Preschool children and relative analgesia: satisfaction grading through a verbal questionnaire

S. ARCARI, R. FERRO

ABSTRACT. Aim The aim of the study was to assess 100 preschool children’s satisfaction grading of relative analgesia (RA) after completing dental treatment by collecting their opinion on this technique through a verbal questionnaire. Methods After completing dental care a simple verbal questionnaire (3 questions) was administered by the operator. The questionnaire investigated: 1) patient’s satisfaction about the sedation treatment; 2) patient’s agreement to re-experiment the technique and 3) patient’s emotions while sedated. Moreover, following treatment, each child was invited to make a drawing on the experience. Results Data obtained were classified in 3 groups: group 1 (87% of children) appreciated RA and would agree to repeat the experience; group 2 (4% of the sample) did not answer the verbal questionnaire and group 3 (9%) did not “enjoy” the sedation technique. Only 15 children completed a drawing; conducting a psychological analysis through C.R. Rogers’ theory of Person Centred Approach coupled with the handwriting analysis methodology defined by Girolamo Moretti, positive features were found in the majority of the drawings (13 out of 15). Conclusion The majority (87%) of the sample appreciated to experience nitrous oxide inhalation sedation and would undergo a further appointment under RA.

KEYWORDS: preschool children; Relative analgesia; Dental anxiety; Verbal questionnaire.

Introduction conditioning the child’s dental behaviour and experience such as: child’s age and knowledge level, personality Going to the dentist for the first time may often have a traits, parents’ own fear and life style, previous traumatic stressful impact on a child: dental anxiety and fear are the experiences and social environment [Townend et al., involved emotional components. 2000; Klaassen et al., 2003]. Usually a child under 3 Fear is a sensitive answer associated to a visible years of age is classified as pre-cooperating, showing impending danger for the subject: aggressive limited understanding and poor cognitive mechanism instruments, such as the drill and an injection, may lead [Marzo et al., 2003; Magnusson et al., 1985]. There is the child to think he/she will be hurt [Berggren and evidence that parental presence during Italian children’s Meynert, 1984]. Several studies highlight the role played first visit may affect their behaviour leading to a lower by such tools in causing dental fear amongst children cooperation [Marzo et al., 2003] as well as maternal [Alvesalo et al., 1993; Klingberg et al., 1995; Foley, anxiety, which can be one of the most significant 2005a]. Anxiety is a discomfort condition which may determinants of a child’s dental anxiety [Karjalainen et occur even without a recognisable risk: forecasting an al., 2003; Balmer et al., 2004]. unpleasant event, such as a dental session connected to Pain experienced during past dental care is often anticipated fear of pain, may produce this emotional state associated to a higher anxiety level [Holst and Crossner, [Majstorovic and Veerkamp, 2005]. Anxiety and fear can 1984; Raadal et al., 2002] which causes a disposition to both affect a child referring to a dentist for the very first experience every stimulus as painful. Painful dental care time. Multiple aetiological factors are involved in delivery has been reported to be important in the aetiology of dental fear: children who have been hurt while Dental Surgery Unit, AUlss n 15 receiving dental treatment are more likely to avoid dental Regional Centre for the Study, Prevention and Treatment care as adults [Nakai et al., 2000]. Anxiety and pain can of Dental Diseases of Veneto Region, Italy e-mail: [email protected] be modified by psychological techniques, although in many instances pharmacological approaches are required:

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very young children who do not understand how to cope 1) Do you think your child is anxious? should be sedated [American Academy of Paediatric 2) Has he/she had any past traumatic dental experience? Dentistry, 2005]. Conscious sedation carried out through When at least one positive answer was found, the child inhalation of nitrous oxide and oxygen flow is reported to could possibly be treated under RA, although the be a successful technique for managing paediatric decision to select the child for this study depended upon patients’ dental anxiety and fear [Shaw et al., 1996; Bryan 4 prerequisites: et al., 2002]. Sedation for paediatric patients is an essential 1) preschool age; tool which may represent an adjunct to behaviour 2) a fearful attitude; management during dental practise and is a potential 3) delivery of treatment requiring a local anaesthesia alternative to General Anaesthesia (GA) [Paterson and injection; Tahmassebi, 2003]. However, few investigations of the 4) medical history review assessing a healthy general perceived acceptability amongst young children are found condition. in international literature [Foley, 2005a]. During the first appointment children were carefully The aim of the study is to assess preschool children’s observed by the dentist while they were showed dental satisfaction grading of relative analgesia (RA) when tools and were invited to try the instruments on their completing dental treatment by collecting their opinion fingers through the tell-show-do technique. on this technique through a verbal questionnaire. The final decision to include a preschool child in the study was subject to child’s behaviour during the first visit; a child expressing one or more attitudes as: Materials and methods - crying; Data was collected over a 18 month period (November - reluctant to cooperate; 2004-April 2006) on a sample of 100 preschool children - frightened by noise; aged 3 to 6, mean age 5 (SD=1) (56 females and 44 - tightly holding the arms of the dental chair when males; 96 Caucasians, 1 Asiatic, 2 Africans) attending seated, the same dental surgery office. The children were was selected and was introduced to sedation referred to the office for different reasons: equipment on the first visit as a “game” to be played on - 24 were addressed by their paediatricians because of next appointment. He was showed the equipment caries; focusing on the “balloon” which he was going to deflate - 12 were sent by paediatricians who noticed the by smelling through the “little scented Micky Mouse eruption of a permanent lower incisor without the nose” (i.e. nasal hood). At this time the dentist was loss of the corresponding deciduous; showing the patient how to deflate through the nasal - 19 reported previous negative dental experience and hood before discharge. Prior to start the following were referred to the office because of their dental session, RA equipment was set close to the dental chair fear; and the dentist focused one more time on the machine as - 29 were sent by other dentists who did not deal with a game, showing the little patient how to deflate the children’s dental care; “black balloon” by inhaling through the “little scented - 16 were address by other patients’ parents for a fist Micky Mouse nose”. dental visit. The same operator (licensed paediatric dentist) Informed consent about nitrous oxide and oxygen administrated nitrous oxide-oxygen flow via the scented administration was obtained from all children’s nasal mask connected to Quantiflex MDM Relative accompanying adults and documented in every patient’s Analgesia machine. Dental personnel assisting the record prior to a dental session under RA. Review of the sedationist during RA treatment was the same trained patient’s medical history was always verified prior to nurse. Oxygen and nitrous oxide were provided in decide upon the use of inhalation sedation. Conditions different percentages according to patient’s need, as to such as allergic reactions to medicines, asthma, chronic obtain individual optimal level of sedation: when reached, obstructive pulmonary disease, severe emotional it was noted down. Starting titration was equal for all 100 disturbances were considered as contraindications for children: 55% oxygen, 45% nitrous oxide. Further flow the use of nitrous oxide/oxygen inhalation. increases were provided to reach a limit percentage of At the first appointment parents were asked to fill in a 40% oxygen and 60% nitrous oxide. Duration of session questionnaire about their child’s medical history. ranged from 25 to 50 minutes, with a median sedation Moreover an acknowledgement of the child’s anxiety time of 31.8. Upon completion of dental procedures a and of previous negative dental experience was 100% oxygen flow was provided for 2-3 minutes before investigated with the following questions. nasal mask removal, as to obtain faster nitrous oxide

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elimination. Table 1 shows treatments which were - Size of the drawing and of single components: small provided. During each session local analgesia was versus regular versus big. delivered by infiltration into the periodontal ligament - Graphic quality against the child’s age. space. A topical anaesthetic gel was applied on the same - Direct reference to the recent dental treatment area for greater pain control [Anand et al., 2005]. A experience. simple verbal questionnaire, due to the patients’ young age, was administered by the operator following treatment. The questionnaire investigated the following. Results - Patient’s satisfaction about the sedation machine One hundred preschool children were included in this (“Did you like this new game that we just played prospective study. Nitrous oxide and oxygen flow was with?”). We believe that all patients were aware of administered by the sedationist during every dental the question meaning as the machine was always treatment and an injection of local analgesia was always pointed out. performed. Data were classified in 3 groups with no - Whether patient agreed on being reappointed using significant difference between sex distributions (Table 2). the sedation machine (“Would you like to play this - Group 1: 87% (47 females, 40 males) appreciated game again next time you come here?”). RA and would agree to repeat the experience. - In case they answered “NO” to the previous - Group 2: 4% (3 females, 1 male) did not answer to questions, the reasons (“Why didn’t you like it?”) the verbal questionnaire. were asked. - Group 3: 9% (6 females, 3 males) did not “enjoy” the - Patient’s emotions during session under RA (“how sedation technique and did not agree to undergo a did you feel?”). future appointment using the same technique. Upon completion of treatment, the child was sent back In Group 1, children’s enthusiasm regarding their to the waiting room and invited to draw, as drawing can conscious sedation experience was assessed to be be considered a way for children to express their related to: emotional life [Oliviero Ferraris, 1973; Crotti and - good scent (71; 41 females, 31 males) exhaled by the Magni, 2006]. The drawings were evaluated by a nasal hood (tutti-frutti or vanilla scent); psychologist and psychotherapist of the Carl R. Rogers - pleasant sensations during treatment (16; 6 females, Person Centred Approach, coupled with the handwriting 9 males). analysis methodology defined by Girolamo Moretti. In Group 2 children’s emotions could not be defined, Rogers’ theory focuses on the established relationship as the median age was indeed very young: 3.3. However, between doctor and child [Rogers, 1951] on which the in 2 cases children underwent a second sedation phenomenological meaning analysis of the drawings appointment and did not offer any resistance when was based. Each drawing has been analysed considering reintroduced to the inhalation equipment. the following variables, identified by Girolamo Moretti Processing data obtained in Group 3, different [Moretti, 1972]. attitudes were found amongst those 9 children who - Description capteured at the end of the drawing expressed aversion for the sedation technique: activity, where available. - the adverse effects of nausea and vomiting, reported - Contents: figures, shapes, composition. to be the most common ones when administrating - Space allocation on the sheet: total versus partial, nitrous oxide and oxygen [AAPD, 2005], occurred in upper/lower/central/right/left section. 2 cases (1 female, 1 male), frightening the subjects; - Choice of colours and shading quality. - unpleasant taste was reported by one patient (male), - Stroke: regular versus irregular, marked versus light pressure. Satisfaction rate groups Percentage Children who appreciated and agreed to repeat Treatment on both dentitions Percentage the experience 87% Pulpotomy of 1 or more deciduous teeth 71% Children who did not answer 4% Extraction of 1 or more primary teeth 16% Children who did not appreciate nor agreed Restorative work in primary teeth or first permanent to repeat the experience 9%s molars 13% TABLE 2 - Answers were divided in three groups according TABLE 1 - Treatments delivered. to the acceptance rate.

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as a result of dental material employment although environment (dentist and dentist’s instruments). the child linked his sensation to the sedation - Children expressing anxiety (10:15) in different levels equipment; of intensity (worry, agitation, deep anxiety) as to - gas flow interruption was repeatedly asked by one match the parents’ evaluation of anxious traits in their patient. A previous negative experience during children. Thus in no case anxiety is out of control. surgery, when a mask had been forced on the patient, - Children expressing depressive feelings (isolation, was reported by the child’s mother. lack of confidence, sadness) (4:15) cannot link this - numbness due to local analgesia was considered as emotional state to the RA experience. particularly unpleasant by three children (females), - Overall most of the drawings (13:15) presents feature who connected their discomfort related to local which in the contents, colours, stroke, pressure, size, analgesia to the sedation machine; space allocation are linked to positive elements: - mourning and crying were found in two patients energy, vitality, trust, confidence, variety and (females) who were noticed as reluctant to perform intensity of emotions. even simple commands during their first visit. No desire in repeating the inhalation sedation experience was shown by the above mentioned 9 Discussion patients. The local anaesthetic injection did not create Although the sample size was relatively small, the study any discomfort in 78 cases, where an appropriate level of highlights the possibility of successfully completing sedation was achieved. dental care in very young patients. Appreciation of Upon completion of dental treatment, children were providing nitrous oxide and oxygen flow was showed by invited to draw and 15 drawings were completed and the majority of the involved patients (87%). evaluated. The following common features were pointed Titrated doses of nitrous oxide and oxygen were out conducting an analysis on the available drawings. administrated by the seditionist (paediatric dentist), as to - Contents: moving shapes 13:15. continue the downward trend of using general - Space allocation: complete distribution over the sheet anaesthesia for very young children requiring dental 13:15. treatment. The goal of procedural sedation is the safe and - Colours: bright and multicoloured 12:15.. effective control of pain anxiety and motion, as to allow - Stroke: for the most regular (9) and partially regular a necessary procedure to be performed and to provide an (2), always marked (15:15). appropriate degree of memory loss and decreased - Size: for the most big (7) or medium (5) 12:15. awareness [Krauss and Green, 2000]. As a matter of fact, - Graphic quality: good (10) or reasonably good (3) RA has been reported to represent a successful alternative 13:15. form of pain and anxiety control to GA as patients show - Direct reference to the dental experience: absent their ability to cope with the treatment [Shepard and Hill, 13:15. 2000; Bryan, 2002]. At preschool age coping skills are The assessment of the emotional impact of RA on the still deficient: we found that patients’ poor cooperation children subject of the study was conducted making a during previous simple procedures, such as first visit distinction between an emotional state linked to the requisites, improved under RA. dental session (state anxiety) and an emotional state not A recent study carried out in the UK investigated referred to the dental experience (trait anxiety). A further young children’s acceptability of this technique through step was taken to isolate children’s anxious status from a a questionnaire: it resulted as well in a similar depressive status which cannot be referred to the percentage (90%) of satisfied children [Foley, 2005a], contingent experience as it represents more complex although children’s age was higher. Two more studies familiar dynamics. In order to understand the stressed the importance of using RA instead of GA to effectiveness of the RA approach, the analysis verified control children’s fears, but the considered age was how the status of anxiety was managed by the children, older, as the authors were focusing on adolescents whether in the form of an uncontrolled anxiety (potential [Sheperd and Hill, 2000; Show et al., 1996]. negative impact) or a self-controlled anxiety (not-negative The American Academy of Paediatric Dentistry impact) through drawings. recognises nitrous oxide and oxygen inhalation as a safe The main findings of the analysis are the following. and effective technique to reduce anxiety, produce - No evidence of traumatic emotions linked to the RA analgesia and effective communication between patient experience as no over exposure of teeth or mouths on and health care provider, as it may enable the paediatric the people or animals represented in the drawings. patient to tolerate unpleasant procedures [AAPD, 2005]. neither alterations in the characteristics of the dental A few children’s perception of RA can be described

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