Received: 7 November 2018 

|  Revised: 4 February 2019 

|  Accepted: 15 March 2019

DOI: 10.1111/ipd.12499

REVIEW ARTICLE

Use of distraction techniques for the management of anxiety

and fear in paediatric dental practice: A systematic review of
randomized controlled trials

Ivana Meyer Prado   | Larissa Carcavalli   | Lucas Guimarães Abreu   |

Júnia Maria Serra‐Negra   | Saul Martins Paiva   | Carolina Castro Martins

Department of Pediatric Dentistry

and Orthodontics, School of
Dentistry, Universidade Federal de Minas
Gerais, Belo Horizonte, Minas Gerais,
Brazil
Correspondence
Ivana M. Prado, Department of Pediatric
Dentistry and Orthodontics, School of
Dentistry, Universidade Federal de Minas
Gerais, Av. Antônio Carlos,
6627 – Faculdade de Odontologia,
Campus Pampulha. Belo Horizonte,
Minas Gerais, Brazil.
Email: imyprado@gmail.com
Funding information
Coordenação de Aperfeiçoamento de
Pessoal de Nível Superior, Grant/Award
Number: 001; Conselho Nacional de
Desenvolvimento Científico e Tecnológico;
Fundação de Amparo à Pesquisa do Estado
de Minas Gerais; Universidade Federal de
Minas Gerais
Abstract
Objective: To determine whether distraction techniques (DT) reduce children's/ado-
lescent's anxiety and fear during dental treatment.
Methods: Randomized controlled trials (RCTs) in which any type of DT were used
to manage dental anxiety and dental fear in children/adolescents were included. A
systematic search of PubMed, Web of Science, Scopus, Cochrane Library, Lilacs,
and Google Scholar was conducted. Two independent reviewers selected studies,
extracted data, assessed methodological quality of studies using the Cochrane
Collaboration's Risk of Bias tool (CCRBT), and approached certainty of evidence
using GRADE (Grading of Recommendations, Assessment, Development and
Evaluation). Data were analysed descriptively.
Results: Twenty studies covering several types of DT (audio, audiovisual, instru-
ments camouflage, biofeedback, dental operating microscope, toys) were included.
Qualitative analysis showed with very low certainty of evidence that DT effectively
reduced dental anxiety and fear depending on the distraction type, instrument used to
measure dental anxiety and dental fear, and dental procedure. CCRBT evaluation
identified many methodological issues in included studies.
Conclusion: There is a very low certainty of evidence that DT can be effective in
managing children's/adolescents’ dental fear and anxiety during dental treatment.
The heterogeneity of methodologies and findings in the studies, however, suggests
more robust, and well‐executed RCTs are needed.

KEYWORDS
child behaviour, dental anxiety, dental fear, distraction

1  |   IN TRO D U C T ION their expression may vary between individuals.1,3 Anxiety

Dental anxiety is an emotional condition anteceding a dental
appointment.1-3 Dental fear is the emotional reaction (some-
times hysterical) to the dental appointment or to a specific
situation in a dental setting.1,2 Both can involve behavioural,
cognitive, emotional, and physiological components, and
and fear main function is to act as a signal of danger, threat,
or conflict, and they are predominantly mediated by sympa-
thetic activation (hypertension, tachycardia).4 The prevalence
of dental fear and anxiety among children ranges from 6%
to 42% in different populations.5-9 The management of chil-
dren's dental fear and dental anxiety can be challenging and

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© 2019 BSPD, IAPD and John Wiley & Sons A/S. Int J Paediatr Dent. 2019;29:650–668.
Published by John Wiley & Sons Ltd
PRADO et al.
stressful, not only for the paediatric dentist but also for the
patient and his/her caregiver.5,10,11
Pain perception has a large psychological component based
on the amount of attention directed toward the noxious stimu-
lus modulating the pain.12 Distraction techniques are anxiety‐
reducing strategies that overload the patient's limited attention
capacity, thus diverting their attention from unpleasant pro-
cedures (noxious stimuli).12-14 Distraction techniques can be
active or passive.15 Active techniques involve activities that
require the direct participation of the child, such as the use of
toys and games.15 Passive techniques rely on the use of music
and video and do not require the child to directly participate.15
Distraction seems to be a safe and low‐cost strategy that
can have a positive impact on young individual's dental fear
and anxiety, thus improving the quality of dental care.16-18
Knowledge on the effectiveness of distraction techniques
may be helpful to increase clinician's confidence during the
management of fearful or anxious children and to assist the
practitioner in the improvement of children's and adolescent's
behaviour and experience during dental care, creating a more
pleasant environment for the patient, his/her parents and the
paediatric dentist.
Many original studies have evaluated the effect of differ-
ent types of distraction techniques for dental fear and dental
anxiety. Two reviews19,20 have addressed this issue, but these
studies have summarized the evidence regarding specific
techniques, such as audiovisual distraction19 and non‐phar-
macological interventions.20 No systematic review in the
literature, however, has summarized the scientific evidence
regarding the efficacy of all types of distraction techniques
during dental treatment thus far. Therefore, the aim of the
present systematic review was to determine whether distrac-
tion techniques reduce children's and adolescent's dental anx-
iety and fear during dental treatment.
2  |  M ATE R IA L S A N D ME T HODS
The reporting of this systematic review follows the Preferred
Reporting Items for Systematic Reviews and Meta‐Analyses
(PRISMA) statement checklist.
2.1  |  Protocol and registration
This systematic review was registered on the International
Prospective Register of Systematic Reviews (PROSPERO)
under protocol number CRD42018084731.
2.2  |  Eligibility criteria
The inclusion criteria were randomized controlled trials
(RCTs) in which distraction techniques were used for the
management of dental anxiety and dental fear in paediatric
  
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Why this paper is important for paediatric
dentists
• Children's and adolescents’ dental fear and dental
anxiety can be a challenge and a stress factor for
paediatric dentist but also for patients and their
parents/caregivers. Distraction techniques are fre-
quently used by paediatric dentists during dental
treatment, but it is important that clinicians know
the scientific evidence regarding this topic.
• This paper shows the very low certainty of evi-
dence about the use of distractions techniques to
reduce dental anxiety and fear among children and
adolescents, discussing the efficacy of each type
of distraction technique and rises important issues
on the topic for future research.
dental patients under 18 years old. The following PICO was
applied: Population: children and adolescents younger than
18 years old with no alterations in growth or development
and without cognitive disorders or syndromes; Intervention:
use of distraction techniques during dental treatment;
Comparison: no use of distraction techniques during dental
treatment; Outcome: dental anxiety and/or dental fear.
There were no restrictions regarding article publication
date, language, or types of distraction technique. Exclusion
criteria were preliminary studies without conclusive results,
review articles, case reports, letters to the editor, expert opin-
ions, and meeting abstracts.
2.3  |  Information sources
Electronic searches from the databases’ date of inception
up to July 2018 were conducted in the following databases:
MEDLINE through PubMed, Web of Science, Scopus,
Cochrane Library, and the Latin American and Caribbean
Health Sciences Literature (Lilacs). A manual search of the
references of the included articles was also performed to
identify any other studies that might have been missed in the
electronic search. A grey literature search was performed
using the clinical trials database of the US National Library
of Medicine. Finally, a search in Google Scholar, restricting
the search by the first 100 most relevant hits, was conducted.
References were managed using Endnote® software (Clarivate
Analytics).
2.4  |  Search strategy
The search strategy used in each database is presented in
Table 1. The descriptors used were identified using Medical
Subject Headings (MeSH) terms.
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652       PRADO et al.

T A B L E 1   Search strategy used in each database

Electronic databases Search strategy

PubMed, Web of Science, Scopus, Cochrane Library, ((dental anxiety OR dental fear OR dental phobia OR odontophobia) AND (distrac-
Lilacs tion OR behavior guidance OR child management OR audiovisual distraction OR
music distraction) AND (dental care OR dental treatment OR dentistry OR oral
health))
Clinical trials ((dental anxiety OR dental fear OR dental phobia OR odontophobia) AND (distrac-
tion OR behavior guidance OR child management OR audiovisual distraction OR
music distraction))
Google Scholar ((dental anxiety OR dental fear OR dental phobia OR odontophobia) AND (distrac-
tion OR behavior guidance OR child management OR audiovisual distraction OR
music distraction) AND (dental care OR dental treatment OR dentistry OR oral
health))

authors when necessary. All extracted information is shown

2.5  |  Study selection
Study selection was completed by two independent and
trained researchers (LCS and IMP) in two phases. In phase
one, the researchers screened and pre‐selected the studies
based on their titles and abstracts. Studies that did not fulfil
the eligibility criteria were excluded. The full text of manu-
scripts lacking sufficient information in the titles/abstracts
was retrieved to aid the decision for inclusion or exclusion.
In phase two, the full‐text articles were evaluated according
to the same eligibility criteria; those meeting the eligibility
criteria were included. Disagreements between the two re-
searchers at any phase were resolved by means of a discus-
sion until a consensus was reached. When necessary, a third
researcher (CCM) was involved. Multiple publications refer-
ring to a single study were included when the articles evalu-
ated the use of distraction techniques during different dental
procedures.
in Table 2.
2.8  |  Risk of bias in individual studies
Two researchers (LCS and IMP) independently assessed
the risk of bias in each selected study according to the
Cochrane Collaboration's Risk of Bias tool (Version 5.1).
Methodological quality appraisal was evaluated through
seven domains: sequence generation, allocation conceal-
ment, blinding of participants and personnel, blinding of
outcome, incomplete outcome data, selective outcome
reporting, and other sources of bias. Each domain from
each study was characterized as having “low,” “high,” or
“unclear” risk of bias. In cases of disagreement, the two
researchers discussed and re‐examined the study until con-
sensus was reached.

2.9  |  Summary measures

2.6  |  Data collection process
Data were independently extracted from each of the selected
studies by two researchers (LCS and IMP) using standard-
ized tables. Subsequently, the two researchers discussed and
compared the findings, and in case of discrepancies, they re‐
examined the results until an agreement was reached.
2.7  |  Data items
The following information was independently extracted
from the selected studies: authors, year, country where the
study was conducted, publication language, study design,
sample size, participants’ age, instruments used to measure
dental anxiety and dental fear, dental procedure performed,
distraction technique used, statistical analyses, overall re-
sults, and direction of the effect (statistically significant or
not). Additional information was obtained by contacting the
Researchers extracted all measures regarding the use of
distraction techniques during any dental treatment for the
management of dental anxiety and dental fear and the com-
parisons with the control group (absence of a distraction
technique). All study results are shown in Appendix S1.
A summary of results comparing intervention and control
groups according to the type of instrument used for assessing
dental anxiety and dental fear (eg, questionnaire and scale
or heart rate, oxygen saturation, and blood pressure) is pre-
sented in Tables 3 and 4.
2.10  |  Synthesis of results
The included articles were evaluated with respect to the
methodological heterogeneity. A qualitative analysis was
done, and no meta‐analysis was performed due to methodo-
logical heterogeneity.
PRADO et al.
2.11  |  Certainty of evidence rating and
strength of recommendations grading
The certainty of evidence was assessed through GRADE
(Grading of Recommendations, Assessment, Development,
and Evaluation) approach for narrative summary of different
effects across studies.21 The assessment with GRADE was
carried out by two independent researchers (CCM and LGA),
and disagreements were resolved by consensus. Certainty of
evidence starts with high for RCTs, and the final judgement
can be either high, moderate, low, or very low.22 We rated
down certainty of evidence if there were problems in risk of
bias, inconsistency, indirectness, imprecision, and publica-
tion bias.21,22
2.12  |  Additional analysis
The unit of analysis was the study and not the publication.
Multiple publications referring to a single study were in-
cluded if the articles evaluated different outcomes or the use
of distraction techniques during different dental procedures.
3  |   R E S U LTS
3.1  |  Study selection
A total of 1468 studies were identified in the electronic
search, and 13 were identified manually. Twenty‐one RCTs
met the eligibility criteria and were included in this system-
atic review. A flow diagram of the selection process is shown
in Figure 1. The list of full‐text articles excluded based on the
exclusion criteria is presented in Appendix S4.
3.2  |  Study characteristics
Included articles were published between 2005 and 2018
and were conducted in Brazil,20 Chile,23 India,13,15,16,24-29
Iran,17,30,31 Mexico,32,33 Saudi Arabia,34 Thailand,35,36 and
the USA.37 All included studies were published in the English
language.13,15-17,23-38 Sample size ranged from 28 to 176 par-
ticipants and participant age ranged from 4 to 16 years. Table
1 summarizes the characteristics of all included studies.
The types of distraction technique used in the studies
were audio distraction, audiovisual distraction, instrument
camouflage (syringe and needle), biofeedback therapy, den-
tal operating microscope, and toys. All distraction techniques
used are presented in Tables 3 and 4. The dental procedures
performed in the included studies were dental examination,
oral prophylaxis, local anaesthesia, dental restoration, end-
odontic treatment, and extraction. Data were collected during
all these procedures (except during endodontic treatment),
and at pre‐ and post‐operatory moments, during high‐speed
handpiece use and rubber dam placement. Many instruments
  
|
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were used to evaluate dental fear and dental anxiety in the
studies. The number of instruments used ranged from one29
to six,15,29 and most studies used three or more instru-
ments.13,15,17,24-26,28-30,32-36 The most frequent instruments
used were objective instruments, such as pulse oximeter and
blood pressure cuff, which evaluate heart rate, oxygen satura-
tion, and systolic and diastolic blood pressure.13,15,16,24-27,31-36
3.3  |  Risk of bias within studies
Risk of bias was assessed using the Cochrane Collaboration's
Risk of Bias tool (Version 5.1). The main shortcoming identified
was blinding of participants and personnel,13,15-17,19,20,23-35,38 as
well as blinding of outcome assessors.13,16,17,19,20,23-35 Another
shortcoming was other sources of bias. Most studies failed to
calculate an appropriate sample size or present a power test
and used convenience samples.13,16,17,19,24-27,35 Selective out-
come reporting was another common drawback among stud-
ies.13,17,23,27,29,35,36 Figure 2 summarizes the risk of bias within
included studies. The individual assessment of each included
article has been provided in Appendix S2.
3.4  |  Results of individual studies
A synthesis of the study results according to the different in-
struments used to measure dental anxiety and dental fear is
presented in Tables 3 and 4, and GRADE approach is listed
in Appendix S3 (Figure 2).
3.5  |  Audio distraction compared to no
distraction technique
English, Hindi, or Punjabi song efficiency was evaluated by
subjective and objective instruments in children aged four to
eight years. When using subjective instruments, children pre-
sented lower levels of anxiety after dental examination (aged
4‐6 years), before, during, and after local anaesthesia and
after restoration (aged four to eight years) when compared to
children who did not listen to the same songs (P < 0.05).25
When using objective instruments, the levels of dental anxi-
ety were lower after local anaesthesia and after restoration
when compared to children who did not listen to English,
Hindi, or Punjabi songs.25
Nursery rhyme music efficiency was evaluated by subjec-
tive and objective instruments in children aged four to eight
years. Measured by a subjective instrument, listening to nurs-
ery rhyme music resulted in lower levels of anxiety during
dental examination, oral prophylaxis, restoration, and dental
extraction when compared to children who did not listen to
nursery rhymes (P < 0.05).26 By objective instruments, chil-
dren listening to nursery rhyme music presented lower levels
of dental anxiety during clinical examination, restoration,
and dental extraction when compared to children who did not
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654       PRADO et al.

T A B L E 2   Summary of characteristics from included studies: authors, country, study design, sample age and size, instruments used,
outcome, and intervention (n = 20)

Type of distraction Sample

Study (Location) technique Study design Age (y) size Instrument to measure anxiety and fear
Ramírez‐Carrasco et al Audio (classic directive Randomized 5‐9 40 Face, Legs, Activity, Cry, Consolability;
(2017) (Mexico) hypnosis) clinical trial Heart Rate; Skin Conductance
Kaur et al (2015) Audio (English or Hindi Randomized 4‐8 60 Pulse Oximeter; Dental Subscale of Children
(India) or Punjabi songs) clinical trial Fear Survey Schedule‐Short Scale;
Audiovisual (computer Clinical Anxiety Rating Scale;
screen) Co‐Operative Behavioural Rating Scale
Marwah et al (2005) Audio (instrumental Randomized 4‐8 40 Venham's Picture Test; Venham's
(India) music/non‐specified clinical trial Anxiety Rating Scale; Pulse Oximeter
music)
Nuvvula et al (2015) Audio (non‐specified Randomized 7‐10 90 Modified Child Dental Anxiety Scale;
(India) music) clinical trial Wright's Modification of Frankl Rate Scale;
Audiovisual (3D Frankl Scale; Houpt Scale; Pulse Oximeter;
eyeglasses) Structured Face‐to‐Face, Closed,
Fixed‐Response Interview; Visual
Analogue Scale
Rojas‐Alcayaga et al Audio (non‐specified Randomizes 6 176 Facial Image Scale; Frankl Behavioural
(2018) (Chile) music) clinical trial Rate Scale
Singh et al (2014) Randomized 6‐12 60 Venham's Picture Test; Pulse Oximeter
(India) clinical trial
Yamini et al (2010) Randomizes 6‐12 20 Venham's Picture Test
(India) clinical trial
Naithani et al, (2014) Audio (nursery rhymes) Randomized 4‐8 75 Venham's Picture Test; Venham's Rating of
(India) clinical trial Clinical Anxiety; Child Fear Survey
Schedule‑Dental Subscale; Pulse Oximeter
Hoge et al (2012) Audiovisual (3D Randomized 4‐16 128 Face Pain Scale ‐ Revised; 5‐Point Faces
(USA) eyeglasses) controlled Rating Scale
Audiovisual clinical trial
(eyeglasses)
Al‐Khotani et al Audiovisual (3D Randomized 7‐9 56 Facial Image Scale; Blood Pressure Cuff;
(2016) (Saudi Arabia) eyeglasses) controlled Pulse Oximeter; Modified Venham's
clinical trial Clinical Ratings of Anxiety and Cooperative
Behaviour Scale
Ghadimi et al (2018) Audiovisual (cartoon Cross‐over 4‐5 28 Venham Picture Test; Hear Rate; Frankl
(Iran) played on a monitor) randomized Behaviour Rating Scale
controlled
clinical trial
Asvanund et al (2015) Audiovisual Cross‐over 5‐8 52 Faces Pain Scale‐Revised; Blood Pressure Cuff;
(Thailand) (eyeglasses) randomized Face, Legs, Activity, Cry and
controlled trial Consolability Scale
Garrocho‐Rangel et al Cross‐over 5‐8 72 Face, Legs, Activity, Cry, Consolability;
(2018) (México) randomized Heart Rate; Oxygen Saturation
controlled
clinical trial
Mitrakul et al (2015) Cross‐over 5‐8 48 Blood Pressure Cuff; Faces Pain Scale‐Revised;
(Thailand) randomized Face, Legs, Activity, Cry and
controlled trial Consolability Scale
PRADO et al.
Outcome (dental procedure)
Local anaesthesia injection
Dental examination, restorative procedures,
local anaesthesia injection
Dental examination, prophylaxis, restorative
procedures and extractions
Local anaesthesia injection
Usual dental care that included an education
session
Extraction
Dental examination, restorative procedures and
local anaesthesia injection
Dental examination, prophylaxis, restorative
procedures, extractions
Restorative procedures, endodontic treatment
and extractions
Dental examination, prophylaxis and restorative
procedures
Local anaesthesia injection, pulpotomy and
restorative procedures
Local anaesthesia injection
Local anaesthesia injection
Restorative procedures
  
|
   655
Intervention Control
Audio distraction with classic directive Absence of audio distraction with classic
hypnosis directive hypnosis
Audio distraction with English or Hindi or Absence of audio distraction and
Punjabi songs (group 2) and audiovisual audiovisual distraction
distraction with a computer screen (group 3)
Audio distraction with instrumental music Absence of audio distraction with
(group B) and nursery rhymes music (group C) instrumental and nursery rhymes music
Audio distraction with non‐specified music Absence of audio and audiovisual
(group II) and audiovisual distraction with 3D distraction
eyeglasses (group III)
Audio distraction with non‐specified music Absence of audio distraction with
non‐specified music
Audio distraction with non‐specified music Absence of audio distraction with
non‐specified music
Audio distraction with non‐specified music Absence of audio distraction with
non‐specified music
Audio distraction with nursery rhymes (group Absence of audio and audiovisual
B) and audiovisual distraction with a television distraction
screen (group C)
Audiovisual distraction with eyeglasses Absence of audiovisual distraction with
eyeglasses
Audiovisual distraction with eyeglasses Absence of audiovisual distraction with
eyeglasses
Audiovisual distraction with cartoon played on Absence of audiovisual with cartoon
a monitor played on a monitor
Audiovisual distraction with eyeglasses Absence of audiovisual distraction with
eyeglasses
Audiovisual distraction with video eyeglasses/ Absence of video eyeglasses/earphones
earphones system system
Audiovisual distraction with eyeglasses Absence of audiovisual distraction with
eyeglasses
(Continues)
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656       PRADO et al.

T A B L E 2   (Continued)

Type of distraction Sample

Study (Location) technique Study design Age (y) size Instrument to measure anxiety and fear
Asl Aminabadi et al Audiovisual (virtual Randomized, 4‐6 120 Screen for Child Anxiety Related Disorders
(2012) (Iran) reality eyeglasses) cross‐over, Questionnaire; Face Version of the Modified
clinical trial Child Dental Anxiety Scale Questionnaire;
Wong Baker FACES Pain Rating Scale
Dedeepya et al (2014) Biofeedback Randomized 9‐13 40 Heart Rate; Blood Volume Pulse; Visual
(India) clinical trial Analogue Scale
Rank et al (2017) Books and children’s Randomized 4‐6 62 Facial Image Scale; Behaviour Rating Scale
(Brazil) story clinical trial
Mirror and
conversation Toys
Ujaoney et al (2013) Camouflage syringe Randomized <15 100 Venham's Clinical Rating Scale; Venham's
(India) clinical trial Picture Test (VPT); Parental Emotional Stress
Questionnaire
Sayed et al (2016) Dental operating Randomized, 7‐9 90 Pulse Oximeter; Venham's Picture Selection Test
(India) microscope controlled,
cross‐over,
cross‐sectional
clinical trial
Habib‐Agahi et al Telescopic needle Randomized 4‐8 50 Visual Analogue Scale; Sound, Eye, Motor
(2017) (Iran) clinical trial Scale; Venham's Anxiety and Cooperative
Behaviour

listen to nursery rhyme music (P < 0.05). In contrast, another

study found no effect (P > 0.05) of nursery rhyme music on
dental anxiety levels during any dental procedure using sub-
jective and objective instruments among children of the same
age.13
Three studies evaluated dental anxiety in children aged six
to twelve years using objective and subjective instruments when
listening to music (type of music not specified).15,16,29 One study
reported that listening to music reduced children's dental anxiety
levels by subjective and objective instruments, before and after
the dental extraction procedure (P < 0.05).16 Not listening to
music, however, increased children's dental anxiety levels (when
measured with subjective instruments) when comparing pre‐
and post‐dental extraction procedure periods (P < 0.05).16 Two
other studies reported that individuals who listened to music
displayed lower levels of dental anxiety (measured with subjec-
tive instruments) during and after local anaesthesia administra-
tion when compared to individuals who did not listen to music
(P < 0.05).15,29 When dental anxiety was measured with objec-
tive instruments, one study found that children (aged 7‐10 years)
who listened to music displayed lower levels of dental anxiety
during local anaesthesia administration when compared to chil-
dren who did not listen to music (P < 0.05).15
As regards distraction techniques, researchers reported
both effect in reducing dental anxiety and dental fear levels
as well as no effect, among children undergoing audio dis-
traction and no distraction technique.13,15,16,25,26,29
3.6  |  Audiovisual distraction compared to no
distraction technique
Children aged seven to ten years using 3D eyeglasses as a dis-
traction technique displayed lower levels of dental anxiety be-
fore, during, and after local anaesthesia administration when
compared to children not using 3D eyeglasses (P < 0.05).15
One study evaluated dental anxiety in children aged four
to eight years using audiovisual distraction on a computer
screen. This technique induced lower levels of anxiety, as
measured by subjective instrument, after clinical examination
and before, during, and after local anaesthesia and restoration
(P < 0.05) when compared to children who did not use dis-
traction techniques.25 All except one of the three subjective
instruments used found no statistical difference in dental anx-
iety levels (P > 0.05) when comparing children using audio-
visual distraction on a computer screen to children not using
distraction techniques.25 When using objective instruments,
audiovisual distraction on a computer screen reduced den-
tal anxiety (P < 0.05) before and after clinical examination,
local anaesthesia, and restoration when compared to children
not using distraction techniques.25
A study with children aged 4 and 5 years found that
watching cartoon playing on a monitor during local anaesthe-
sia decreased participant's mean heart rate and self‐reported
dental anxiety in comparison with individuals not watching
cartoon (P < 0.001).31
PRADO et al.   
|
   657

Outcome (dental procedure) Intervention Control

Fluoride therapy and restorative procedures Audiovisual distraction with virtual reality Absence of audiovisual distraction with
eyeglasses virtual reality eyeglasses

Restorative procedures Biofeedback Absence of biofeedback

Dental examination, oral prophylaxis and Mirror and conversation (group 2), toys (group Absence of a distraction technique
restorative procedures 3) and children's stories (group 4)

Local anaesthesia injection Camouflage syringe Conventional syringe

Restorative procedures Dental operating microscope Absence of the dental operating

microscope

Local anaesthesia Telescopic dental needles Conventional injection

The use of eyeglasses in children aged five to nine years

during35 and after34 local anaesthesia injection, during the
pre‐operative period, and first use of high‐speed handpiece36
reduced children's dental anxiety when compared with not
wearing eyeglasses (P < 0.05). Children and adolescents, aged
four to sixteen years, using eyeglasses also presented lower lev-
els of disruptive behaviour and higher treatment satisfaction in
comparison with children and adolescents not using eyeglasses
(P < 0.05).37
Individuals aged four to eight years receiving audiovisual
distraction on a television screen presented lower levels of
dental anxiety during clinical examination when compared
to children receiving no audiovisual distraction (P < 0.05).26
The effect was positive for oral prophylaxis, restoration and
after local anaesthesia administration, when compared to in-
dividuals receiving no distraction.26
Children aged four to seven years presented lower levels
of dental anxiety and dental fear during fluoride therapy,
local anaesthesia administration, and restorative procedures
when wearing virtual reality eyeglasses in comparison with
not wearing the device (P < 0.05).17
As regards distraction techniques, researchers reported
both effect in reducing dental anxiety and dental fear levels
for some dental procedures as well as no effect for other pro-
cedures among children undergoing audiovisual distraction
and no distraction technique. 15,17,25-27,34-37
3.7  |  Other distraction techniques compared
to no distraction technique
Biofeedback therapy was evaluated in individuals aged nine
to thirteen years. Biofeedback therapy used during restoration
procedure resulted in lower levels of dental anxiety, accord-
ing to heart rate and blood pressure volume, when compared
to children receiving no distraction (P < 0.05).24
Usage of camouflaging syringes during local anaesthesia
in individuals younger than 15 years old resulted in better
behaviour (crying and smiling), and their parents were less
stressed compared to children being treated with a conven-
tional syringe during local anaesthesia (P < 0.05).28
One study used a dental operating microscope on two
groups of children aged five to seven years. Group A used
the dental operating microscope during the first resto-
ration visit and no distraction technique during the second
restoration visit. Group B used no distraction technique
during the first restoration visit and used the dental oper-
ating microscope during the second restoration visit. The
dental operating microscope reduced anxiety (P < 0.05)
in the second visit for both groups.27 Dental anxiety
levels were similar in both groups during the first visit
(P > 0.05).27
Individuals aged four to eight years using telescopic den-
tal needles for local anaesthesia injections displayed better
T A B L E 3   Synthesis of significant results measured by subjective and objective instruments from included studies
|

Dental procedure ‐ Questionnaire, scale, heart rate, oxygen saturation, and blood pressure (significant association when compared to control group)
658      

Pulpotomy and
Distraction Clinical Oral pre‐formed metal
technique (type) Instrument examination prophylaxis Local anaesthesia Restoration Endodontic treatment Extraction crowns
Audio (Classic Heart rate     Ramírez‐Carrasco et        
directive hypnosis) al (2017)
Audio (English or CARS     Kaur et al (2015) Kaur et al (2015)      
Hindi or Punjabi DFSS‐SF Kaur et al     Kaur et al      
songs) (2015)a  (2015)b 
Heart rate     Kaur et al (2015)c  Kaur et al      
(2015)d 
Audio (non‐speci- MCDASf     Nuvvula et al        
fied music) (2015)e 
VPT     Yamini et al (2010)     Singh et al (2014)f   
WM‐FS     Nuvvula et al        
(2015)g 
Heart rate     Nuvvula et al (2015)     Singh et al (2014)f   
Systolic           Singh et al (2014)f   
blood
pressure
Audio (nursery CFSS‐DS   Naithani et al   Naithani et al   Naithani et al  
rhymes) (2014) (2014) (2014)
VPT Naithani et al Naithani et al   Naithani et al   Naithani et al  
(2014) (2014) (2014) (2014)
VARS Naithani et al         Naithani et al  
(2014) (2014)
Heart rate Naithani et al     Naithani et al   Naithani et al  
(2014) (2014) (2014)
Audiovisual (3D HS     Nuvvula et al (2015)        
eyeglasses) MCDASf     Nuvvula et al        
(2015)e 
MVARS       Al‐Khotani et al      
(2016)
WM‐FS     Nuvvula et al (2015)        
Heart rate     Nuvvula et al (2015)        

(Continues)
PRADO et al.
 PRADO et al.

T A B L E 3   (Continued)

Dental procedure ‐ Questionnaire, scale, heart rate, oxygen saturation, and blood pressure (significant association when compared to control group)

Pulpotomy and
Distraction Clinical Oral pre‐formed metal
technique (type) Instrument examination prophylaxis Local anaesthesia Restoration Endodontic treatment Extraction crowns
Audiovisual Heart rate             Ghadimi et al (2018)
(cartoon played on VPT             Ghadimi et al (2018)
a monitor)
Audiovisual CARS     Kaur et al (2015) Kaur et al (2015)      
(computer screen) DFSS‐SF Kaur et al     Kaur et al (2015)      
(2015)c 
Heart rate Kaur et al   Kaur et al (2015)h  Kaur et al      
(2015)c  (2015)h 
Audiovisual 5‐PFRS       Hoge et al (2012) Hoge et al (2012) Hoge et al (2012)  
(eyeglasses) FLACC     Asvanund et al Mitrakul et al      
(2015) (2015)i 
VR       Hoge et al (2012) Hoge et al (2012) Hoge et al (2012)  
(disruptive
behaviour)
Heart rate     Asvanund et al Mitrakul et al      
(2015) (2015)j 
Audiovisual CFSS‐DS Naithani et al Naithani et al   Naithani et al   Naithani et al  
(television screen) (2014) (2014) (2014) (2014)
VPT Naithani et al Naithani et al   Naithani et al   Naithani et al  
(2014) (2014) (2014) (2014)
VARS Naithani et al Naithani et al   Naithani et al   Naithani et al  
(2014) (2014) (2014) (2014)
Heart rate Naithani et al Naithani et al   Naithani et al   Naithani et al  
(2014) (2014) (2014) (2014)
Audiovisual (virtual MCDASf       Asl Aminabadi et      
reality eyeglasses) al (2012)
WBFS       Asl Aminabadi et      
al (2012)
  

(Continues)
|   659
T A B L E 3   (Continued)
|

Dental procedure ‐ Questionnaire, scale, heart rate, oxygen saturation, and blood pressure (significant association when compared to control group)
660      

Pulpotomy and
Distraction Clinical Oral pre‐formed metal
technique (type) Instrument examination prophylaxis Local anaesthesia Restoration Endodontic treatment Extraction crowns
Biofeedback Heart rate       Dedeepya et al      
(2014)
Blood       Dedeepya et al      
volume (2014)
pulse
Camouflage Syringe PESQ     Ujaoney et al        
(2013)k 
VCRS     Ujaoney et al (2013)        
VPT     Ujaoney et al        
(2013)l 
Dental operating VPT       Sayed et al      
microscope (2016)
Telescopic needle SEM     Habib‐Agahi et al        
(2017)
VACB     Habib‐Agahi et al        
(2017)
VAS     Habib‐Agahi et al        
(2017)
Notes. Abbreviations: 5‐PFRS: 5‐Point Face Rating Scale; CARS: Clinical Anxiety Rating Scale; CFSS‐DS: Child Fear Survey Schedule‐Dental Subscale; DFSS‐SF: Dental Subscale of Children's Fear Survey Schedule‐Short
Scale; FLACC: Face, Legs, Activity, Cry and Consolability Scale; FS: Frankl Scale; HS: Houpt Scale; MCDASf: Modified Child Dental Anxiety Scale; MVARS: Modified Venham's Clinical Ratings of Anxiety and
Cooperative Behaviour Scale; PESQ: Parental Emotional Stress Questionnaire; SEM: Sound, Eye, Motor Scale; VACB: Venham's Anxiety and Cooperative Behaviour; VARS: Venham's Anxiety Rating Scale; VAS: Visual
Analogue Scale; VCRS: Venham's Clinical Rating Scale; VPT: Venham's Picture Test; VR: Video Recording; WM‐FS: Wright's Modification of Frankl Behaviour Rating Scale.
a
Statistically significant after the procedure for children aged 4‐6 y.
b
Statistically significant before the procedure for children aged 4‐6 y and after the procedure for children aged 4‐6 and 6‐8 y.
c
Statistically significant after the procedure for children aged 4‐6 and 6‐8 y.
d
Statistically significant after the procedure for children aged 6‐8 y.
e
Statistically significant after local anaesthesia.
f
Did not compare to control group.
g
Statistically significant during local anaesthesia.
h
Statistically significant during and after the procedure for children aged 4‐6 and 6‐8 y.
i
Statistically significant at pre‐operatory and first use of high‐speed hand piece.
j
Statistically significant at pre‐operatory moment.
k
Statistically significant for “angry, child was not co‐operating.”
l
Statistically significant for “crying,” “smiling,” and “crying and shocked.”
PRADO et al.
PRADO et al.   
   661
|
T A B L E 4   Synthesis of non‐significant results measured by subjective and objective instruments from included studies
Dental procedure—Questionnaire, scale, heart rate, oxygen saturation and blood pressure (non‐significant association when compared to
control group)

Distraction Pulpotomy and

technique Clinical Oral Local Dental Endodontic pre‐formed
(type) Instrument Non‐specified examination prophylaxis anaesthesia isolation Restoration treatment Extraction metal crowns

Audio FLACC       Ramírez‐          

(classic Carrasco et al
directive (2017)
hypnosis) Heart Rate       Ramírez‐          
Carrasco et al
(2017)
Skin       Ramírez‐          
Conductance Carrasco et al
(2017)
Audio DFSS‐SF   Kaur et al       Kaur et al      
(English or (2015)a  (2015)b 
Hindi or CARS   Kaur et al              
Punjabi (2015)
songs)
Heart Rate   Kaur et al   Kaur et al   Kaur et al      
(2015) (2015)c  (2015)d 
Audio VPT   Marwah et al Marwah et     Marwah et   Marwah et  
(instrumen- (2005) al (2005) al (2005) al (2005)
tal music) VARS   Marwah et al Marwah et     Marwah et   Marwah et  
(2005) al (2005) al (2005) al (2005)
Heart rate   Marwah et al Marwah et     Marwah et   Marwah et  
(2005) al (2005) al (2005) al (2005)

Oxygen   Marwah et al Marwah et     Marwah et   Marwah et  

saturation (2005) al (2005) al (2005) al (2005)
Audio FIS Rojas‐                
(non‐speci- Acayaga et
fied music) al (2018)
FS Rojas‐                
Acayaga et
al (2018)
HS       Nuvvula et al          
(2015)
MCDASf       Nuvvula et al          
(2015)e 
VARS   Marwah et al Marwah et     Marwah et   Marwah et  
(2005) al (2005) al (2005) al (2005)
VPT   Marwah et al Marwah et     Marwah et   Marwah et  
(2005); al (2005) al (2005); al (2005)
Yamini et Yamini et
al (2010) al (2010)
WM‐FS       Nuvvula et al          
(2015)e 
Diastolic               Singh et al  
blood (2014)f 
pressure
Heart rate   Marwah et al Marwah et     Marwah et   Marwah et  
(2005) al (2005) al (2005) al (2005)
Oxygen   Marwah et al Marwah et     Marwah et   Marwah et  
saturation (2005) al (2005) al (2005) al (2005);
Singh et al
(2014)f 

(Continues)
 |
662       PRADO et al.

T A B L E 4   (Continued)
Dental procedure—Questionnaire, scale, heart rate, oxygen saturation and blood pressure (non‐significant association when compared to
control group)

Distraction Pulpotomy and

technique Clinical Oral Local Dental Endodontic pre‐formed
(type) Instrument Non‐specified examination prophylaxis anaesthesia isolation Restoration treatment Extraction metal crowns

Audio VARS     Naithani et     Naithani et      

(nursery al (2014) al (2014)
rhymes) CFSS‐DS   Naithani et al              
(2014)
Heart rate     Naithani et            
al (2014)
Oxygen   Naithani et al Naithani et     Naithani et   Naithani et  
saturation (2014) al (2014) al (2014) al (2014)
Audiovisual FIS           Al‐Khotani      
(3D et al
eyeglasses) (2016)
FPS‐R           Hoge et al Hoge et al Hoge et al  
(2012) (2012) (2012)
MCDASf       Nuvvula et al          
(2015)e 
Pulse rate           Al‐Khotani      
et al
(2016)
Audiovisual FS                 Ghadimi et al
(cartoon (2018)
played on a
monitor)
Audiovisual DFSS‐SF   Kaur et al              
(computer (2015)g 
screen) CARS   Kaur et al              
(2015)
Heart rate   Kaur et al   Kaur et al   Kaur et al      
(2015)c  (2015)g  (2015)g 
Audiovisual FLACC       Garrocho‐ Garrocho‐ Mitrakul et      
(eye- Rangel et al Rangel al (2015)h ;
glasses) 2018 et al Garrocho‐
(2018) Rangel et
al (2018)
Heart rate     Garrocho‐ Garrocho‐ Garrocho‐ Mitrakul et      
Rangel et Rangel et al Rangel al (2015)i ;
al (2018) (2018) et al Garrocho‐
(2018) Rangel et
al (2018)
Oxygen     Garrocho‐ Garrocho‐ Garrocho‐ Garrocho‐      
saturation Rangel et Rangel et al Rangel Rangel et
al (2018) (2018) et al al (2018)
(2018)
Audiovisual Oxygen   Naithani et al Naithani et     Naithani et   Naithani et  
(screen saturation (2014) al (2014) al (2014) al (2014)
attached to
the ceiling)
Biofeedback VAS           Dedeepya et      
al (2014)
Books and BRS   Rank et al Rank et al     Rank et al      
children's (2017) (2017) (2017)
story
(Continues)
PRADO et al.   
   663
|
T A B L E 4   (Continued)

Dental procedure—Questionnaire, scale, heart rate, oxygen saturation and blood pressure (non‐significant association when compared to
control group)

Distraction Pulpotomy and

technique Clinical Oral Local Dental Endodontic pre‐formed
(type) Instrument Non‐specified examination prophylaxis anaesthesia isolation Restoration treatment Extraction metal crowns

Camouflage PESQ       Ujaoney et al          

syringe (2013)j 
VPT       Ujaoney et al          
(2013)k 
Dental Heart rate           Sayed et al      
operating (2016)
microscope Oxygen           Sayed et al      
saturation (2016)
Mirror and BRS   Rank et al Rank et al     Rank et al      
conversa- (2017) (2017) (2017)
tion
Toys BRS   Rank et al Rank et al     Rank et al      
(2017) (2017) (2017)

Notes. Abbreviations: BRS, Behaviour Rating Scale; CARS, Clinical Anxiety Rating Scale; CFSS‐DS, Child Fear Survey Schedule‐Dental Subscale; DFSS‐SF, Dental subscale of
children's Fear Survey Schedule‐Short scale; FIS, Facial Image Scale; FLACC, Face, Legs, Activity, Cry and Consolability scale; FPS‐R, Pace Pain Scale‐Revised; FS, Frankl
Scale; HS, Houpt Scale; KRS, Koppitz Rating Scale; MCDASf, Modified Child Dental Anxiety Scale; MDAS, Modified Corah Dental Anxiety Scale; NCBRS, North Carolina
Behaviour Rating Scale; PESQ, Parental Emotional Stress Questionnaire; VARS, Venham's Anxiety Rating Scale; VAS, Visual Analogue Scale; VCRS, Venham's Clinical Rating
Scale; VPT, Venham's picture test; WM‐FS, Wright's modification of Frankl behaviour rating Scale.
a
Not statistically significant before the procedure for children aged 4‐6 and 6‐8 y and after the procedure for children aged 6‐8 y.
b
Not statistically significant before the procedure for children aged 6‐8 y.
c
Not statistically significant before and during treatment for children aged 4‐6 and 6‐8 y.
d
Not statistically significant before and during the procedure for children aged 4‐6 and 6‐8 y and after the procedure for children aged 4‐6 y.
e
Not statistically significant before the procedure.
f
Did not compared to control group.
g
Not statistically significant before the procedure for children aged 4‐6 and 6‐8 y.
h
Not statistically significant at rubber dam placement and during the remaining treatment.
i
Not statistically significant at rubber dam placement, first use of high‐speed hand piece and during the remaining treatment.
j
Not statistically significant for “none,” “some,” and “definite” from “child's tendency to cry in the dental clinic”; “happy, relaxed, doctor handled it well,” “concerned, wanted to
help the child,” “sad, cannot see the child cry” from “parents emotional stress quotient” and for “stop the treatment till child relaxes,” “let the dentist handle the manipulative
child,” permit physical restraint over the child,” and “use new treatment that is non‐traumatic” from “expectations from the dentist.”
k
Not statistically significant for “running out of chair,” “afraid before treatment but unaffected after treatment,” “shocked,” “angry, “did not react,” and “crying and running out of
chair”.
l
Not statistically significant considering the average heart rate over the entire treatment.

pain‐related behaviour during local anaesthesia (P < 0.001),
less distress (P < 0.05), and reported less pain after local an-
aesthesia (P = 0.0001) when compared to individuals receiv-
ing conventional injections.30
A mirror was used to distract children aged four to six
years by allowing them to monitor their own treatment. This
technique, used until the application of local anaesthesia,
and conversation (talking about matters of child's interest)
reduced dental anxiety and improved behaviour during the
second visit (P = 0.022).23
3.8  |  Certainty of evidence rating and
strength of recommendations grading
In general, audio songs, hypnosis, 3D eyeglasses, eye-
glasses, audiovisual techniques, biofeedback, camouflage
syringes, dental operating microscope, telescopic needle
were effective distraction techniques for paediatric dentistry
with very low certainty of evidence (Appendix S3). Major
concerns were regarding indirectness (very serious), risk
of bias (serious), inconsistency (serious), and imprecision
(serious).
3.9  |  Additional analysis
Two articles35,36 of the same study were included. One
article 36 evaluated the distraction technique in individuals
undergoing local anaesthesia, and the other35 evaluated the
distraction techniques in individuals submitted to restora-
tive treatment.
4  |  DISCUSSION
In this systematic review, most of the evaluated distraction
techniques had a significant effect on reducing anxiety and
 |
664       PRADO et al.

F I G U R E 1   PRISMA flow diagram showing the numbers of studies identified, screened, assessed for eligibility, and included in this
systematic review [Colour figure can be viewed at wileyonlinelibrary.com]

F I G U R E 2   Summary of risk of bias

Adequate sequence generation
within included studies using the Cochrane
Allocation concealment
Collaboration's Risk of Bias tool (version
5.1) [Colour figure can be viewed at Blinding of participants, personnel
wileyonlinelibrary.com] Blinding of outcome assessors
Incomplete outcome data
Selective outcome reporting
Other potential threats to validity
0% 25% 50% 75% 100%

Low risk of bias Unclear risk of bias High risk of bias

PRADO et al.
fear levels at some point during dental treatment. Thus, the
use of distraction techniques during dental treatment may be
a good strategy for the management of children's and adoles-
cent's dental anxiety and dental fear.
Audio distraction was widely used in studies.13,15,16,25,26,29
The results indicate that listening to music and children's
stories during some treatment procedures reduces dental
fear and dental anxiety depending on the assessment instru-
ment used.13,15,16,25,26,29 More evidence is needed to confirm
these findings, as other studies found no significant changes
in dental anxiety and fear levels when using audio distrac-
tion.13,15,16,25,26,29 It seems that the use of nursery rhymes and
children's stories,13,26 two types of audio distraction tech-
niques, may be more difficult to apply in young children in
comparison with music because individuals need to pay at-
tention for it to work. It is also possible that children may be
more focused at the beginning of the story then as it goes on,
which makes it more efficient for procedures occurring at the
beginning of the dental appointment.39
Audiovisual distraction was also widely used. This type
of distraction technique leads to the total involvement of the
patient, screening out the sight of dental treatment, resulting
in a pleasurable experience.12,25,37,40 It can be used in many
forms, such as 3D eyeglasses, eyeglasses, virtual reality eye-
glasses, computer and TV screens, screens attached to the
ceiling, and dental operating microscopes. These audiovisual
distraction techniques are quite different from each other, in
particular 3D eyeglasses (eyeglasses with 3D movies) and
eyeglasses (eyeglasses with 2D movies). 3D eyeglasses’ vid-
eos are reportedly more effective than 2D videos, due to the
effective isolation of the child from the sounds and views in
the dental office,15 but all these forms of audiovisual distrac-
tion significantly reduced dental anxiety and dental fear at
some point in the dental treatment.15,17,25-27,34,35,37 Non‐sig-
nificant results, however, were also reported during some
treatment periods and depending on the instrument used to
evaluate dental fear and dental anxiety.15,17,25-27,34-37
The heterogeneity in audio and audiovisual distraction
results may be due to the different forms and types of equip-
ment used, different types of content played, and the volume.
It is possible that the audio may not be enough to mask some
sounds in the dental operatory (eg, high‐speed handpiece,
and the saliva ejector), as the volume must allow the patient
to hear the dentists’ commands and explanations.41 Some
equipment involved headphones while some did not, which
may interfere in the techniques’ efficiency. In addition, some
types of headphones may help block outside sounds, allowing
a deeper immersion in the music.41 The dental anxiety and
fear of certain procedures, such as intraoral injection, may
be too overwhelming to be overridden by audio and audio-
visual distraction.41 Even though more evidence is needed to
confirm the efficiency of audio and audiovisual distraction in
managing dental anxiety and dental fear, it seems that there
  
|
   665
is no contraindication for the use of such techniques; they
are widely accepted by paediatric patients and are clinically
feasible and safe, with no need for prior training for clinicians
and patients.12,13,15,16,29,41
There were six other types of distraction techniques used
in the studies. The use of camouflaged syringes reduced pa-
tients’ dental anxiety and fear during local anaesthesia injec-
tion. This is probably because it allows more involvement of
the patient in the treatment protocol, which helps to alleviate
dental fear.28 The use of a telescopic dental needle was effi-
cient in managing patients’ pain‐related behaviour, distress,
and pain level during local anaesthesia. This instrument al-
lows the professionals to cover the needle, so they can show
the syringe and say that they are going to “colour the child's
teeth,” making paediatric patients less tense and stressed
during this procedure.30 Biofeedback therapy also seemed to
reduce dental anxiety when assessed using objective instru-
ments.24 It appears that this technique requires motivation
and reinforcement as well as a complex cognitive process-
ing and sustained attention, which may not be appropriate for
young children.24 More studies are necessary to confirm the
applicability of such techniques in reducing children's and
adolescent's dental fear and dental anxiety.
The influence of age on the distraction process is still
unclear, and only a few of the included studies evaluated
the efficacy of the distraction techniques in different age
groups.25,37 It seems that patients must actively participate
in the distraction process for it to be maximally effective, as
well as recognize their uncomfortable feeling and choose to
control the anxiety by concentrating on the distraction stimu-
lus.42 Young children may lack the cognitive ability to sustain
focus42 and depending on the distraction technique and its
content, it may not be interesting for both children and ado-
lescents (eg, 3D eyeglasses, biofeedback, children's stories,
dental operating microscope, nursery rhymes, live modelling,
telescopic needle, toys, virtual reality eyeglasses). Most stud-
ies involved only children,13,15,17,23,25-27,30-36,38 and no study
included only adolescents.
The studies used two different methods to measure den-
tal anxiety and dental fear: subjective instruments, which
evaluate self‐perception of dental anxiety and dental fear
(eg, scales and questionnaires), and objective instruments,
which evaluate physiological measures that indicate bio-
logical changes (eg, heart rate, blood pressure, and oxygen
saturation levels).16,43 Biological markers are likely to eval-
uate anxiety reduction more accurately than subjective in-
struments, by measuring patients’ actual physiological state
during the dental procedure.44 There is no contraindication
for using objective instruments during any dental procedure.
The information regarding heart rate and oxygen saturation
may be an ally of paediatric dentists, as children may have
difficulty verbalizing and describing what they are feeling.8
There are smaller devices with reasonable cost‐effectiveness
 |
666       PRADO et al.
available that are clinically useful and less intimidating for
children.15
Subjective instruments rely on children's ability to express
what they feel, which may be difficult for some. Younger chil-
dren are unlikely to consider their anxious feeling or disrup-
tive behaviour as being inappropriate.42 The combination of
subjective and objective methods may provide the best over-
view of the patient for anxiety management. The use of many
instruments, however, may cause confusing results, making
it difficult to understand the actual effect of the distraction
technique. It should be noted that the great variety of instru-
ments used by the included studies provides very heteroge-
neous results, making it difficult to compare all the results.
Blinding of participants and personnel was the main
shortcoming among studies. The outcome measurement can
be influenced by the operators’ knowledge, but it may not
be possible to control this risk of bias when studying some
types of distraction techniques. Most of the distraction tech-
niques used the dental environment or were very difficult to
hide from personnel and participants (eg, audiovisual with a
screen, camouflage syringe, live modelling). Eyeglasses could
be used in the control group without any video to reduce the
risk of bias; however, children may feel uncomfortable and
scared.36 To reduce this type of bias in the audio distraction
method, operators and the children could use headphones,
while a third person controls the measurements and the audio
player. Future studies should apply a methodology that blinds
personnel and participants when possible. Most studies failed
to calculate an appropriate sample size or present a power test
and used a convenience sample instead. The number of partic-
ipants in clinical trials should be sufficient for the probability
of finding differences between groups by chance to be low
and thus the probability of detecting significant differences
to be high.45 The lack of an adequate sample size limits the
extrapolation of the results to the general population.
This systematic review has strengths that should be rec-
ognized. Distraction techniques are applied during dental
treatment to divert patient's attention from the dental proce-
dure.12-14 Two systematic reviews19,20 have focused on specific
distraction techniques: audiovisual and non‐pharmacological
techniques. In the present work, however, we included all
types of distraction techniques as intervention, resulting in a
more comprehensive synthesis of the evidence and providing
clinicians with several strategy options to be applied during
dental practice. Moreover, only RCTs comparing one group
of children submitted to distraction technique and a control
group of individuals who were not submitted to any distrac-
tion intervention were considered. Findings of RCTs with
control groups allow the reader to assign any detected effect to
the intervention evaluated. Non‐randomized trials, however,
preclude assertive conclusions on the efficacy of the treatment
implemented.46 Additionally, we used GRADE to summarize
certainty of evidence of effects from narrative synthesis.21
In all outcomes, certainty of evidence was rated down
in two levels due indirectness. Trials compared distraction
techniques according to some dental procedures. Moreover,
most studies13,15,17,24,28,31,32,34-36,38 included in their sample
children who presented cooperative behaviour. Therefore, af-
firming that distraction techniques are effective for all dental
procedures or effective for uncooperative children is an indi-
rect evidence. We rated down risk of bias in one level. Trials
had high risk of bias of blinding the participant, personnel
and outcome assessors. Although blinding was not feasible in
this kind of trial, knowing the group of randomization by the
outcome assessor would likely affect the measurement of the
final outcome. Inconsistency was rated down in one level due
reporting different estimates across studies. We considered
optimal information size (OIS)21 to rate down imprecision in
one level. OIS is the minimum required number of events and
sample size across all studies, which is considered 400 for
continuous outcome. Publication bias was not considered a
problem, and it was not rated down. We conducted a compre-
hensive search including multiple databases and grey litera-
ture in US National Library of Medicine. Although studies
with statistically significant results are more likely published
than studies with non‐significant results,47 we included stud-
ies reporting both significant and non‐significant results.
The present systematic review has also limitations. Due to
methodological heterogeneity among studies, meta‐analysis
was impossible. The feasibility of any meta‐analysis relies on
the existence of clinical trials with more robust and homoge-
neous methodological characteristics. The use of behaviour
guidance techniques on both control and intervention groups
was reported in included studies. Those are techniques em-
ployed by dentists to establish communication and adequate
rapport with the patient,48 improving child's cooperation.49
They were used in both groups (intervention and control) as
a matter of ethical aspects. Therefore, what really made inter-
vention and control groups different was the use of distrac-
tion techniques.
Changes in emotion, such as enjoyment, reflect on the au-
tonomic nervous system's activities50 consequently reducing
dental anxiety and fear and improving behaviour during dental
treatment. Cooperative behaviour is essential for a successful
dental treatment. Therefore, any strategy that contributes to
the management of children's and adolescent's behaviour may
be helpful in the paediatric dentistry clinic. Paediatric den-
tists’ awareness of the effectiveness of different distraction
techniques may be useful to improve the clinicians’ capabil-
ities to mitigate fear/anxiety, enhancing paediatric patients’
experience during dental treatment. It is important that the
paediatric dentists are aware of all different techniques, al-
lowing them to apply the most appropriate strategy according
to each child's or adolescent's individual characteristics.
The studies available to date in the literature suggest that
distraction techniques can be effective in managing children's
PRADO et al.
and adolescents’ dental anxiety and fear during dental treat-
ment with very low certainty of evidence. Future studies
with more homogeneous methodological characteristics and
further research comparing different distraction techniques
among children with different ages are encouraged.
ACKNOWLEDGEMENTS
This study was financed in part by the Coordenação de
Aperfeiçoamento de Pessoal de Nível Superior—Brasil
(CAPES)—Finance Code 001. This article received finan­cial
support from the following Brazilian agencies: the Conselho
Nacional de Desenvolvimento Científico e Tecnológico (National
Council for Scientific and Technological Development) (CNPq),
the Fundação de Amparo à Pesquisa do Estado de Minas Gerais
(Research Support Foundation of the State of Minas Gerais)
(FAPEMIG), and the Pró‐Reitoria de Pesquisa Universidade
Federal de Minas Gerais (PRPq/UFMG).
CONFLICT OF INTEREST
The authors report no conflicts of interest and are alone re-
sponsible for the content and writing of the paper.
AUTHORS CONTRIBUTIONS
IMP. and LC collected the data; JMSN, CCM designed and
conceived the ideas; LGA analysed the data; SMP edition
and funding support; IMP., CCM, LGA, SMP final edition.
ORCID
Ivana Meyer Prado  https://orcid.org/0000-0002-3233-5927
Larissa Carcavalli  https://orcid.org/0000-0002-2844-3490
Lucas Guimarães Abreu  https://orcid.
org/0000-0003-2258-8071
Júnia Maria Serra‐Negra  https://orcid.
org/0000-0001-6098-3027
Saul Martins Paiva  https://orcid.
org/0000-0002-3968-1638
Carolina Castro Martins  https://orcid.
org/0000-0001-9072-3226
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SUPPORTING INFORMATION
Additional supporting information may be found online in
the Supporting Information section at the end of the article.    
How to cite this article: Prado IM, Carcavalli L,
Abreu LG, Serra‐Negra JM, Paiva SM, Martins CC.
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;29:650–668. https://doi.
org/10.1111/ipd.12499