Assessing an active distracting technique during primary mandibular molar pulpotomy (randomized controlled trial)

Abstract Objectives This study aims to evaluate the effectiveness of two different distraction techniques (Audio Video Distraction/Video Game Distraction) in the management of anxious pediatric patients during dental treatment. Materials and Methods One hundred and five children were randomly divided into three groups; Group A: active distraction using video games on a tablet device and wireless joystick (VG). Group B: passive distraction using video on tablet, and wireless headphones (AV). Group C (Control group): basic behavior guidance technique Tell Show Do was used (C). The children were selected from the department of pediatric dentistry at the Faculty of Dentistry, Damascus University, who required pulpotomy in primary mandibular molars. All children were assessed by: Simplified Wong‐Baker FACES for pain scale (self‐report), and “HOUPT” Behavior Rating Scale for Overall Behavior (non‐self‐report), at the end of treatment. Results One hundred and five children completed the study (57 boys and 48 girls) aged between 6 and 10 years (mean age of 7.4 years). The active distraction (VG) group was superior to the passive distraction (AV) group and the control group (C) on the pain scale with statistically significant differences as appeared in Simplified Wong‐Baker Scale (p = .000), The active distraction (VG) group was superior to the control group (C) in overall behavior as appeared in HOUPT scale (p = .041), but it was no statistically significant differences between (VG) group and (AV) group in overall behavior (p = .605). With the use of Bluetooth technology and wireless devices, the workspace was comfortable for the dentist and did not interfere with the movement of his hands. Conclusion Positive distraction with video games by wireless joystick displayed on the portable tablet on the dental chair was the best technique for reducing dental anxiety and reported pain in school children (6‐10 years) and was better than negative distraction by video cartoons on the tablet device.

The number of clinical studies on the effectiveness of the distraction technique in the management of dental fear and anxiety in children and adults during dental treatment is very low, and there is no consensus in methodologies and research results, which indicates the need for more controlled clinical studies on this technique (Prado et al., 2019).
Distraction is defined as a behavior management technique that relieves pain and behavioral disturbance by diverting children's attention away from painful stimuli during extensive dental procedures (Aminabadi et al., 2012). The distraction technique is a safe strategy that relies on the patient's limited attention span and diverts his attention from unpleasant actions (Flores et al., 2022).
The distraction can be negative or positive (active or passive), where audiovisual distraction is a type of negative distraction that affects two types of senses, hearing and vision, while playing video games is a positive distraction that affects an additional sense, which is the kinesthetic sense (Allani & Setty, 2016).
Active distraction depends on the child participating in certain activities during the procedures and includes singing songs, pressing a ball with the hand, taking deep breaths, and playing with electronic devices (Srouji et al., 2010). Many studies have done active distractions using children's toys such as coloring and wooden toys, making different movements of hands and feet, or drawing in the air to distract the child from painful treatments (Abdelmoniem & Mahmoud, 2016;Debs & Aboujaoude, 2017).

| Study design
This study was designed as a randomized controlled trial (RCT) to compare the effectiveness of (VG) distraction and (AV) distraction to a control group during pulpotomy in primary mandibular molars in 6-10-year-old children.
This clinical trial was conducted in the Department of Pediatric Dentistry at Damascus University in protocol record (IRB No. UDDS-1987-15082019/SRC-1450 and approved by ClinicalTrials.gov (NCT05191836). After ethical consent was obtained, informed consent was obtained from parents or guardians to participate in this study.

| Sample size calculation
The sample size was calculated using G-Power 3.1 statistical program with (α = .05, and power = .95). The effect size was calculated according to previous studies (Mohammed et al., 2018). The sample size was 105 children, (35 children in each group) ( Figure 2).

| Patient selection
Children were selected from the Department of Pediatric Dentistry, Damascus University, Faculty of Dentistry, based on the following inclusion criteria: 1. Children required pulpotomy in a primary mandibular molar.
3. Children were categorized definitely positive or positive ratings on the Frankl scale.
Exclusion criteria: 1. Children with a previous dental experience.
2. Children with systemic or mental disorders.

| Randomized allocation
The children were randomly assigned according to the website www. randomaization.com into three groups.

| Intervention
the overall behavior scale p = (.041) and a significant difference was noticed between three groups on the pain scale p = (.000) as shown in (Table 1). The Bonferroni test was applied for multiple-dimensional comparisons to identify the trend of statistically significant differences.
There was a statistically significant difference in pain scale between Group A (VG) and Group B (AV) (p = .020) and between Group A (VG) and Group C (C) (p = .000) toward Group A, so the use of video games reduces the pain described by children. While there are no statistically significant differences between Group B (AV) and Group C (C) (p = .665), as shown in (Table 2).
There was a statistically significant difference in the overall behavior scale between Group A (VG) and Group C (C) (p = .035). On the other hand, there were no statistically significant differences compared to the overall behavior scale between the Group A(VG) and Group B (AV) (p = .605), as well as between Group B (AV) and Group C (C) (p = .605), as shown in (Table 3).
This indicates that the use of video games with joystick and portable tablet added a significant improvement in the behavior of children and reduce the self-reported pain during the primary mandibular molar pulpotomy.
All connections were via Bluetooth and we did not use any wired devices so that the workspace remained empty and didn't interfere with the movement of the doctor's hands.
There were no statistically significant differences between males and females in three groups according to the scales used in the research HOUPT Scale and W-B Scales, as shown in (Table 4).

| DISCUSSION
Dental fear and anxiety have an impact on the quality of dental treatment (Milgrom et al., 2010). Dental treatment usually includes violent procedures, repeated injections, and the use of sharp tools at high speed, and may extend over several visits. These aspects affect the child's ability to tolerate dental treatment, which poses a F I G U R E 3 Simplified Wong-Baker FACES pain rating scale (Baker & Bashir al-Mangal, 2015).
F I G U R E 4 "HOUPT" Scale for overall behavior.
T A B L E 1 One-way ANOVA to study the difference in three groups (p value < .05) Simplified W-P FACES .000 challenge to the dentist, and therefore it is impossible to perform a successful dental treatment if the child's behavior is not controlled (Anthonappa et al., 2017).
Therefore, many procedural, behavioral, and nonpharmacological techniques have been proposed to reduce pain and discomfort during pediatric dental treatment. This study was conducted to compare different distraction techniques (active distraction-passive distraction) in reducing perceived pain during pulpotomy in children.
There are many scales for classifying behavior in children, the most famous of which is the Frankel Scale, which divides behavior into four categories (Definitely negative, Negative, Positive, and Definitely positive) (Dean, 2021 visits. These aspects affect the child's ability to tolerate treatment, which poses a challenge to the dentist and, therefore, it is difficult to achieve successful dental treatment if the child's behavior is not controlled technology and wireless devices, the workspace was comfortable for the dentist and did not interfere with the movement of his hands, The tablet was placed in a high position on the dental chair, so the child raised his head high, which facilitated treatment. As our study results show, the use of the joystick and video games added a significant improvement in the behavior of children and the self-reported pain during the dental treatment procedure, so that all children in active distraction group were treated with acceptable and satisfaction general behavior according to the scales used in the research. Thus, our method of distraction outperformed the passive distraction using video films. this is due to the physical activity of the child and they were blocked out from the surrounding environment, and our results agreed with many research that have been studied the effectiveness of active distraction through video games on a tablet device while performing different dental procedures, and their results showed that active distraction is superior to passive distraction (Attar & Baghdadi, 2015;Pande et al., 2020).
In addition, active distraction using the joystick, which was fixed to the dental chair, was superior in pain control during pulpotomy compared to using AV distraction and control group, but it was similar in child behavioral management during pulpotomy compared to using AV distraction.
Active distraction using video games is superior to passive distraction using video games for pain described by children, although other studies used an effective technique in improving self-reported pain, PlayStation video games did not affect overall behavior (Guinot et al., 2021). This is may due to blocking out the sounds of dental by the use of headphones in two techniques active and passive distraction.
Some studies have found that playing video games has improved a child's adaptation to the dentist, compared to watching cartoons while injecting local anesthesia. In addition, playing a video game and watching cartoons film during dental treatment reduced heart rate, compared to traditional distraction techniques (Kumprasert et al., 2021) As found in our study that the use of video games is the most effective distraction technique for reducing disruptive behavior while performing dental treatments.
On the other hand, some studies used effective distraction in reducing the vomiting reflex while taking the upper and lower alginate impression, and they used the Intellectual Colored Game, which distracted the child's attention during the stressful alginate impression (Kulkarni et al., 2021). This is consistent with our study, which demonstrated the effectiveness of active distraction in diverting the child's attention away from the disturbing cause.
In contrast to our study, some studies found that distraction did not provide additional advantages in reducing fear and pain when compared to traditional methods such as directing behavior and positive reinforcement, but it is a way to attract the child's attention and activate the child's nervous and emotional centers, which leads to relaxation (Al-Khotani et al., 2016;Shekhar et al., 2022).
This study found that playing a video game during dental treatment could better method a child's cooperation with the dentist, compared with watching cartoons and other conventional distractions (Cozzi et al., 2021).

| CONCLUSION
Within the limits of this study, it can be concluded that the use of video games via joystick on tablets and headphones gave the best result in relieving dental anxiety and pain during pulpotomy in children.
Although the use of cartoon films through the tablet and headphones did not reduce the described pain in children, it was acceptable in managing children's behavior when performing the dental treatment and may lead to desirable behaviors in future visits.

DETERMINANTS
A limitation of this study was the inability to blind the external investigator from the use of joystick and headphones, and the unacceptability of some children to use joystick and headphones.

AUTHOR CONTRIBUTIONS
Ekram AlSibai conceived the idea and provided the treatment. Ekram AlSibai contributed to the writing. Hasan Alzoubi to the documenting.
Nada Bshara conceived the idea and supervised the treatment. Laith Al Sabek contributed to study design.

ACKNOWLEDGMENTS
We thank the staff from the pediatric department at Damascus University for facilitating the procedure during this study. This research has received no external funding.