A Commentary on

Prado I M, Carcavalli L, Abreu L G, Serra-Negra J M, Paiva S M, Martins C C.

Use of distraction techniques for the management of anxiety and fear in paediatric dental practice: a systematic review of randomized controlled trials. Int J Paediatr Dent 2019; DOI: 10.1111/ipd.12499.

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Commentary

Dental anxiety in children is common1 and its management is challenging for all those involved, from the patient, to the treating clinician and any patient caregiver. Each year in the UK, tens of thousands of children are subject to pharmacological management techniques such as general anaesthesia to facilitate addressing their dental needs. However, the evidence base relating to the detrimental effects of such techniques on children's development, their perceptions of dentistry and the health economic implications are significant. Fear and anxiety are emotional states that might trigger behavioural management problems during dental appointments, manifesting as inability, or difficulty, to cooperate and engage during dental treatment and delivery of oral care advice. Additionally, negative dental experiences during childhood and adolescence can influence people's perceptions of dental care in their adult life.2

Helping child patients to manage their dental anxiety may be of great importance to their self-efficacy around oral health throughout life and so tools to assist dental care professionals in achieving this are important. Distraction techniques are taught at undergraduate level and considered effective in other areas of healthcare3 yet the evidence for its use in dentistry is not clear. Synthesis, to clarify what works and what doesn't, as well as who certain distraction techniques might work best for, would help guide clinicians in successful use of distraction as one of the tools in their box.

This systematic review of RCTs to assess the efficacy and effectiveness of dental anxiety management through distraction techniques followed an intensive database search, inclusive of grey literature, without restrictions imposed on publication date or languages. Following independent screening, the authors included 21 studies that used a range of distraction techniques to manage children's dental anxiety. Data extraction was completed by the same authors, independently, using standardised forms. The Cochrane Collaboration's Risk of Bias Tool (CCRBT) was used to assess the methodological quality of the studies. Intra-study risk of bias was variable across domains, with only sequence generation of high methodological quality across all studies. The authors state blinding of participants and assessors as the main sources of bias, however, it is unclear how this could have been achieved given the nature of the interventions.

Between the 21 studies, the variety of distraction tools/techniques used, the participant age ranges studied, and the different methods with which child dental anxiety was measured (n = 25): physiological measurements (n = 5); patient reported outcome measures (n = 11); and dentist perception (n = 9), meant that inter-study heterogeneity was too great to allow meta-analyses to be performed. As such, the results of this systematic review are inconclusive and the evidence presented of very low certainty.

Within dentistry, there are several studies that have investigated the clinical effectiveness of distraction techniques to reduce dental anxiety in children, yet there is a lack of synthesised evidence, or datasets that allow for quantitative synthesis. There is no evidence of harm, nor any contraindications, associated with the use of distraction techniques to manage children's dental anxiety. However, because of the study quality, wide range of techniques available and the different outcomes that are measured, this systematic review provides only evidence of very low certainty relating to their clinical effectiveness. The evidence base would benefit from high quality RCTs with homogenous data sets to allow meta-analyses, consistency of distraction techniques employed and agreed outcome sets to direct clinicians around use of potentially low-cost, easily applied techniques that could have significant implications for patients' treatment and perceptions of dental care.