualitative analysis showed with very low certainty of evidence that DT effectively reduced dental anxiety and fear depending on the distraction type, instrument used to measure dental anxiety and dental fear, and dental procedure. CCRBT evaluation identified many methodological issues in included studies.

CONCLUSION

There is a very low certainty of evidence that DT can be effective in managing children's/adolescents' dental fear and anxiety during dental treatment. The heterogeneity of methodologies and findings in the studies, however, suggests more robust, and well-executed RCTs are needed.