Comparison of anxiety levels associated with noise in the dental clinic among children of age group 6-15 years Radhika Muppa, Prameela Bhupatiraju, Mahesh Duddu, Narendra Varma Penumatsa, Arthi Dandempally, Priyanka Panthula Department of Pedodontics and Preventive Dentistry, Panineeya Institute of Dental Sciences and Research Centre, Dilsuknagar, Hyderabad, Andhra Pradesh, India Abstract Fear or anxiety due to noise produced in the dental clinic is rated third among the reasons to avoid dental visits The aim of the present study was to determine anxiety levels associated with noise in a dental clinic The study was done using a survey questionnaire containing 10 questions and was divided into two parts The first part included demographic information such as name, age, gender, and school; the second half included questions regarding patient’s feelings toward noise in the dental clinic and its possible link to dental anxiety Two‑hundred and fifty children and adolescents of age group 6‑15 years participated in the study Results of the study showed that 50% of females, 29% males avoided a visit to the dentist because of anxiety and fear, 38% subjects of age group 6‑11 years reported that sound of the drill makes them uncomfortable, followed by having to wait in the reception area Gender gap was also observed with more females feeling annoyed than males on the 1‑10 annoyance level scale More than 60% felt “annoyed” to “extremely annoyed” by noise in the dental clinic 45% of subjects preferred watching television to cope with such noise This study concludes that the noise produced in dental clinic is anxiety provoking and significantly contributes to avoidance of dental treatment and the best way opted by the majority of subjects to overcome this anxiety was audiovisual distraction method Keywords: Anxiety, audiovisual distraction, noise, sounds of dental drill Introduction Anxiety is defined as an emotional response (e.g., feelings of fear, apprehension, tension, uneasiness) and/or physiological response (e.g., sweating, feeling restless or tense, rapid heartbeat) to known and/or unknown causes that may range from a normal reaction to extreme dysfunction (indicative of an anxiety disorder).[1] Dental anxiety is a significant problem for patients and dental care providers Children who have dental anxiety tend to avoid necessary dental treatment and once in the dental chair they are often difficult to treat.[2] Avoidance of dental treatment owing to anxiety is common and appears to be associated strongly with significant deterioration of oral and dental health, leading to a vicious cycle of cumulative anxiety and increase in avoidance.[2] Access this article online Quick Response Code: Website: www.noiseandhealth.org DOI: 10.4103/1463-1741.112371 PubMed ID: *** Noise & Health, May-June 2013, Volume 15:64, 190-93 Over recent decades, clinical practice of dentistry has moved ahead with major advances in techniques, technologies and materials at the same time public awareness of oral health has improved Despite these gains, anxiety related to dental environment is a problem suffered by many patients Dental anxiety has been ranked fifth among commonly feared situations Given its high prevalence, it is not unexpected that patients with dental anxiety avoid dental visits.[3] Anxious children demand considerable dedication and expertise in child management techniques from the dentist and dental staff Although many management techniques are successful, the present trend is moving toward non‑invasive techniques, which are successfully used in medical setting.[4] Quite a large number of studies have been conducted to identify the potential anxiety provoking stimuli present in the dental setting These stimuli include the sight of the needle, smell of different dental materials, noise produced in dental clinic and various aspects of the drill such as its appearance, sound and feeling.[5] The present study is aimed at one such factor that is noise in the dental clinic and its effect on patient’s anxiety 190 Muppa, et al.: Anxiety associated with noise in dental clinic among children Methods 0.001) and 27% of females, 23% males reported to avoid visit to the dentist because of noise produced in dental setup Sample selection Two hundred and fifty children and adolescents of age group 6‑15 years who reported to Department of Pedodontics and Preventive Dentistry for treatment were selected for study to assess the effect of noise on the patients Questionnaire survey Survey questionnaire based on Corah’s dental anxiety was used containing 10 questions, which consisted of two parts: The first part included demographic information such as name, age, gender, and school The second part of the survey included questions aimed at patient’s feelings toward noise in the dental clinic and its possible link to dental anxiety Results A First part of survey questionnaire was about demographic information [Table 1] The entire sample was divided into two groups, i.e., 6‑11 years (pre‑adolescent) and 12‑15 years (adolescent) age, majority of them were females B Second part of the questionnaire included the following questions: Is it your first visit to the dentist? For 26% of children it was their first visit to the dentist How they feel about anticipatory dental visit? a Comfortable b Anxious c Fearful d Extremely fearful Majority of females feel more anxious about their dental visit Reasons for avoiding visit to dentist? a Anxiety and fear b Past dental experience c Fear of noise produced in dental setup d Other factors Avoidance of dental visits because of anxiety and fear was significantly higher among females than males (P < Table 1: Demographic data (%) Gender Male Female Age (years) 6‑11 12‑15 191 39 61 70 30 Which of the following makes them uncomfortable? a Sound of dental drill b Sound of suction apparatus c Smell in dental clinic d Having to wait in reception area Majority of pre‑adolescent age group ranked sounds of the drill as the first factor, which makes them uncomfortable followed by having to wait in reception area How annoying you find the noise from various dental tools in dental clinic? Annoyance scale [Table 2] was used to assess the response of patients who were asked to circle their level of annoyance on the following scale.[6] According to you, which is the most effective way to cope with noise? a Listening to soft music b Watch TV c Constant interaction with operator d Nothing would effect Discussion The present study was aimed at determining the effect of noise in dental clinic and its effect on children in the age group 6‑15 years In dentistry, researchers have focused on the effect of noise in the dental clinic on dental professionals, who are exposed to high noise levels for extended periods Study done by Folmer linked noise from tools used in the dental clinic, such as hand pieces, to induce‑hearing loss.[5] This study as well as other studies[7‑10] have concentrated on professionals working in dental clinics, ignoring the effect of such noises on the patients Even though exposure is limited to the treatment time, which may not induce hearing loss, there are indications that dental anxiety, related to fear is aroused by dental equipment/instruments which tend to be a source of patient discomfort.[11,12] Avoidance of dental treatment is associated strongly with significant deterioration of oral and dental health,[13] leading to a vicious cycle of cumulative anxiety and increased avoidance.[14] From this point of view it is easy to see why as children it is important for everyone to learn adaptive and effective ways of coping with dental anxiety Table 2: Annoyance scale Not at all annoyed Moderately annoyed Annoyed Very annoyed Extremely annoyed Noise & Health, May-June 2013, Volume 15 Muppa, et al.: Anxiety associated with noise in dental clinic among children In the present study when compared to males, majority of females (50%) avoid dental visits because of anxiety and fear [Figures and 2], the results of which coincided with majority of studies, which have found higher prevalence rates for dental anxiety in females than males.[15‑19] It was also suggested by Chellappah et al.[20] that dental high‑speed air turbine (drill), which is an indispensable apparatus in dental treatment, is the cause of dental anxiety in young children In the present study, 38% of children in the age group of 6‑11 years and 21% of children of age group 12‑15 years have reported that sounds of drill makes them uncomfortable, followed by having to wait in reception area [Figure 3] The period of time spent waiting for dental treatment is cited commonly by patients as being anxiety provoking, as it increases time to think about what will (or could) happen and to ponder the worst‑case outcomes.[21] It was also evident that more than 60% of the subjects felt “annoyed” to “extremely annoyed” from dental tools [Figure 4] This emphasizes the need for supporting staff in the dental practice to be aware of an anxious patient and to actively take measures to reduce their concern A wide variety of techniques are available in managing a child with dental anxiety such as tell‑show‑do, relaxation, distraction, systematic desensitization, modeling, audio analgesia, hypnosis.[22] Among all these techniques, behavior management techniques such as papoose board and hand &RPIRUWDEOH $Q[LRXV 0DOH )HDUIXO ([WUHPHO\ IHDUIXO )HPDOH Figure 1: Percentages showing subjects feeling toward dental visit over mouth technique can be successful, but the attitude of parents and dental professional toward these techniques are changing.[23] Now non‑aversive techniques like distraction are becoming more popular In the present study, 45% children preferred watching TV to cope with noise followed by listening music of their own choice [Figure 5] Observations by Aitken et al have shown that audiovisual distraction was most effective means of managing the anxious children.[24] Reduction of anxiety in the audiovisual distraction technique may be attributed to a variety of reasons According to Klein and Winklestein[25] this will help the children to gain control over the unpleasant stimulus and give them a feeling of being in a familiar environment Secondly, the child seeing the audiovisual presentation will have multi‑sensory distraction as he/she will tend to concentrate on the TV screen thereby blocking the sight of dental treatment, the sound of the program will help the child to eliminate the unpleasant dental sounds such as the sound of handpiece Other than distraction techniques there are various other methods through which child can cope with anxiety Coping can be categorized into behavioral and cognitive type In behavioral coping three strategies are identified: Information seeking according to Curry and Russ (1985) is an “attempt to obtain information by asking question or inspection of instruments.” In the present study, 23% males and 16% females preferred interacting with the operator in order to cope with dental anxiety Support seeking includes physical and verbal contact with dentist or assistant $Q[LHW\ IHDU 3DVW H[SHULHQFH 0DOH 1RLVH 2WKHU )HPDOH Figure 2: Reasons for avoiding dental treatment 6RXQGRI GULOO 6RXQGRI VXFWLRQ \HDUV 6PHOOLQ GHQWDO RIILFH +DYLQJWR ZDLWLQ UHFHSWLRQ 2WKHUV \HDUV Figure 3: Reasons which make the children more uncomfortable in dental clinic Noise & Health, May-June 2013, Volume 15 1RWDWDOO 0RGHUDWHO\ $QQR\HG DQQR\HG DQQR\HG 0DOH 9HU\ DQQR\HG ([WUHPHO\ DQQR\HG )HPDOH Figure 4: Annoyance level - >60% of subjects felt “annoyed” to “extremely annoyed” by noise from dental tools 192 Muppa, et al.: Anxiety associated with noise in dental clinic among children /LVWHQLQJWR VRIWPXVLF :DWFKWY 0DOH &RQVWDQW 1RWKLQJZRXOG LQWHUDFWLRQ HIIHFW ZLWKRSHUDWRU )HPDOH Figure 5: Preferred ways to cope with noise in dental clinic Majority of children prefer watching TV to cope Direct effort is when the ‘child attempts to actively participate in the treatment process which should be encouraged by the dentist In cognitive coping strategy child is encouraged to think positive about the treatment which is known as positive restructuring According to a study done by Van Meurs et al (2005) the older children use cognitive strategies and younger children use more of behavioral coping strategies Evidence supports that coping skills in case of pain and anxiety can be taught to children to overcome dental anxiety Conclusion This study concludes that noise produced in a dental clinic is anxiety provoking and significantly contributes to avoidance of dental treatment and the best way opted by majority of subjects to overcome was audiovisual distraction method These results clearly indicate that noise produced by various tools used is a cause of concern to patients as well as dentists Further research in area of manufacturing quieter dental hand pieces needs to be done to avoid long‑term health effects and dental drop outs Address for correspondence: Dr Radhika Muppa, Department of Pedodontics and Preventive Dentistry, Panineeya Institute of Dental Sciences and Research Centre, Dilsuknagar, Hyderabad - 500 060, Andhra Pradesh, India E-mail: svs.radhika@gmail.com References Shahrrokh, N.C., and Hales, R.E.:American psychiatric glossary (8th ed.) Washington, D.CAmerican psychiatric publishing, 2003 Lahmann C, Schoen R, Henningsen P, Ronel J, Muehlbacher M, Loew T, et al Brief relaxation versus music distraction in the treatment of dental anxiety: A randomized controlled clinical trial J Am Dent Assoc 2008;139:317‑24 Yamini V, Bailwad SA, Nirmala SVSG Effectiveness of music distraction in the management of anxious pediatric dental patients Ann Essence Dent 2010;2:1‑5 Kudo T, Mishima R, Yamamura K, Mostafeezur R, Zakir HM, Kurose M, et al Difference in physiological responses to sound stimulation 193 in subjects with and without fear of dental treatments Odontology 2008;96:44‑9 Wong HM, Mak CM, Xu YF A four‑part setting on examining the anxiety‑provoking capacity of the sound of dental equipment Noise Health 2011;13:385‑91 Elmehdi HM Assessing acoustic noise levels in dental clinics and its link to dental anxiety and fear among UAE population ICA; August 2010 pp 23‑7 Hearing loss and high‑speed dental tools, 2006 Available from: http:// www.medicalnewstoday.com [Last accessed 2006 Aug 17] Prevention of noise‑induced hearing loss: A report of a WHO‑PDH Informal Consultation, Geneva; Available from: http://www.who.int/ pbd/deafness/en/noise.pdf October 1997 [Last accessed 1997 Oct 28] Hopp ES Acoustic trauma in high‑speed dental drills Laryngoscope 1962;72:821‑7 Wazzab KA, Al Qahtani, MQ, Al‑Muhaimeed HS, Khan H Hearing problems among dental professionals J Pak Dent Assoc 2005;14:210‑4 10 Hoelimar FA Factors affecting patient drop out from dental care at the community health centres of Kelurahan Master Thesis Indonesia: University of Sydney; 1985 11 Unlu A, Boke B, Belgin E, Samrmadi H Effect of equipment used in laboratory environment on dental technicians hearing threshold J Islamic Acad Sci 1994;7:237‑40 12 Mehrstedt M, Tönnies S, Eisentraut I Dental fears, health status, and quality of life Anesth Prog 2004;51:90‑4 13 Enkling N, Marwinski G, Jöhren P Dental anxiety in a representative sample of residents of a large German city Clin Oral Investig 2006;10:84‑91 14 Hakeberg M, Berggren U, Carlsson SG Prevalence of dental anxiety in an adult population in a major urban area in Sweden Community Dent Oral Epidemiol 1992;20:97‑101 15 Neverlien PO Normative data for Corah’s Dental Anxiety Scale (DAS) for the Norwegian adult population Community Dent Oral Epidemiol 1990;18:162 16 Doerr PA, Lang WP, Nyquist LV, Ronis DL Factors associated with dental anxiety J Am Dent Assoc 1998;129:1111‑9 17 Moore R, Birn H, Kirkegaard E, Brødsgaard I, Scheutz F Prevalence and characteristics of dental anxiety in Danish adults Community Dent Oral Epidemiol 1993;21:292‑6 18 Milgrom P, Fiset L, Melnick S, Weinstein P The prevalence and practice management consequences of dental fear in a major US city J Am Dent Assoc 1988;116:641‑7 19 Chellappah NK, Vignehsa H, Milgrom P, Lam LG Prevalence of dental anxiety and fear in children in Singapore Community Dent Oral Epidemiol 1990;18:269‑71 20 Cohen SM, Fiske J, Newton JT The impact of dental anxiety on daily living Br Dent J 2000;189:385‑90 21 Allen KD, Stanley RT, McPherson K Evaluation of behavior management technology dissemination in pediatric dentistry Pediatr Dent 1990;12:79‑82 22 Lawrence SM, McTigue DJ, Wilson S, Odom JG, Waggoner WF, Fields HW Jr Parental attitudes toward behavior management techniques used in pediatric dentistry Pediatr Dent 1991;13:151‑5 23 Prabhakar AR, Marwah N, Raju OS A comparison between audio and audiovisual distraction techniques in managing anxious pediatric dental patients J Indian Soc Pedod Prev Dent 2007;25:177‑82 24 Aitken JC, Wilson S, Coury D, Moursi AM The effect of music distraction on pain, anxiety and behavior in pediatric dental patients Pediatr Dent 2002;24:114‑8 25 Klein SA, Winkelstein ML Enhancing pediatric health care with music J Pediatr Health Care 1996;10:74‑81 How to cite this article: Muppa R, Bhupatiraju P, Duddu M, Penumatsa NV, Dandempally A, Panthula P Comparison of anxiety levels associated with noise in the dental clinic among children of age group 6-15 years Noise Health 2013;15:190-3 Source of Support: Nil, Conflict of Interest: None declared Noise & Health, May-June 2013, Volume 15 Copyright of Noise & Health is the property of Medknow Publications & Media Pvt Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission However, users may print, download, or email articles for individual use ... Panthula P Comparison of anxiety levels associated with noise in the dental clinic among children of age group 6- 15 years Noise Health 2013 ;15: 190-3 Source of Support: Nil, Conflict of Interest:... turbine (drill), which is an indispensable apparatus in dental treatment, is the cause of dental anxiety in young children In the present study, 38% of children in the age group of 6? ??11 years. .. Constant interaction with operator d Nothing would effect Discussion The present study was aimed at determining the effect of noise in dental clinic and its effect on children in the age group 6? ? ?15 years