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Evaluation of Toothache Severity in Children Using a Visual Analogue

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Evaluation of Toothache Severity in Children Using a Visual Analogue Scientific Article Evaluation of Toothache Severity in Children Using a Visual Analogue Scale of Faces Eliane de Paula Reis Barrêtto, BDS, MSc Efigênia Ferreira e Ferreira, BDS, PhD Isabela Almeida Pordeus, BDS, PhD Dr. Barrêtto is pediatric clinician, pediatric dentistry, and Drs. Ferreira and Pordeus are senior lecturers, Dental School, Federal University of Minas Gerais (FO-UFMG), Minas Gerais, Brazil. Correspond with Dr. Barrêtto at [email protected] Abstract Purpose: Pain is a frequent symptom of oral disease. It is difficult to measure, however, due to its subjectivity, especially among children. The purpose of this study was to verify the utility and applicability of a visual analogue scale of faces (VASOF), adapted for 8- to 9-year-olds, to measure the severity of toothaches. Methods: A cross-sectional study was undertaken, which included 601 boys and girls ran- domly selected from state and private schools in the city of Belo Horizonte, Minas Gerais, Brazil. They were interviewed and clinically examined, and a VASOF was applied. Results: The VASOF’s application revealed a high percentage of intense/very intense pain in the sample (39%). The presence of this pain intensity was accompanied by a high incidence of children who cried, were awakened by the pain, and were unable to carry out habitual tasks. Furthermore, this severe pain was strongly associated with less- privileged economic groups and the presence of oral pathology (P≤.05). The scale was well understood by children, independent of gender or economic group. Conclusions: A VASOF was found to be capable of measuring toothache severity expe- rienced by school-age children. (Pediatr Dent. 2004;26:485-491) KEYWORDS: TOOTHACHE, VISUAL ANALOGUE SCALE, SEVERITY, CHILDREN Received October 13, 2003 Revision Accepted May 5, 2004 ain is a frequent symptom of oral dis- such as verbal reporting or observations of behaviors that ease1,2 and often the most important moti- suggest pain (vocalization, facial expression, and body Pvation for seeking dental treatment.3 Therefore, den- movements). Indirect reporting can introduce bias into tists frequently encounter clinical situations in which pain studies on pain. Pain evaluation based on observations by is present. third parties must be interpreted with caution, whereas self This and other symptoms, such as discomfort, fatigue, reporting (made by the child in pain), in spite of its limi- malaise, weakness, anxiety, and fear, are common experi- tations, is considered more valuable. Questions formulated ences but generally difficult to define. This is due to the for children, however, must be different from those directed subjective nature of pain symptoms. The clinician is en- toward adults13,16,17 to take into account emotional, cogni- tirely dependent on the patient to try to quantify the extent tive, and language development factors. of the problem.4 Thus, the way in which children and adolescents are The majority of toothache studies have been undertaken approached, using appropriate language for each age group, with adults and, frequently, the elderly1, 5-10 rather than is important for the researcher. For children to understand children. This is probably due to the greater ability of adults and be capable of offering an objective response it is nec- to communicate and provide valid data. essary to understand the pain language used by children.4 The epidemiological studies of pain, its characteristics, and Studies have evaluated quantitative and qualitative de- related factors in children are few in number and have only scriptions of pain by children. They show that: been published recently.11-15 This paucity is probably related 1. children can do this in a clear way, regardless of sig- to the difficulty children have in verbalizing their pain.4 nificant age differences; Pain measurement in children has depended on parents, 2. even those as young as 4 to 6 are able to quantify these caregivers, and/or health professionals in an indirect form, symptoms as well as adults; Pediatric Dentistry – 26:6, 2004 Evaluation of toothache severity using VASOF Barrêtto et al. 485 3. it is possible to identify frequently used words by age, In all, 751 questionnaires were distributed, of which 662 race, or gender, in sensory, affective, evaluative areas, and were completed, for a response rate of 88%. Of this num- in the localization and intensity of pain.18,19 ber, 61 children were excluded due to: Young patients often have difficulty understanding con- 1. absence on data collection days; cepts of pain, due to the incipient development of cognition 2. illness; or and language.20 As a result, there is an increasing amount 3. a new birthday during interview periods, which placed of research aimed at discovering the best method of mea- them outside the age group of the study. suring subjective sensations, such as pain, and to define methodologies and instruments that can be applied to dif- Data Collection ferent age groups. Through interviews with the children, this study collected Verbal reports in the form of questionnaires and inter- a range of toothache-related pain data, such as prevalence, views have been used frequently to measure pain attributes, pain characteristics (location, cause, frequency, severity), such as prevalence, impact, etc.11Other techniques using impact on the child and family, remedial actions taken, and nonverbal reporting such as the visual analogue scale (VAS) general information. In addition, the relationship between have been tested in research principally to measure pain in- pain experience (for all children who reported pain in the tensity.20-23 This technique uses images that represent specific last month) and oral health status were evaluated via clini- feelings and can take the form of faces, numbers, colors, cups cal examination. The data collection instruments were tested containing different volumes of liquid, tokens, thermometers, and improved in 2 pilot studies. All interviews and exami- and others. These types of scales can be understood by nations were undertaken by a single researcher. younger preschool-age children.4 The clinical examinations were standardized (K=81% for This study’s objective was to verify the utility and ap- intraexaminer calibration), and undertaken using recom- plicability of an adapted visual analogue scale of faces mended infection control procedures.26 To evaluate the oral (VASOF) to measure toothache severity among children. health status, a definitive criteria list was adopted27 represent- ing signs of disease or nonpathological conditions associated Methods with pain symptoms and which are common among chil- dren in the age group involved. The pathological conditions Study Location, Sample, and Criteria Selection noted included alterations in teeth, periodontium, occlusion, This cross-sectional study took place in the city of Belo and mucosa. In addition, nonpathological painful conditions Horizonte (BH), Brazil and included a sample of 601 boys were registered that were limited to the dentition. and girls, each 8 or 9 years old at the time of data collec- The impact on the child was measured based on replies tion, who were enrolled in BH schools. The sample size to 2 basic questions: was calculated via the estimate of proportions formula24 1. “Were you awakened by the pain?” using an α value of 0.05, a detectable error of 4%, and the 2. “Were you unable to carry out any habitual task be- prevalence data of toothaches in 8-year-old children from cause of the pain?” a study by Shepherd et al (1999).10 Severity of pain was measured based on replies to 2 ques- The eligibility criteria for children were: tions: 1. the child was present on the day of data collection; 1. “Did you cry when you had the toothache?” 2. informed consent to participate was obtained from a 2. “How was it when the pain was at its worst?” parent/guardian; This last question evaluated the VASOF, which con- 3. the child was in an adequate physical, psychological, tained drawings of boys and girls of both African American and mental condition to participate in the examination. and Caucasian races, adapted from the study by Beltrame et al (Figure 1).4 Each set consisted of 5 drawings with dif- Sample Randomization ferent expressions, ranging from a child smiling to a child To select a representative sample of children of this age crying, corresponding to variables 1 to 5, which signified: group, the number of schools in each administrative area 1. very light pain, without provoking a disagreeable sen- (AR) was determined and a random selection was made. sation; In all, 9 schools participated—1 from each AR—composed 2. light pain, lightly disagreeable sensation; of 2 private, 3 municipal, and 4 state schools. From these, 3. moderate pain, disagreeable sensation; children who fulfilled the inclusion criteria were randomly 4. intense pain, very disagreeable sensation; selected among classes and attendance list names. 5. excruciating or unsupportable pain, the most disagree- able sensation. Consent and Response Rate The scale was shown to each child with the following In addition to giving informed consent, parents or guardians questions according to their abilty to understand: responded to a questionnaire—the Criteria for Brazilian Eco- 1. “Point to how you felt when the tooth hurt most,” or nomic Classification,25 from which 3 economic groups were 2. “When you were in the most pain, which of these pic- created, according to average income: upper, middle, and lower tures did you look like?” 486 Barrêtto et al. Evaluation of toothache severity using VASOF Pediatric Dentistry – 26:6, 2004 The corresponding image chosen by the child was noted in the data form. The VASOF was tested twice, with a 1-week interval on the same 20 children who participated in the second pilot study. Its reliability was very high (K=90%). Children requiring treatment were guaranteed care at health centers and emergency clinics in the area, with the backing of the local health department.
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