Altan et al. BMC Oral Health (2019) 19:59 https://doi.org/10.1186/s12903-019-0756-y

RESEARCHARTICLE Open Access The colour of children with in Turkish population Halenur Altan1*, Hüseyin Çevik1, Serkan Doğru2, Alem Coşgun3, Mustafa Süren2 and İsmail Okan4

Abstract Background: Toothache is a common consequence of untreated caries, predisposed by poor oral hygiene and high caries risk. Most children expressed their pain through their parents or carers. The aim of this study was to determine the colour of pain presence and absence. Methods: Patients aged between 4 and 14 and referred to a dentist for the first time due to toothache had a short-term pain of 1 month caused by deep cavities. The children chose paintings from the box of 24 standard colours (Crayola, Spain) and the circles were painted. Pain was rated by children on the Visual Analoge Scale. Normality and variance were tested using the one-sample Kolmogorov-Smirnov test. Associations were performed by using the Pearson correlation coefficient. Analyses were completed by using the Statistical Package for Social Sciences (SPSS Inc., Chicago, IL) version 20.0 program. Results: A total of 147 patients including 78 girls (53.1%) and 69 boys (46.9%) were included in the study. The principal component analysis showed that red has the highest factor loading in children with pain, whereas yellow was the other highest one in children without pain. Conclusion: The presence of pain was mainly associated with red, and the absence of pain was associated with yellow in Turkish population. Description of pain with colour can be useful tool to recognize the children and to improve dentist-patient or dentist-parents communication. Keywords: Children, Colour, , Toothache

Background The lack of children’s pain experiences and the low Pain is an unpleasant sensory and emotional experience number of words through which they can express their associated with actual or potential tissue damage, or de- problems make it difficult for children to correctly iden- scribed in terms of such damage [1]. Toothache, stom- tify their pain [5]. For this reason, unlike adults, most achache, , limb pain, and chest or are children expressed their pain through their parents or experienced occasionally or frequently by up to 30% of carers [4, 6]. children. Toothache is consistently associated with Various methods of evaluation have been developed the population’s levels of caries risk factor, and it is for the expression of pain by children. These methods highly prevalent among children [2]. Dental pain in vary with the change in the child’s ability to perceive, in- children and adolescents affects community health, terpret, and express in relation to developmental stages, individuals and their families by 15–25%. The fre- past pain experiences, and other environmental factors quency and severity of pain negatively affects daily ac- [7–9]. There are various scales to describe the intensity tivities such as nutrition, sleep, inability to go to of pain. These include pain measure scales (visual analog school, and smiling and oral care [3]. scale, numerical scale, face scales, colour scale) based on The presence and intensity of the pain is reported by personal expression; pain measure scales based on be- the patient himself, and this way is the gold standart [4]. havioral patterns, combined scales (Children’s Hospital of Easter of Ontario Pain Scale (CHEOPS)) and physio- * Correspondence: [email protected] logical changes (blood pressure, pulse, respiration, oxy- 1Department of Pediatric Dentistry, Gaziosmanpaşa University, Faculty of Dentistry, Tokat, Turkey gen saturation) [10]. Full list of author information is available at the end of the article

© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Altan et al. BMC Oral Health (2019) 19:59 Page 2 of 8

Children’s capability of using self-reporting pain tools any dental or facial prolonged pain for more than one changes over time [11]. Children under three years of month were excluded from the study. age are unable to quantify pain using the currently avail- One hundred eighty-one pediatric patients were in- able self-report measures. Children over the age of three cluded in the study and a total of 147 patients were eval- can rate their pain on appropriate scales [4, 12]. For uated in accordance with the exclusion criteria (Fig. 1). younger children with undeveloped numerical concept knowledge, an alternative means for communicating Study design their pain is provided by colour identification [11]. This is a prospective descriptive study. The study proto- Several colour-based tools have been developed for the col was approved by the Gaziosmanpaşa University Clin- assessment of pain [4–7, 13, 14]. The Analogic Chro- ical Research Local Ethics Committee (17- KAEK-070). matic Continuous Scale is composed of a color scale, Written consent was obtained from parents. from light pink (no pain) through shades of red to black (severe pain). The colour Analog Scale is a similar scale Colours and pain which was developed to be used in pediatric populations Two circles were drawn on A5 size white paper entitled and includes the respondent sliding a marker along a “Pain Presence” and “Pain Absence” (Fig. 2). We asked colour thermometer from light pink (no pain) to deep red “Which colour do you want to use if you have pain?” (worst pain) [14]. The pictorial Scale of Pain Intensity is and “Which colour do you want to use if you have no composed of a sequence of vertically aligned red circles, pain?” The children chose paintings from the box of 24 which increase in size to represent increasing pain inten- standard colours (Crayola, Spain) and the circles were sity [15]. The PAULA pain-meter is composed of five col- painted. ored emoticon faces, with the red colored face representing the worst imaginable and the yellow-colored Visual pain scale face representing no pain [16, 17]. When the painting was completed children rated their Correlation between the prevalence of dental caries pain on the Visual Analog Scale (Fig. 3). and toothache has been reported to be moderate to strong [3]. Toothache is a common consequence of un- Statistical analysis treated caries occurring due to poor oral hygiene, high We would detect a simple correlation (r = 0.3) between caries activity or excessive use of refined food [3]. Chil- VAS and pain presence using a two-sided test with an dren in Turkey have the highest caries risk among chil- alpha of 0.05 and a power of 80%, the required sample dren in European countries, and hence, pain (toothache) size is approximate 113 (n = 113). experience begins at younger ages [18]. The aim of this The Kaiser-Meyer-Olkin measure of sampling ad- study was to examine whether they could use colour to equacy and Bartlett’s test of sphericity were performed describe the pain of children experiencing with tooth- to determine the evaluation of the factor analysis for col- ache and show the any relation between pain intensity ours. The interaction between colours and pain intensity and pain colour. was completed by using the principal components ana- lysis. To perform this analysis, the components were ex- tracted with an eigen value of higher than one. Varimax Methods rotation with Kaiser normalization was chosen, and the Sample rotation converged in seven iterations, with values below Children admitted to the outpatient unit of the Depart- 0.40 being excluded. ment of Pediatric Dentistry, Gaziosmanpasa University, The distribution of the variables were analyzed using who had acute toothache, were invited to participate in one-sample Kolmogorov-Smirnov test. Quantitative data the study. Patients with no systemic diseases, aged be- were presented as mean and standard deviation, and tween 4 and 14, referred to a dentist for the first time qualitative data as frequency and percentage. The linear- due to toothache with a short-term pain of up to 1 ity of the variables were assessed by using Pearson cor- month caused by deep cavities in teeth were included in relation analysis (r). All analyses were conducted by the study. using the Statistical Package for Social Sciences (SPSS Children were excluded if they had altered mental sta- Inc., Chicago, IL) version 20.0 program. The statistical tus or any degree of cognitive impairment, were significance for all analyses was set at p < 0.05. non-cooperative, had color-blindness or motor abnor- malities leading to score of the scales, could not under- Results stand explanations and commands in Turkish, or Sample characteristics response time or colour selection lasting more than ten A total of 147 patients including 78 girls (53.1%) and minutes. Children who had no pain, and experienced 69 boys (46.9%) were included in the study. Altan et al. BMC Oral Health (2019) 19:59 Page 3 of 8

Fig. 1 Consort Flow Diagram

Demographic characteristics of the patients are pre- Colour analysis sented in Tables 1, 2 and 3. The mean age of the In the study, 14 colours in the presence of pain and subjects was 8.63 ∓ 2.18, where 8.72 ∓ 2.37 in girls, 10 colours in the absence of pain were not used in and 8.52 ∓ 1.96 in boys. The mean VAS value was 5.5 the 4–6 aged group. All colours were chosen in the ∓ 2.99 among girls and 5.52 ∓ 2.82 among boys. 7–10 age group in the pain presence (Table 1 and 2). Four different colours were not used in the 7–10 age group in the pain absence. Eleven and eight different colours were not chosen in the 11–14 age group in the pain presence and absence. When all age groups were evaluated, the presence of pain was mainly asso- ciated with red (n =35), magenta (n = 12), black (n = 10), red orange (n = 10) and yellow (n = 10); and the

Fig. 2 Circles for painting in pain absence and presence Fig. 3 Visual Analoge Scale Altan et al. BMC Oral Health (2019) 19:59 Page 4 of 8

Table 1 Frequency of colours in children with pain among age groups

absence of pain was associated with yellow (n = 20),white (n = 17), sky blue (17). There was no correlation between visual analogue scale According to the gender, girls preferred red, ma- (VAS) and pain presence (r = 0.096, p:0.245) and pain genta, and yellow in the presence of pain; while boys absence (r = 0.005, p = 0.948). preferred red, black, red orange, yellow. In the ab- sence of pain, the girls chose yellow, white,and pink while boys chose yellow, white, and sky blue Discussion (Table 3). Parent-reports in the assessment of pain may cause in- The principal component analysis showed that red has correct in children [19]. Incorrect the highest factor loading in children with pain, whereas pain management increases negative thoughts in chil- yellow was the other highest one in children without dren and causes reluctance to treatment; it has been re- pain (Table 3). ported that the parents feel helpless in connection with Altan et al. BMC Oral Health (2019) 19:59 Page 5 of 8

Table 2 Frequency of colours in children without pain among age groups

this [20]. Self-report in children is difficult, and an as- old) exhibited a preference for the colour red and black, sessment pain tool is needed to recognize pain [5–7]. respectively. In a study of children hospitalized for chil- Children use colors as a kind of individual expression. dren with musculoskeletal disease, red and purple were Colored objects easily attract children [21]. Several stud- chosen to represent severe and moderate pain [25]. In a ies focused on the selection of colours for measuring study, osteoarthritis (OA) pain was described using col- pain experiences in medicine (injections, venipuncture, ours in adult patients [17]. The majority of participants intravenöz (IV) insertion and post-operative pain) [13– chose red to describe high-intensity pain and chose 16]. However, little is known about using colours to as- white,yellow,orange,blue and green to describe the ab- sess pain in children with toothache [22]. Scott [23] re- sence of pain. ported that non-hospitalized children chose the red In some studies, contrary to above information, chil- colour and warm colours (red, orange, yellow) from dren primarily selected black from among eight colours among nine colours to describe the needle injection and as the worst pain colour, and then they selected red and hammer operation. Savedra et al. [24] also found that blue as the worst pain colours, respectively. Orange, the hospitalized and non-hospitalized children (9–12 years most common colour was selected for the least pain. A Altan et al. BMC Oral Health (2019) 19:59 Page 6 of 8

Table 3 Factor analysis of colours in pain presence and absence in girls and boys

Highest factor loadings are indicated in bold new scale, the colour circle pain scale (CCPS) in adult and presence by girls and boys. Yellow is used for “no postoperative patient in Ghana, was consisted of six col- pain” meaning in many colour pain tools, since yellow is ours (white, green, gold, blue, red, black) [13]. Unbear- the brightest and most vibrant of colours, it often able pain and the most severe pain were described with arouses optimism, joy and happiness in people. We black and red; no pain was described with white. Arabic think that the main reason for the association of pain children in an American school described black and blue with yellow colour is cultural perception. In Turkish lan- as the pain colour [26]. guage, yellow colour may be used negatively; as meaning The present findings provide us with preliminary pale, faded, and illness. Children in our study did not ex- knowledge of the pain colour of Turkish children with press the presence and absence of pain in green and toothache. The presence of pain was mainly associated blue. with red, and the absence of pain was associated with Unlike other studies, colour choices were made from yellow. Girls preferred red, magenta, and yellow in the among 24 colours without making colour restriction. presence of pain; while boys preferred red, black, red or- Nevertheless, accumulation was observed only in some ange, and yellow. Red symbolizes that inflammation, colors. This accumulation shows that children make emergency, fire, blood, anger and traffic lambs and has a colour choices consciously. Gender and age are import- strong visual impact on children [17]. In the absence of ant factors in colour preference and use. Children in pain, the girls chose yellow, white, pink, and aqua green; school period chose bright and vivid colours predomin- while the boys chose yellow, white and sky blue. Inter- antly in the absence of pain. We think that the reason estingly, yellow colour was chosen both in pain absence why preschool children (4–6 ages) used few colours is Altan et al. BMC Oral Health (2019) 19:59 Page 7 of 8

because of limited knowledge of colours. In pre-school Acknowledgements period, more colour is preferred depending on the in- Not applicable. crease of colour knowledge. In the adolescent children Funding (11–14 ages), the colour preferences are diminished and The study was self-funded. No public or private funding source was used for the presence and absence of pain are concentrated in this research. certain shades of colour, indicating that progressive age Availability of data and materials groups can relate the pain feelings to colours more. The The datasets used and/or analyzed during the current study are available child in adolescence period can make more realistic from the corresponding author on reasonable request. choices thanks to what they learn and observe. Authors’ contributions The VAS has been also used to examine children’s in- H.A and H.Ç conceived the ideas; H.A and İ.O collected the data; H.A and tensity of pain. In our study, there was no correlation S.D. analysed the data; and H.A, M.S., S.D. and A.C led the writing. All authors read and approved the final manuscript. between description of pain colour and responses on the VAS in Turkish children with toothache. The colour Ethics approval and consent to participate shows the presence of pain in children but does not give The study protocol was approved by the Gaziosmanpaşa University Clinical Research Local Ethics Committee (17- KAEK-070). Written consent was ob- us full information about the pain intensity. tained from parents. Since the verbal expression of feelings is an abstract phenomenon, it might continue to develop throughout Consent for publication Not applicable. the growth of children. The pain perception and expres- sion, perhaps one of the the most subjective feelings in Competing interests human, is strongly effected by gender, age, culture and The authors declare that they no competing interests. so on. Instead of expecting a verbal expression from a ’ child, a visual aid to express their pain on a color scale Publisher sNote Springer Nature remains neutral with regard to jurisdictional claims in with a range of shades might help dentist to perceive the published maps and institutional affiliations. real feeling and the strength of pain in the clinical set- Author details tings. In case the validation of color code with the chil- 1 ’ Department of Pediatric Dentistry, Gaziosmanpaşa University, Faculty of dren s pain expression is established, color-aided pain Dentistry, Tokat, Turkey. 2Department of Anesthesiology and Reanimation, communication in dentistry might reveal the nature and Gaziosmanpaşa University, Faculty of Medicine, Tokat, Turkey. 3Kayseri Nimet the perception of pain in children. Bayraktar Oral and Dental Health Hospital, Clinic of Pediatric Dentistry, Kayseri, Turkey. 4Department of General Surgery, Gaziosmanpaşa University, Limits of the study; We did not inquire about any past Faculty of Medicine, Tokat, Turkey. painful episodes in the children’s lives. In addition, we only studied children with acute pain so our results are not ap- Received: 18 December 2018 Accepted: 3 April 2019 plicable to children with . However, the sug- gestion should be taken with a word of caution, since the References perception of pain is especially subjective in children. 1. Cano-García FJ, González-Ortega MD, Sanduvete-Chaves S, Chacón-Moscoso S, Moreno-Borrego R. Evaluation of a Psychological Intervention for Patients Therefore, clinical examination findings and appropriate with Chronic Pain in Primary Care. Front Psychol. 2017;23:435. radiological modalities should be used to make a prompt 2. Peretz B, Sarnat H. 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