Animal-assisted Therapy as a Potential Tool for Management of Dental Anxiety in Children: A Questionnaire-based Cross-sectional Study
Correspondence Address :
Dr. Bashyam Nalini,
D-No-24-81-2/2, Sanath Nagar, Gajuwaka, Visakhaptnam, Andhra Pradesh, India.
E-mail: nalini.bashyam99@gmail.com
Introduction: Animal-Assisted Therapy (AAT) is being developed as an alternative approach to reduce the anxiety and comfort the apprehensive patients. Hence, to evaluate the child’s and parental acceptance of pets in dental operatory, their favourite pet, child’s choice of live pet over soft toy, their preference of own pet vs therapy, more hairy pets vs less hairy pets, play area vs child’s lap, the present study is undertaken.
Aim: To evaluate the influence of pets in reducing anxiety of children in the dental operatory and acceptance of this technique by the children and the parents.
Materials and Methods: This questionnaire-based cross-sectional study was conducted on 65 children of age group 3-12 years and their parents who attended the Department of Pedodontics and Preventive Dentistry, GITAM Dental college and Hospital, Visakhapatnam, Andhra Pradesh, India for a period of two weeks in the month of July 2018. They were assessed for anxiety and the influence of pets on anxiety levels using questionnaire and picture cards. The data was statistically analysed using Chi-square test.
Results: An 83.3% of parents and 75.4% of children felt that pets in the dental operatory are useful in reducing the anxiety. A 58.5% of children preferred live pets whereas only 33.3% parents preferred them. Dog was found to be the most favourite pet for very young children (31.6%) whereas older children preferred rabbit (43.5%).
Conclusion: Animal-assisted therapy was found to be useful in reducing the anxiety of children during dental visit.
Behaviour management, Fear, Parents, Pets
In children, fear and anxiety are significant barriers to the dental care resulting in avoidance of dental treatment and consequent poor oral health and reduced quality of life (1). Statistics have shown that between 3-43.4% of the children exhibited anxiety during dental treatment worldwide (2). Dental fear is defined as an emotional reaction to a threatening stimuli in a dental setup, while, a state of apprehension that something dreadful is going to happen in relation to dental treatment is termed as dental anxiety. Dental anxiety is also associated with a sense of losing control (3). Children are not very capable to express their fears and anxiety because of their limited communicative skills and their inability to cope up with threatening dental stimuli often manifests in behaviour management problems. So, early recognition and management of fear and anxiety is the key for effective dental treatment (4).
Many non pharmacological and psychological behaviour management techniques have been in use to address the child’s behaviour in dental operatory. Some of them aim to improve the communication between the patient and the pedodontist, while others are intended to eliminate the inappropriate behaviour and reduce anxiety (4).
Various forms of pre-exposure to the dental setting procedures have been suggested in modifying child’s behaviour and one such technique is AAT. Animal assisted therapy is an applied interdisciplinary approach that uses animals to solve human behavioural problems, as an adjunct to other therapies (5). It involves the interaction between the patient and an animal that has been specially trained for this therapy (6). Using animals for solving human issues has been in practice since a long time, Levinson BM and Mallon GP, a psychologist and one of the early pioneers of AAT first used a dog in psychotherapy sessions with children and found that children were better able to communicate and express their feelings when relating to a therapy dog during these sessions (7). Apart from dogs, other animals like cats, rabbits, fish, and tortoise have also been tried as therapeutic animals in AAT (6).
The Pedodontist solely cannot make decisions regarding the use of any behaviour guidance techniques other than communicative management. It should also involve the parent and the child, if appropriate (8). The parent shares the decision whether or not to treat and must be consulted regarding treatment strategies and potential risks. Informing the parent about the nature, risk, and benefits of the technique to be used and any professionally-recognised or evidence-based alternative techniques is essential to obtaining informed consent (8).
Hence, in order to bring awareness about the concept of AAT in dental operatory, the present study was undertaken to evaluate the influence of pets in reducing anxiety of children in the dental operatory and acceptance of this technique by the children and their parents.
This questionnaire based cross-sectional study was conducted in the Department of Pedodontics and Preventive Dentistry at GITAM Dental College and Hospital, Visakhapatnam, Andhra Pradesh, India, with the permission taken from the Head of the Department. Since the study was questionnaire based, Ethical Committee Clearance may not warrant.
A total of 65 children and their parents, 33 male and 32 female in the age group of 3-12 years with no prior dental visit were randomly selected for a period of two weeks in the month of July 2018 and included in the study after obtaining the parental consent. Considering the present study as pilot study, smaller sample size was taken. The total number of parents participated in the study were 60. The difference in the number of children and parents was because the children were siblings of same parent. Children were divided into two groups based on their age:
Group 1- children of 3-6 years
Group 2- children of 6-12 years
Inclusion criteria: Children aged between 3-12 years without prior dental visit were included in the study.
Exclusion criteria:
• Children with a previous dental experience.
• Children and parents who are not willing to participate.
• Children with systemic diseases, mental and physical disorders.
Survey Procedure
Once the children and their parents enter the dental operatory they were briefly informed about the nature of the study and both children and parents were given separate questionnaire containing 12 [Annexure 1] and 11 [Annexure 2] questions respectively with multiple options in their language of preference and were asked to mark the most appropriate answer. The questionnaire was prepared on the basis of previous study (6) and modified according to the present study. Also, for better understanding, younger children between 3-6 years were showed the picture cards containing the images of pet animals. All this was carried out by a single interviewer to avoid the bias.
Statistical Analysis
All the collected data was entered into an Excel file (Microsoft version 2010) and analysis was carried out using Statistical Package for the Social Sciences (SPSS) version 21.0. Chi-square test was used for analyses of categorical data with p-value <0.05 considered to be statistically significant.
Parent’s acceptance: About 83.3% of the parents (Table/Fig 1) considered the relationship between the child and the pet to be positive and felt that this association of the child with soft toys/live pets would reduce the child’s anxiety in the dental operatory. A 33.3% of the parents preferred live pets against soft toys and dog was found to be the preferred animal (60%) (Table/Fig 1). Only 21.7% of the parents (Table/Fig 1) wanted these pets to be trained and many (85%) (Table/Fig 2) felt that pets are better placed in the play area rather than on the patient’s lap. As none of the parent had answered the 12th question i.e, it was considered as miscellaneous.
Child’s preference according to age and gender: Of the total 65, 30 children (46.2%) felt that they would be anxious on entering the dental operatory (Table/Fig 3) and 75.4% felt that their association with the pets would reduce the dental anxiety (Table/Fig 4) and many of them (58.5%) opted for live pets over soft toys (Table/Fig 5).
Most of the younger children (31.6%) preferred dog or cat whereas older children (43.5%) preferred rabbit as their favourite pet (Table/Fig 4). About 66.4% (Table/Fig 5) preferred own pets rather than the trained pets and 78.5% of the children preferred more hairy pets (Table/Fig 4).
Fear refers to the actual or activated response to an object or situation whereas anxiety is an emotional state which precedes an encounter with a feared object or situation (9). Anxiety has been described as coherent and a unique cognitive affective structure within our motivational and defensive system (10). Even both anxiety and fear involve behavioural, physiological, emotional, and cognitive components, but their way of expression is different from child to child (9). It is important for a Pedodontist to employ a wide range of behaviour guidance techniques in order to meet the needs of the individual child since they exhibit a diversity of attitudes and temperament. To provide a good oral healthcare for infants, children, adolescents, and persons with special healthcare needs, the American Academy of Pediatric Dentistry (AAPD) recognised a continuum of both non pharmacological and pharmacological behaviour guidance techniques to promote a positive dental attitude, safety, and quality of care which are of utmost importance (11). Besides, the uncomplicated techniques such as providing information, tell show do, and signalling, there are various distinct psychological approaches to control dental fear and anxiety in children which may range in complexity from those that are relatively easy to perform while others require specialised training (5). One such technique is AAT, a type of psychotherapy which employs the presence of animals within therapy setting, addresses the issues and provides approach for circumventing the difficulties during treatment (12).
Hence, the questionnaire-based cross-sectional study was carried out to find the parental and child’s acceptance of pets in the paediatric dental clinic. In the present study, 33.3% of the parents have believed that the presence of pets would reduce their child’s anxiety in dental operatory, and this is in accordance with a study conducted by Stefanini MC et al., in Italy, where the parents of the children with severe psychiatric problems thought that their children had greater acceptance of hospital experience, clinical practices and treatments with a significant improvement in their emotional expression and social skills after receiving AAT (13). Also, mostly parents of all age groups gave consent for the presence of pet, in which 50% of the parents were of 9-12-year-old children (6). The results of the present study have showed that about 60% of the parents preferred dog, 78.3% of the parents preferred own pets over trained pets and 85% of the parents have felt that play area is safe rather than on child’s lap.
Taking into consideration, the Piaget’s grouping of children based on cognitive growth (14), the present study divided the children into two groups of 3-6 years and 6-12 years.
Children of 3-6 years preferred dog or cat as their favourite pet. This could be because dog is the most common pet in Indian households and kittens being ?uffy feline, which is in accordance to study by Gupta N and Yadav T (6). About 48.5% of the boys preferred dog as their favourite pet. This is similar to the results obtained from study conducted by Gupta N and Yadav T where 56.7% of the boys preferred dog (6). In the present study, most of the girls (43.8%) preferred rabbit as in the study conducted by Wedl M and Kotrschal K (15). About 58.5% children in this study preferred live pets over soft toys and the reason for this could be the fact that interaction with a live dog creates a more playful and social environment when compared to toys in children (16).
About 66.4% of the children preferred own pets rather than the trained pets which is explained by Kidd AH and Kidd RM that 98% of the 3-year-old children loved their family pets which already formed a human companion animal attachments (17). A 75.8% of the boys preferred that pets are better to be placed in the play area whereas girls gave equal preference to play area and the child’s lap for placing the animal.
Beetz A et al., stated that support by a friendly dog was associated with significantly lower cortisol levels than support by a friendly human during a social stress test in children with insecure attachments (18). Children receiving sensitive, appropriate, and consistent care giving behaviour by a significant approach will become securely attached and will be able to enter into loving, trusting, empathetic relationships (12). However, infection control guidelines and potential health risks must be take into account when incorporating a therapy dog because parents are concerned about bites and scratches, hygiene issues and health risks like parasitic infections (1).
The eventual objective of the pedodontist is to accomplish communication in order to alleviate fear and anxiety, deliver quality dental care, build a trusting relationship between the dentist and child, and promote the child’s positive attitude toward oral health and oral healthcare.
Limitation(s)
A large sample size is required in order to obtain considerable result which was considered as limitation of the study. Since, the present study was questionnaire-based, further clinical trials are necessary in order to assess the acceptance and influence of AAT in the reduction of dental anxiety in children. Furthermore, the use of biological markers like pulse oximeter could be a proof that AAT helps in reduction of child’s anxiety.
Hence, AAT could be a potential behaviour management tool for children having anxiety issues as most of the children felt that their association with the pets would reduce the dental anxiety. Also, parents considered the relationship between the child and the pet to be positive. Furthermore, parents should be made more aware of clinical application of AAT in dental operatory.
DOI: 10.7860/JCDR/2022/48868.15992
Date of Submission: Feb 04, 2021
Date of Peer Review: Mar 09, 2021
Date of Acceptance: Nov 26, 2021
Date of Publishing: Feb 01, 2022
AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? No
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. No
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