Background

ABSTRACT
Background
The aim of this study was to compare and evaluate the effect of sensory adapted dental
environment and regular dental environment in reducing anxiety levels in children with
intellectual disability.
Objectives:
1. To evaluate the efficacy of sensory adapted dental environment (SADE) on
cooperation and anxiety levels in children with intellectual disability.
2. To evaluate the efficacy of regular dental environment on cooperation and anxiety
levels in children with intellectual disability.
3. To compare the efficacy of sensory adapted dental environment and regular dental
environment on cooperation and anxiety levels in children with intellectual
disability.
Methodology:
This study was carried out on 24 children with mild intellectual disability aged between 8-
13 years. Developmental screening test was utilized to categorize and include the children
in the study with mild intellectual disability with IQ score between 52-67. Then the
children were randomly allocated and subjected to routine dental prophylaxis into two
different dental environments. In the study group SADE was used and a regular dental set
up in control group. Dental anxiety levels for both the groups, were assessed at baseline,
5 minutes, and at the end of the procedure using the Venham’s anxiety rating scale, pulse
rate and blood pressure values.
viii
Results: The data was coded and analyzed using software SPSS (IBM version 22.0) for
statistical analysis. Comparison between groups was done using Independent T- test and
repeated measured ANOVA for objective assessment of intergroup and intragroup anxiety
levels respectively, and using Mann Whitney U test and Friedman’s test for subjective
assessment of intergroup and intragroup anxiety levels respectively
Interpretation and Conclusion: The current study suggests that SADE significantly
decreased anxiety levels and cooperative behaviour in children with mild Intellectual
disability and SADE can be used as an alternative behaviour management technique in
effectively handling children with intellectual disability when compared to conventional
behaviour management techniques.
Key words: Behaviour management; SADE; Dental Anxiety; Mild Intellectual disability
ix
Introduction
INTRODUCTION
Special care dentistry is the field of dental practice that provides oral care and treatment
needs for patients with physical, mental, medical problems, or any other limitations. It
majorly involves prevention, diagnosis and treatment services.1 These patients are generally
unable to maintain proper oral health on their own due to lack of motor dexterity 2 and their
dental care is neglected primarily because of insufficient encouragement and awareness
about oral health.1 Therefore, providing primary and comprehensive, preventive and curative
oral care for people with special health care needs is a fundamental element of the paediatric
dentistry speciality.3
Approximately, there are about 650 million individuals who are affected with the disability
which is advancing with the increasing population. According to the reports of United Nation
Development Programme in 2006, about 80% of people having disabilities reside in
developing countries,4 with India being world's largest populated country having children
with high risk of developmental disabilities.5 It can be estimated that there are nearly 24
million individuals in India with intellectual disabilities, out of which 15 million are children
below 10 years of age. Intellectual disability(ID), in former times referred as mental
retardation, is a condition involving significantly sub-average intellectual development from
birth to early childhood.6
Features of this condition comprise of substantial impediments in intellectual functioning
(including learning, reasoning, problem solving) and adaptive functions, which covers
variety of everyday social and practical abilities.7
The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) has
classified four different degrees of intellectual disabilities as: Mild intellectual disability,
1
Introduction
moderate intellectual disability,severe and profound intellectual disability, in which majority
of the population (about 85%) with intellectual disabilities is mildly disabled.6
The etiologic factors for Intellectual disability are various which can be broadly categorized
into hereditary and environmental factors. The hereditary factor being of paramount
importance as there is increased incidence of disabled parents who produce children with
disability. This group of hereditary conditions also involves certain disorders which are
associated with mental retardation like Phenol ketonuria, Cretinism, Microcephaly,
Neurofibromatosis, and Huntington’s chorea. The environmental aspect of causation
affecting intellectual development encompass infections in the prenatal period like viral
infections in the third month including maternal rubella, viral encephalitis, rhesus
incompatibility, fetal irradiation and infections in peri-natal periods such as bacterial
meningitis, anoxia during the time of delivery and traumatic brain injury.8
Children with intellectual disabilities are unable to execute various tasks such as issues in
communication, socialization, as well as looking after themselves. They experience
difficulties with fundamental activities, including eating, dressing, communicating and
walking. They are extremely prone to depression, low self-appreciation and confidence.
They experience challenges in learning, and grasp things at a considerably slower rate than
children who do not have intellectual disability.6
Oral hygiene is a crucial component of overall general health. Good Oral health increases
one's overall quality of life.9 The oral health of individuals is influenced greatly by their
physical and mental capacities, as well as the cooperation and motivation of the support staff.
Unfortunately, oral care of these children is one of the extreme unmet health needs than the
normal population.10 This has been linked to the fact that there are challenges associated with
2
Introduction
practical difficulties during routine treatment sessions, lack of oral health supervision by
parent/caregiver, socioeconomic status, their nutrition, eating pattern, medication, physical
limitations like lack of muscle coordination and awareness about significance of brushing
and flossing, neglecting the treatment needs or pain, obstacles in communication and
cooperation, lack of effective preventive strategies to reduce the need for this care, negative
attitudes of parents and healthcare providers, and lastly insufficient skills of dentists in
providing dental care.10,11
According to various studies people with intellectual disabilities have poor oral health and a
higher incidence of gingivitis. In comparison with normal population, these subjects had the
highest degree of negligence towards dental health.10 Numerous authors noted that amongst
the disabled, the mentally handicapped had a high prevalence of poorer oral health which
was suggested to be the predominant cause of periodontal disease in these individuals.9
Furthermore, reports also suggest that a significant correlation exists between oral hygiene
and periodontal conditions in these children. Grants and Stern have proved that there is
general increase in OHI-S scores as well as extent of periodontal disease with the increase
in age.11
Casamassimo,Seale, and Ruehs (2004) noted that 60–80% of dentists reported that they were
not willing to provide care to disabled population because of their resistive behaviours. Apart
from these, multiple other factors that create barriers to good oral care are anxiety-induced
reactions which can be difficult to manage them resulting in a reduction in access to or
changes in the manner in which dental care is offered.12
Anxiety is physiologic experience that arises when an individual is exposed to stress, which
can be caused by unpredictable or unfamiliar circumstances, medical treatment, or an
3
Introduction
uncomfortable experience.13 For individuals with intellectual disability, anxiety can also
result from cognitive impairments, reduced adaptive behaviours, and perceived increased
vulnerability to environmental demands.12 Anxiety related to dental treatment is one such
barrier, which poses a challenge and can lead to patient’s avoiding dental appointments.
Though all individuals are afflicted by anxiety, various studies have shown that people with
special needs are eminently vulnerable to dental challenges.13 To overcome such behavioural
challenges, the use of sedative drugs or general anaesthesia, have shown to be beneficial.
However, there are still conflicts with the use of these procedures on subjects with
disabilities,14 as these behaviour management strategies can be costly, often necessitating
treatment in a more specialised facility, such as a hospital, rather than an outpatient dental
office.12
According to American Academy of Paediatric Dentists, Hand over mouth and Physical
Restraint techniques have been disregarded in the management of these children while
performing various oral care procedures, as they pose a major obstacle in managing stronger
and active patients with mental disabilities. Moreover, these techniques are not only
traumatizing to the patient but can also cause inconvenience to the operator as well as dental
staff, therefore compliance from dental staff and public for these techniques have been
reasonably inferior. Furthermore, as acceptance of restraint techniques decrease, behavioural
challenges in the dental chair among those with intellectual disabilities continue to increase.
Around 53% of dentists used restraint preferably rather than sedation to treat a child with
disability in order to overcome behaviour problems in the dental clinic. However, use of
restraints could not only lead to dental fear but also reluctance in visiting dentist
subsequently. Positive ways for behaviour management do exist that place accentuation on
reinforcement and remodelling without the utilization of restraint procedures. There is a
4
Introduction
predictability that with the utilization of such strategies as systematic desensitization, in vivo
desensitization, differential reinforcement, a more extensive acknowledgment by patients,
caretakers as well as by the dental practitioners would be accomplished.14
In regular dental environment(RDE) disabled children are sensitive and easily invoked to
sensory stimuli such as high-speed hand piece, overhead light, loud ambient noises, texture
and taste of prophylaxis paste.15 This altered neurophysiological predisposition of
individuals with developmental disability encountered in regular dental set up could
negatively impact their behaviour and level of cooperation making it more difficult for
dentists to provide treatment.16 Stein et al suggests that there exists a relationship between
sensory over-responsivity and uncooperative behaviours in the dental office.17
Health professionals have studied sensory-based treatment in dental management of people
with developmental disability. This Sensory-based treatments are intended to give
individualized, regulated sensory experiences in order to modulate responses to external
stimuli. They aim to promote sensory processing and self-regulation, boost adaptive
function, and assist the child in participating in daily activities. However, there is not a
universally accepted protocol for implementing sensory-based treatment into practice.
Sensory-based treatment has been researched in the dental field as a novel technique to
reduce dental anxiety in children.15
A cross-over trial in 2009 reported that sensory adaptive technique was very productive in
dental treatment amongst children with neurological and developmental disorder compared
to those children treated in a regular dental environment. Effect of sensory adaption showed
substantial cooperation in children and they were reported to be found relaxed. Another
study in 2011 reported that there were difficulties in the behavioural management of children
5
Introduction
with disabilities, especially those with autism, however, the result showed that the sensory
environment helped a lot to facilitate dental care.18
The sensory-adapted dental environment (SADE) comprises of a specialised room with
controlled multi-sensory stimuli that is partially lighted, with relaxing music. SADE has
been proposed to help people with developmental disabilities, Alzheimer's illness, and
traumatic brain injury, improve their quality of life by reducing anxiety, pain, and unrest. 16
However, the efficacy of sensory-based treatments are yet to be conclusive.
Apparently, there are no studies done regarding the use of SADE in children with mild
intellectual disabilities. Also, the present study employed the concept of camouflaging the
instruments aiming to additionally supplement decreased anxiety during dental procedures
in children with mild intellectual disabilities. As the literature lacks the data regarding the
use of sensory adapted dental environment based upon the Snoezelen environment and
camouflaging instruments during a routine scaling procedure in children with mild
intellectual disability. So, the present study was framed to compare and evaluate the effect
of sensory adapted dental environment and regular dental environment in reducing anxiety
6
Aim and Objectives
AIM AND OBJECTIVES
1. AIM OF THE STUDY:
• To compare and evaluate the effect of sensory adapted dental environment and
regular dental environment in reducing anxiety levels in children with intellectual
disability.
2. OBJECTIVES OF THE STUDY:
• To evaluate the efficacy of sensory adapted dental environment on cooperation and
anxiety levels in children with intellectual disability.
• To evaluate the efficacy of regular dental environment on cooperation and anxiety
• To compare the efficacy of sensory adapted dental environment and regular dental
environment on cooperation and anxiety levels in children with intellectual
disability.
7
Review of Literature
REVIEW OF LITERATURE
According to AAPD, Intellectual disability (ID) is defined as ‘‘a condition of arrested or
incomplete development of mind, which is specially characterized by impairment of skills
manifested during the developmental period, which contribute to the overall level of
intelligence, i.e., Cognitive, language, motor, and social abilities’’.8
The clinical signs and symptoms of intellectual disability are diagnosed as early as between
infancy and childhood. This predominant clinical presentation significative of intellectual
disability vary depending upon the specific cause and the severity of cognitive deficit. While
infants and young children with severe intellectual deficit profoundly have a characteristic
clinical presentation with an underlying cause, alternatively a large percentage of children
with mild intellectual disability are unlikely to present clinical symptoms and may go
unrecognized until 5–9 years of age or even late childhood.19
DIAGNOSIS OF INTELLECTUAL DISABILITY
Diagnosis of intellectual disability requires a formal and individualized assessment of
cognitive and adaptive functions using standardized tests in accordance with broadly
established definitional criteria. It is important to use standardized assessment tools to assess
intellectual disability, because it is difficult to infer an individual’s intellectual function
based on conversations and observations alone.20
There are various tools for assessment of intellectual disabilities.6 The developmental tests
yield “developmental quotients” which are interpreted in the same way as IQ scores.21
Some of the Developmental screening tests are:
i. Revised Denver Pre-screening Developmental Questionnaire
ii. Kansas Infant Development Screen
8
iii. Bayley Scales of Infant Development
iv. Developmental Screening Test (DST) by Bharat Raj
vi. Functional Assessment Check List for Programming (FACP) 6
Developmental Screening Test (DST) by Bharat Raj
Developmental Screening Test developed by Bharath Raj (1977, 1983) is a simple, reliable
and a valid assessment test which aims to measure the developmental sequence of children
from birth to 15 years of age. It consists of 88 items which represents the behavioural
characteristics of various age groups. In each age group, items are drawn from behavioural
areas, such as motor development, language, speech, and social development. The evaluation
of the child can be done through semi-structured interviews with parents or caregiver of the
child. The IQ calculator assimilated with the test folder helps to calculate the IQ of children
from the mental and chronological age. Developmental screening test is a reliable and valid
test with a very high positive correlation of +.7215 to +.9968 with other tests.22
Grading of development as per score obtained from Bharat Raj’s Developmental
Screening Test: -
52-67 Mild retardation
36-51 Moderate retardation
20-35 Severe retardation
Less than 20 Profound retardation
Approximately 85% of patients with intellectual disability have mild severity. The IQ score
for mild disability is between 50–70. They have difficulties in acquiring and understanding
complex academic and language skills.19
9
A study was done by Verma et al in 1979 on cross validation of Developmental Screening
Test administered among 170 children aged between 1-15 yrs. Gesell drawing test, Vineland
Social Maturity Scale, were also administered along with this by dividing the children into
3 groups 1-5, 6-10, 11-15 years. The results showed that DST showed a very high positive
correlations with other developmental tests, which proved it to be a valid test for all 3 age
groups. Interscorer reliability and test-retest reliability were found to be high than other
tests.23
BARRIERS IN ORAL HEALTH CARE IN INTELLECTUAL DISABLED
CHILDREN:
When considering the oral health of these individuals, there are often reports that they have
significant dental needs, and these needs are often untreated barriers that make it difficult
for these patients to attain the necessary dental care.24
Various barriers seeking dental services have been classified by the Federation Dentaire
Internationale as:
(a) Individuals themselves
(b) The dental profession
(c) Society 25
Barriers with reference to the dental profession:
Experienced and trained personnel equipped with specialized programs, clinics, and
facilities are necessary for managing such patients.9 A majority of studies cited the most
common causes for dentists to neglect to provide dental care is because of the patient’s
behaviour, dental disease severity, disability associated and inadequate training and
experience in treating this population as major obstacles.24
10
Other factors related to these health inequalities such as high employee turnover, lower
levels of trust and cooperation, uneven distribution, insufficient sensitivity to the needs and
requirements of patients, lack of information about treatment, lack of knowledge and
funding, restricted physical environment, lack of accessible language and communication
skills.26
As increased time and efforts are required, dental practitioners tend to abstain from treating
patients with intellectual disability.9
Barriers with reference to society:
Inadequate awareness in community, negative oral health promotion attitudes, insufficient
oral healthcare facilities and human resource planning.26
Barriers with reference to the individual:
These individuals face difficulty following instructions, inability to perform oral health self-
care, anxiety or fear due to previous traumatic experiences, lack of awareness of oral health
care by caregivers, low expectations and issues related to accessibility.26
A cross sectional study designed by Bhaskar et al aimed to analyse the barriers to oral care,
evaluate the oral hygiene and dmft index in 331 school children with disabilities aged
between 6–14 years old in Kochi. They were divided into groups including intellectually
handicapped, hearing impaired, visually handicapped, and orthopaedic handicapped.
Pretested structured questionnaire was given to parents/caretakers to obtain information
regarding access to care and clinically the dentition status and OHI-S index was recorded.
The results showed that 68.6% of them reported financial difficulty as the most significant
11
obstacle to dental care, which was higher among intellectually handicapped (39%) with a
2.81 ± 3.4 dmft score higher among them than others.27
Leal Rocha L et al conducted a cross-sectional study to investigate the dental services
accessibility, the dental services requirements, and factors impacting the use of dental
services by people with motor, visual, and hearing impairments in Brazil. The study
comprised of structured questionnaires which were distributed among dentists and disabled
people. They concluded that 43.1% of disabled people failed to prioritize their basic health
care, 52.5% did not generally pursue dental care, and amongst those who seek care ,76.3%
found it difficult to receive care ,84.5% only seek emergency care and 45% are not aware of
the services provided. Among the dentists 43.8% reported insufficient physical access
infrastructure with 60% of dentists reporting of the transportation difficulties and unsafe
environment as barriers.28
Krsihanan L et al conducted a study which aimed to estimate the health care barriers faced
by children with disability from caregivers and dental professional’s perspectives. A
prevalidated questionnaire was given to 195 dentists and 100 caregivers. The study
concluded that about 83.7% of dentists proclaimed insufficient training in managing the
special needs children, whereas 38% caretakers reported fear of dentist among these
children. Therefore, they suggested there is a need to improve the dental setup to provide
comfort care to these children.29
Alfaraj A et al surveyed to evaluate the barriers in accessing dental care among caretakers
in Saudi Arabia using a questionnaire distributed among 186 caretakers of children with
special health care needs. They concluded that 60.8% of caregivers faced lack of time for
12
getting access to dental care,53.9% reported unsuitable clinic environment,51.9% had
difficulties with transportation.30
ANXIETY
‘Anxiety’ is an emotional state that occurs before actually encountering a threatening
stimulus, and sometimes goes unnoticed whereas ‘dental fear’ is a response to a threatening
stimulus in dental situation. The overwhelming and irrational fear of dentistry related to
destructive feelings such as terror, irritability, high blood pressure, and restlessness is known
as "odontophobia" and is diagnosed as a specific phobia under the International Statistical
Classification of Diseases and Related Health Problems (ICD)-10 and DSM-IV.31
Extreme fear is negatively associated with the frequency of dental visits and perceived oral
health. Numerous studies have shown that people with disabilities have high levels of fear
and anxiety.9 According to Algras et al dental anxiety has been proclaimed as the fifth-most
prevalent cause of anxiety.31
According to Deb et al (2001) and Ramirez & Lukenbill (2007), individuals with intellectual
disability experience more mood and anxiety disorders than normal population. Emerson
and Hatton (2007) reported that in comparison to people without intellectual disability, those
with intellectual disability have 3-4 times increased risk of emotional, behavioural and
anxiety related problems.32 This anxiety experienced by individuals with intellectual
disability affects the desire to avoid dental care, more than the external factors like
transportation and cost, which will definitely affect overall dental health.24
13
SENSORY TRIGGERS OF DENTAL ANXIETY
Anxiety can be triggered by the sensory stimuli, such as the sight of needles, sounds of cavity
cutting with airotor, the smell of eugenol, and the sensation of high-frequency vibrations in
the dental environment.31
A study was done by Fallea et al to evaluate the prevalence of dental anxiety in borderline
intellectual functioning and individuals with mild and moderate intellectual disability, and
to investigate the correlation of dental anxiety with their age and gender among 700
participants aged 6-47 years old. Dental Anxiety Scale was utilized to assess their level of
dental anxiety. The results of the study suggest that mild intellectually disabled population
had 40.61% slight anxiety,18.79 % moderate anxiety,17.5% high anxiety,10.91 % severe
anxiety and dental anxiety was high in younger population with increased prevalence in
females.33
A study done by Keles et al to determine the effect of dental anxiety on oral health related
quality of life in 86 mildly intellectual disabled children. Oral health of the children on their
quality of life and its association with anxiety levels were assessed using Oral health-related
quality of life-United Kingdom Scale, Oral Health Impact Profile-14 and Modified Dental
Anxiety Scale respectively. The results of the study showed that around 30% of individuals
with mild intellectual disability were shown to have dental anxiety and with the increase in
dental anxiety the oral health-related quality of life decreased in these children.34
Assessment Of Dental Anxiety:
There are many ways to assess children's dental fear and anxiety. Among the many options,
the four main types of assessment tools can be grouped according to the types of information
14
collected. They are: - Self-report assessment, Parental proxy assessment, Observation-based
assessment, and Physiological assessment.35
Physiological Assessment (Objective Assessment)
Fear-anxiety plays significant role in the cardiovascular changes occurring during dental
treatment. These responses stimulate the adrenal medulla to release endogenous epinephrine
which causes the peripheral arteries to constrict and can therefore increase blood pressure.
Heart rate is directly affected by the autonomic nervous system and can increase with
hormonal epinephrine.36
A study was done to evaluate the effect of dental treatment procedures on pulse rate and
peripheral oxygen saturation among 100 children aged 6-10 year old. The children were
categorized under 5 dental procedures; including 3 invasive (GIC filling extraction,
Pulpotomy) and 2 non-invasive (scaling and polishing, fluoride application) procedures. The
pulse oximeter was used to record the findings in each child at 5 different times involving
child in play area, child in dental operatory, child on the dental chair prior to treatment,
during the procedure and post treatment. The O2 saturation and pulse rate was evaluated at
each time and recorded. The pulse rate increased subsequently for all the treatment
procedures with its highest recorded value of 134bpm for scaling and polishing.37
Another study evaluated the behavioural and physiological variations during sequential
dental visits and its effect on age and sex among 115 children, between 4-11 years of age.
The child's response was determined using oxygen saturation, blood pressure, heart rate, and
cooperative behaviour. The variables were observed and recorded when the child was in the
waiting room, after initial examination, before and after oral prophylaxis, before and after
15
cavity preparation, before and after extraction. The results concluded that a significant
increase in change in the systolic blood pressure and heart rate in all the situations in the
dental operatory. The diastolic pressure also showed a significant change from the initial
waiting period to the period after initial examination.38
Subjective Assessment (Observation Based)
Venham’s Anxiety Rating Scale
Venham’s anxiety scale is one of the most reliable indicators of dental anxiety. Venham’s
anxiety scale is a 6 point scale (0-5), which describe the child's anxiety level and explain the
most likely behaviour pattern.39
Advantages of rating scales include ease of approach and recording,40 with a high degree of
clarity and reliability even for untrained observer.41 The evaluator uses trait (anxiety) as an
organizing concept, allowing him to select relevant cues and superimpose dimensions on the
subject's behaviour. It has significant correlations indicating that greater anxiety and
uncooperative behaviour were associated with more highly stressed physiological and self-
report measures.40
In a report given by Venham et al, the children’s response to dental stress as assessed by
Venham’s anxiety rating scale showed it to be a reliable and valid scale which could be
easily integrated into clinical and research activities. This study further validated the scales,
the results of which prove Venham’s anxiety rating scale as a standard tool for behavioural
assessment.40
16
MANAGEMENT OF DENTAL ANXIETY IN INTELLECTUALLY
HANDICAPPED CHILDREN:
The AAPD endorses the traditional behavioural guidance such as communication guidance,
voice control, Tell-Show-Do, non-verbal communication, positive reinforcement,
distraction, and nitrous oxide sedation to guide children throughout the dental treatment and
to assist in building their coping skills. However, these approaches are insufficient to engage
children with developmental disability due to unique deficits associated with their
disabilities. Furthermore, the psychological and physical impairments, including sensory
processing difficulties make it even more difficult for children with developmental disability
to cooperate and tolerate dental treatment.15
The use of Hand over mouth (HOM) and Hand over mouth airway restricted (HOMAR) has
been declined in the dental practice. Utilizing these restrictive methods of behaviour
management has raised concerns majorly due to liability and legal issues and potential
effectiveness of alternative less restrictive techniques for behaviour management during
dental procedures in these children. Also, there is lack of evidence on the efficacy of HOM
or HOMAR in reducing disruptive behaviour in children. They cannot be employed as a
behaviour management technique for individuals with intellectual disabilities requiring
dental treatment.42
A study done by Conyers et al compared in vivo desensitization with video modelling for
increasing compliance with dental procedures in 6 individuals with severe or profound
intellectual disabilities. The authors reported that both video modelling and desensitization
were effective in gaining compliance. However extensive time was required for the
desensitization, furthermore, no information was presented on the long-term impact of the
use of desensitization and modelling.43
17
Stark et al. (1989) investigated the use of distraction technique in reducing anxious and
disruptive behaviour in 4 children, as assessed by direct observation in a multiple baseline
design.42 Allen and Stokes (1989) also reported that distraction technique alone is
insufficient to decrease uncooperative behaviour.44 However this technique has not been
applied to individuals with intellectual disability.42
In another study, a tape-slide series was developed using a desensitization and modelling
approach, prior to initial dental examination of children with DD. The children who were
not exposed to series served as a control group. Behaviour of children was assessed using
heart rate, a modified Melamed's scale, and a dentist's subjective evaluation. The results
showed that children exposed to tape-slide series showed worse behaviour and a higher heart
rate than children not exposed to the series.45
Since individuals with intellectual disability remain unaffected by the behaviour of those
around, modelling technique is relatively less effective in them.44
Another study evaluated parental acceptance for use of restraints during dental procedure in
children with intellectual disabilities. Participants were interviewed and they also watched a
video on physical restraint techniques, sedation, and general anaesthesia. Only 22.9% of the
parents accepted general anaesthesia. 50.7% parents considered active restraint, 55.9%
passive restraint, and 58.9% considered sedation, with no statistically significant difference
for acceptance of any of these methods, with general anaesthesia being the least accepted
method of restraint.46
There has been limited attention to development of alternative methods based on the
functional analysis of atypical behaviour for behaviour management of these children, there
is a great need for implementation of intervention programmes for individuals with
18
intellectual disability who require dental treatment for both those with and without
challenging behaviours.42
The sensory adaptive technique is one such technique which has been developed based on
Snoezelen environment. This environment consists of a dental clinic with certain lightning
effects, vibrations, calming music, and aromas.18 This concept intends to stimulate the
elementary senses of sight, touch, feel, and smell, along with patient-centred therapy.31 Since
sensory processing disorders are ubiquitous in those with developmental disability, sensory
flooding leads to emotional discomfort manifesting as high level of anxiety and
uncooperative behaviour. So, providing these children with developmental disability with
an environment in which aversive stimuli is substituted by gentler stimuli, like soft moving
light effects, calming music, and deep pressure, the children would become more focused on
the pleasant stimuli, with reduced awareness of discomforting stimuli,16 therefore
diminishing their fear and anxiety, thus improving their behaviour.18
STUDIES
A study was done to investigate the effect of a sensory-adapted dental environment (SADE)
on anxiety, relaxation, and cooperation of children with developmental disabilities among
16 children aged 6-11 years old with moderate to severe developmental disability. The
children’s cooperation level during the treatment was recorded using the anxiety and
cooperation scale. Utilizing negative dental behaviour checklist, the duration of anxious
behaviours was measured, electrodermal activity was monitored by changes in the skin
conductance. The mean duration of anxious behaviours was low and substantial increase in
relaxation and cooperation in the SADE as opposed to the regular dental environment
19
(RDE), indicating the significance of considering the sensory-adapted environment as a
preferable dental environment for this population.47
Another study was done to determine the effect of sensory adapted environment in
diminishing the behavioural and arousal levels among 16 children aged between 6-11 years
with moderate to severe developmental disability in comparison with 19 age matched normal
children during dental prophylaxis procedure. They evaluated the duration of anxious
behaviours and electrodermal activity before and after the dental procedure. They concluded
that SADE was significantly more beneficial in effectively decreasing anxiety levels in
disabled population than in normal children.16
A study evaluated the impact of SADE in diminishing agitation and anxiety levels during
dental prophylaxis among 41 adult participants with intellectual and developmental
disability compared to RDE. They assessed the blood pressure, heart rate and behavioural
parameters such as duration and frequency of agitated behaviours through video recordings.
The study concluded that SADE effectively reduced the duration and frequency of agitated
behaviours compared to RDE.48
A pilot study was done to assess the effect of a sensory adapted dental environment in
reducing anxiety during routine oral care among 22 children with developmental disabilities
including neurodevelopmental disabilities, Autism Spectrum Disorder, Down syndrome,
Developmental delay, Cerebral palsy, and disabilities associated with chromosomal
disorders. Random allocation was done among the children, each subjected into two dental
setups, one in SADE and other in RDE with a recall period of 3-4-months. They measured
the heart rate, oxygen saturation, frankl behaviour scale to assess the anxiety levels in these
20
children. They concluded that Frankl scores were significantly increased in SADE in
comparison to RDE. SADE was also strongly preferred by 46% of parents for their child’s
further dental treatment proving it to be beneficial in controlling behavioural issues in these
children.15
Another pilot study examined the impact of a sensory adapted dental environment (SADE)
in decreasing discomfort and pain perception during routine oral prophylaxis among 44
children aged 6–12 year old with autism spectrum disorder (ASD). This crossover trial
assessed the physiological anxiety, pain intensity, behavioural distress, and sensory
discomfort among the participants undergoing prophylaxis in SADE and RDE each. The
results concluded that there was decreased anxiety, sensory discomfort and pain in the SADE
condition in comparison to RDE, proving it to be effective in the behaviour management of
these children.17
Another study aimed to evaluate the anxiety levels among 19 children aged 6-11 year old
undergoing routine prophylaxis in SADE. They evaluated behavioural parameters through
the videotaped recordings such as number, magnitude and mean duration of anxious
behaviours. The physiological parameters were recorded by evaluating changes in dermal
resistance. They concluded that there was significant decrease in anxiety levels in SADE
compared with conventional dental environment which proved SADE to be effective in
anxious children undergoing dental procedures.49
21
Methodology
METHODOLOGY
This present in vivo, randomized clinical trial was conducted on 24 children with mild
intellectual disability with an age range of 8-13 years in the Department of Paedodontics
and Preventive Dentistry, Bapuji Dental college and hospital, Davangere, Karnataka,
India, for oral prophylaxis procedure. The study was approved by Ethical Committee
(Ref.No.BDC/Exam/509/2019-20) from the Institutional Review Board, Bapuji Dental
College and Hospital, Davangere and written informed consent from the legal
guardian/care taker of patients willing to participate in the study was taken after
explaining the whole procedure.
INCLUSION CRITERIA:
• Children with the age group of 8-13 years.
• Children with mild intellectual disability with IQ level between 50-69.
• Children who are systemically healthy.
EXCLUSION CRITERIA:
• Children with moderate to severe intellectual disability.
• Children with any other concomitant diseases or syndromes.
22
Methodology
SAMPLE SIZE DETERMINATION:47
Sample size was calculated using G Power Software version
Significance level was fixed at 0.05
Power of the study was fixed at 20% (0.8)
Effect size was fixed at 1.21(calculated based on the results of previous study)
The calculated sample size was 12 per group. The total sample size was 24.
MATERIAL USED:
• Customized handles for mouth mirror
• Customized handles for scalers
• Customized mouth mask
• Butterfly wrap
• Plane mouth mirrors
• Scalers
• Explorers
• Tweezers
• Kidney trays
• Suction tips
• Cotton rolls
• Disposable gloves
• Regular Mouth masks
23
Methodology
EQUIPMENT REQUIRED:
• Portable Music system
• LED colour bulbs
• Pulse oximeter (Choicemmed)
• Digital sphygmomanometer (OMRON)
PROCEDURE: A general examination of children after taking consent from the legal
guardian/care taker was done prior to the study, to assess if he/she comes under selection
criteria. Developmental screening test was conducted for determining IQ level of the
children with intellectual disability and the children were divided into two groups.
SCREENING OF INTELLECTUALLY DISABLED CHILDREN
DEVELOPMENTAL SCREENING TEST
SELECTED INTELLECTUALLY DISABLED

CHILDREN
RANDOMIZATION
REGULAR DENTAL SENSORY ADAPTED

ENVIRONMENT DENTAL ENVIRONMENT
24
Methodology
24 Mentally retarded children were included in the study.
Group – 1 Intellectually disabled Children to be treated Sample size – 12
under regular dental environment

(control)
Group – 2 Intellectually disabled Children to be treated Sample size - 12
(experimental) under sensory adapted dental environment
DEVELOPMENTAL SCREENING TEST:22
This test is designed for the purpose of measuring intellectual development of children
with intellectual disability from birth to 15 years of age. The test provides a brief and
fairly dependable assessment without requiring the use of performance tests.
ADMINISTRATION:
DESCRIPTION OF THE MATERIAL: Developmental schedule consists of a simple
chart with items on it. These items are arranged age wise from 3 months to 15 years.
The items progressively depict greater level of physical and social maturity and
independence.
Instruction to use:
The tester starts with items closest to chronological age of child to establish a ‘basal
age’. This is the age at which all items are likely to be passed or the behavior described
is likely to be present. Gradually tester moves through upper age levels. Each item could
be evaluated either by observing the child (e.g.: head is steady, walks) or by asking the
parents (comb hair by self) or by asking the child (repeat 3 digits).
In each group the child should succeed in at least 60% of the items.22
25
Methodology
The IQ of the child will be calculated using the formula:
IQ= MENTAL AGE X 100
CHRONOLOGICAL AGE
PROCEDURE:
• Children with mild intellectual disability requiring oral prophylaxis
treatment were considered in the study. Randomization among the children
fulfilling the inclusion criteria was done by picking up chits as to which
environment the child will be exposed to.
Intellectually disabled Children treated under regular dental environment:17,48
• After random allocation in the control group, the oral prophylaxis was done
in the standard manner in a small dental room. Anxiety level of the patients
was recorded using physiologic and psychologic parameters.
• The pulse rate was recorded using pulse oximeter and blood pressure
recordings were measured with a digital sphygmomanometer at the start of
the treatment, five minutes after starting the treatment and after completion
of the treatment.
• Children’s level of cooperation during the treatment was recorded on
completion of each treatment using the anxiety and cooperation scale given
by Veerkamp et al (modified VENHAM'S clinical ratings for anxiety and
cooperative behaviour). This standardized scale includes a score range of 0
to 5 according to the child’s behaviour.
26
Methodology
Intellectually disabled Children treated under sensory adapted dental
environment :17,48
After random allocation of children in the experimental group the following specific
modifications were done in the dental room:-
1) VISUAL: Regular dental overhead lamp was turned off, and slow-moving
visual colour effects were displayed onto the ceiling in the child ‘s visual field.
2) CAMOUFLAGING THE INSTRUMENTS: The handles of the instruments
were covered with toys.
3) HEAD LAMP: The head mounted lamp was used to direct light into the child’s
mouth.
4) AUDITORY: Rhythmic music was played through portable speakers.
5) TACTILE: This stimulus consisted of a wrap designed to look like a butterfly
which was wrapped around the child to produce a calming effect. And oral
prophylaxis was carried out in a standard manner. Anxiety level of the patients
was recorded using physiologic and psychologic parameters.
• The pulse rate was recorded using pulse oximeter and blood pressure
recordings were measured with a digital sphygmomanometer at the start of
the treatment, five minutes after starting the treatment and after completion
of the treatment.
• Children’s level of cooperation during the treatment was recorded on
completion of each treatment using the anxiety and cooperation scale given
by VeerKamp et al (modified VENHAM'S clinical ratings for anxiety and
cooperative behaviour).
27
Methodology
VENHAM'S clinical ratings (modified) of anxiety and cooperative behaviour:50
0- Relaxed, smiling, willing, able to converse, best possible working conditions.

Displays the behaviour desired by the dentist spontaneously, or immediately
upon being asked.
1- Uneasy, concerned. During stressful procedure may protest briefly and quickly
to indicate discomfort. Hands remain down or partially raised to signal
discomfort. Child willing and able to interpret experience as requested. Tense
facial expression. Breathing is sometimes held in ("high chest"). Capable of
cooperating well with treatment.
2- Tense tone of voice, questions and answers reflect anxiety. During stressful
procedure, verbal protest, (quiet) crying, hands tense and raised but not
interfering much. Child interprets situation with reasonable accuracy and
continues to work to cope with his/her anxiety. Protest more distracting and
troublesome. Child still complies with request to cooperate. Continuity is
undisturbed.
3- Reluctant to accept the treatment situation, difficulty in assessing situational
threat. Pronounced verbal protest, crying. Using hands to try to stop procedure.
Protest out of proportion to threat or is expressed well before the threat. Copes
with situation with great reluctance. Treatment proceeds with difficulty.
4- Interference of anxiety and ability to assess situation. General crying not
related to treatment. Prominent body movements, sometimes needing physical
restraint. Child can be reached through verbal communication, and eventually
with reluctance and great effort begins to work to cope. Protest disrupts
procedure.
5- Out of contact, with the reality often threat. Hard, loud crying,screaming,
swearing. Unable to listen to verbal communication. Regardless of age, reverts
to primitive flight responses. Actively involved in escape behaviour. Physical
restraint required.
28
Methodology
Developmental Screening Test used in the study for screening children:51
3 years 4years 5 years
Toilet control Tells stories Goes about neighborhood

present
Takes food by self Repeats 3 digits Gives sensible answers to

questions
Begins to ask why? Plays cooperatively Describes actions in pictures

with children
Knows name, uses Comprehends Dresses with no supervision

of common objects ‘hunger’, ‘cold’
Relates experiences Buttons up Makes simple drawings
Copies 0 Defines words
6 years 7years 8 years 9 years
Enjoys constructive Knows comparative Tells time Bathes self-unaided

play value of coins
Gains admission to Enjoys group play Competition in Muscle coordination games
school school/play (marbles)
Writes simple words Spells, reads, writes Makes small Favorite of fairy tales
simple words purchases
Plays games Tells difference of Combs hair by Recognizes property rights
governed by rules, objects self
Can name primary Adapts to home, school Reads on own initiative
colors Tells day, month, year
29
Methodology
10 years 11 years 12 years 13 years
Can stay away from Able to discuss Capable of self- Understands abstract
ideas(justice)
home (camps) problems criticism
Sex differences in play Physical feats liked More independent Interested in dressing up
become marked in spending
Goes about town freely Comprehends social Enjoys books, Plays difficult games
situations Newspapers,
magazines
Has various hobbies, Writes occasional Learns from experience
collections short letters
Cooperates keenly with Shows foresight, planning,

judgement
companions
30
Methodology
SAMPLE SIZE DETERMINATION:47
Sample size was calculated using G Power Software version
Significance level was fixed at 0.05
Power of the study was fixed at 20% (0.8)
Effect size was fixed at 1.21(calculated based on the results of previous study)
The calculated sample size was 12 per group. The total sample size was 24.
23
Results
RESULTS
The present study was conducted in the Department of Pedodontics & Preventive
Dentistry at Bapuji Dental College & Hospital, Davangere, Karnataka, India with the aim
to evaluate the effect of sensory adapted dental environment and regular dental
environment in reducing anxiety levels in children with intellectual disability. A sample
of 24 children with mild intellectual disability aged 8-14 years were selected for the study
for routine oral prophylaxis procedure. The children were accordingly divided into the
control and study groups. The data was collected, coded and analyzed using software
SPSS (IBM version 22.0) for statistical analysis. The data was subjected to normality test
and then Parametric tests were used. The recorded and analysed values are presented in
tables and graphs respectively. The results were analysed using Independent T- test and
repeated measured ANOVA for objective assessment of intergroup and intragroup anxiety
levels respectively, and using Mann Whitney U test and Friedman’s test for subjective
assessment of intergroup and intragroup anxiety levels respectively and p<0.05 was
considered statistically significant.
The results of the present study were evaluated under the following headings: -
1. Masterchart I: Compiled data representing the control group.
2. Masterchart II: Compiled data representing the study group.
3. Table 1: Intergroup comparison of Pulse Rate, Systolic and Diastolic Blood
Pressure values at baseline,5 minutes,at the end of the procedure.
4. Table 2: Intergroup comparison of Venham’s Anxiety Rating Scale at
baseline, 5 minutes, at the end of the procedure.
5. Table 3: Intragroup comparison of Study group based on Pulse Rate, Systolic
and Diastolic Blood Pressure at various time intervals.
39
Results
6. Table 4: Intragroup pairwise mean difference of Study group based on Pulse
Rate, Systolic and Diastolic Blood Pressure at various time intervals.
7. Table 5: Intragroup comparison of Study group based on Venham’s Anxiety
Rating Scale at various time intervals.
8. Table 6: Intragroup comparison of Control group based on Pulse Rate,
Systolic and Diastolic Blood Pressure at various time intervals.
9. Table 7: Intragroup pairwise mean difference of Control group based on
Pulse Rate, Systolic and Diastolic Blood Pressure at various time intervals.
10. Table 8: Intragroup comparison of Control group based on Venham’s
Anxiety Rating Scale at various time intervals.
11. Graph 1: Intergroup comparison based on Pulse rate at baseline, 5 minutes,
at the end of the procedure.
12. Graph 2: Intergroup comparison based on Systolic blood pressure at baseline,
5 minutes, at the end of the procedure.
13. Graph 3: Intergroup comparison based on Diastolic blood pressure at
14. Graph 4: Intergroup comparison based on Venham's Anxiety Rating Scale at
15. Graph 5: Mean difference in the study group for Pulse Rate, Systolic and
Diastolic Blood Pressure at the various time interval.
16. Graph 6: Distribution of Mean rank of study group for Venham’s Anxiety
Rating Scale at baseline, 5 minutes, at the end of the procedure.
17. Graph 7: Mean difference in the control group for Pulse Rate, Systolic and
Diastolic Blood Pressure at the various time intervals.
40
Results
18. Graph 8: Distribution of Mean rank of control group for Venham’s Anxiety
Rating Scale at baseline, 5 minutes, at the end of the procedure.
Observations from Table 1 and Graphs 1,2,3:
Table 1 shows the Intergroup comparison of 3 different parameters that are pulse rate,
systolic and diastolic blood pressure values between the study and control group at
1) There were no statistically significant differences noted in the Pulse Rate at
baseline in the study and control group(p>0.05). The mean value of pulse rate at 5
minutes in the study group was 80.50 and standard deviation was 8.48, the mean
value of pulse rate at 5 minutes in the control group was 99.00 and standard
deviation was 21.83 which showed statistically significant difference with a p-
value of 0.012. The mean value of pulse rate at the end in the study group was
83.25 and standard deviation was 9.25, the mean value of pulse rate at the end in
the control group was 108.50 and standard deviation was 26.03 which showed
statistically significant difference with a p-value of 0.004.
2) There were no statistically significant differences noted in the systolic blood
pressure at baseline in the study and control group (p>0.05). There were no
statistically significant differences noted in the systolic blood pressure at 5 minutes
in the study and control group (p>0.05). The mean value of systolic blood pressure
at the end of the procedure in the study group was 118.08 and standard deviation
was14.77, the mean value of systolic blood pressure at the end of the procedure in
the control group was136.67 and standard deviation was 13.73 which showed
41
Results
3) There were no statistically significant differences noted in the diastolic blood
pressure at baseline,5 minutes, and at the end of the procedure in the study and
control groups
Therefore, the independent sample T-test showed statistically significant decrease in
Pulse rate at 5 minutes and at the end of the procedure in the study group than the
control group and statistically significant decrease in Systolic Blood Pressure at the
end of the procedure. There were no statistically significant differences noted in the
Pulse Rate at baseline, Systolic Blood Pressure at baseline and at 5 minutes and
Diastolic Blood Pressure throughout the procedure between the study and control
groups.
Observations from Table 2, and Graph 4 :
Intergroup comparison of Venham’s Anxiety Rating Scale using the repeated measured
ANOVA test in study group and control group at baseline,5 minutes, at the end of the
procedure showed:
1) There were no statistically significant differences noted in Venham’s Anxiety
Rating Scale at baseline between the study and control groups. (p>0.05).
2) The mean rank of Venham’s anxiety rating scale at 5 minutes in the study group
was 7.46 and sum of ranks was 89.5, the mean ranks of Venham’s anxiety rating
scale at 5 minutes in the control group was 17.54 and sum of ranks was 210.5
which showed high statistically significant difference with a p-value of 0.000.
3) The mean rank of Venham’s anxiety rating scale at the end in the study group was
6.67 and sum of ranks was 80, the mean rank of Venham’s anxiety rating scale at
42
Results
the end in the control group was 18.33 and sum of ranks was 220 which showed
high statistically significant difference with a p-value of 0.000.
Observations from Table 3:
Intragroup comparison of Study group based on pulse rate, systolic and diastolic blood
pressure at various time intervals showed:
1) The mean value of pulse rate in the study group at baseline was 92.42 and standard
deviation was 14.28. The mean value of pulse rate at 5 minutes was 80.50 and
standard deviation was 8.48. The mean value of pulse rate at the end was 83.25
and standard deviation was 9.25 which showed statistically significant difference
with a p-value of 0.006.
2) The mean value of systolic blood pressure at baseline was 129.00 and standard
deviation was 9.39. The mean value of systolic blood pressure at 5 minutes was
126.25 and standard deviation was 9.96. The mean value of systolic blood pressure
at the end of the procedure was 118.08 and standard deviation was 14.77 which
showed statistically significant difference with a p-value of 0.000.
3) The mean value of diastolic blood pressure at baseline was 73.58 and standard
deviation was 15.76. The mean value of diastolic blood pressure at 5 minutes was
69.42 and standard deviation was 16.95. The mean value of diastolic blood
pressure at the end was 66.58 and standard deviation was 16.95 which showed
43
Results
Observations from Table 4 and Graph 5:
Intragroup pairwise mean difference of Study group based on pulse rate, systolic and
diastolic blood pressure at various time intervals showed:
1) The mean difference value of pulse rate at baseline and pulse rate at 5 minutes in
the study group was 11.92 which showed statistically significant difference with a
p-value of 0.003.The mean difference value of pulse rate at baseline and pulse rate
at the end was 9.17 which showed statistically significant difference with a p-
value of 0.01.There was no statistically significant difference in the mean
difference value of pulse rate at 5 minutes and pulse rate at the end in the study
group (p>0.05).
2) There was no statistically significant difference in the mean difference value of
Systolic Blood Pressure at baseline and Systolic Blood Pressure at 5 minutes in
the study group (p>0.05).The mean difference value of Systolic Blood Pressure at
baseline and Systolic Blood Pressure at the end in the study group was 10.92 which
showed statistically significant difference with a p-value of 0.001. There was no
statistically significant difference in the mean difference value of Systolic Blood
Pressure at 5 minutes and Systolic Blood Pressure at the end in the study group
(p>0.05).
3) There was no statistically significant difference between the mean difference value
of Diastolic Blood Pressure at baseline and at 5 minutes in the study group
(p>0.05). The mean difference value of Diastolic Blood Pressure at baseline and
Diastolic Blood Pressure at the end was 7.00 which showed statistically significant
difference with a p-value of 0.01. The mean difference value of Diastolic Blood
Pressure at 5minutes and Diastolic Blood Pressure at the end was 2.83 which
showed statistically significant difference with a p-value of 0.005.
44
Results
Intragroup comparison of Study group based on Venham’s Anxiety Scale at various time
intervals showed:
1) The mean ranks of Venham’s anxiety rating scale in the study group at baseline
was 2.79, at 5 minutes was 1.79 and at the end was 1.42, which showed high
Observations from Table 6:
Intragroup comparison of Control group based on pulse rate, systolic and diastolic blood
pressure at various time intervals showed:
1) There was no statistically significant difference in the mean value and standard
deviation of pulse rate at baseline, 5 minutes, and at the end in the control
group(p>0.05).
2) The mean value of systolic blood pressure in the control group at baseline was
130.00 and standard deviation was 11.28. The mean value of systolic blood
pressure at 5 minutes was 133.67 and standard deviation was 13.53. The mean
value of systolic blood pressure at the end of the procedure was 136.67 and
standard deviation was 13.73 which showed statistically significant difference
with a p-value of 0.001.
3) There was no statistically significant difference in the mean value and standard
deviation of diastolic blood pressure at baseline,5 minutes, and at the end in the
control group(p>0.05).
45
Results
Intragroup pairwise mean difference of Control group based on pulse rate, systolic and
diastolic blood pressure at various time intervals showed:
of pulse rate at baseline and at 5 minutes, between the pulse rate at baseline and at
the end and between the pulse rate at 5 minutes and at the end in the control group
(p>0.05).
2) The mean difference value of Systolic Blood Pressure at baseline and Systolic
Blood Pressure at 5 minutes in Control group was -3.67 which showed statistically
significant difference with a p-value of 0.03. There was no statistically significant
difference in the mean difference value of Systolic Blood Pressure at baseline and
Systolic Blood Pressure at the end (p>0.05). There was no statistically significant
difference in the mean difference value of Systolic Blood Pressure at 5 minutes
and Systolic Blood Pressure at the end (p>0.05).
of Diastolic Blood Pressure at baseline and at 5 minutes, between the Diastolic
Blood Pressure at baseline and at the end, and between the Diastolic Blood
Pressure at 5minutes and at the end in the Control group (p>0.05).
46
Results
Intragroup comparison of Control group based on Venham’s Anxiety Scale at various time
intervals showed :
1) The mean ranks of Venham’s anxiety rating scale in the study group at baseline
was 1.42, at 5 minutes was 1.88 and at the end was 2.71 , which showed high
47
Results
TABLES
Table 1: Intergroup comparison based on pulse rate, systolic and diastolic blood
pressure
Parameter Groups Mean Std. Sig.
Deviation
Pulse rate at baseline Study group 92.42 14.28 0.8
Control group 94.00 15.89
Pulse rate at 5 minutes Study group 80.50 8.48 0.012*
Pulse rate at the end Study group 83.25 9.25 0.004*
Systolic Blood Pressure at baseline Study group 129.00 9.39 0.82
Systolic Blood Pressure at 5 minutes Study group 126.25 9.96 0.14
Systolic Blood Pressure at the end Study group 118.08 14.77 0.004*
Diastolic Blood Pressure at baseline Study group 73.58 15.76 0.40
Diastolic Blood Pressure at 5 minutes Study group 69.42 16.95 0.95
Diastolic Blood Pressure at the end Study group 66.58 16.95 0.41
48
Results
Table 2: Intergroup comparison of Venham Anxiety Scale
Parameter Groups Mean Sum of
Rank Ranks Sig.
Venham Anxiety Scale at baseline Study group 10.29 123.5 0.095
Venham Anxiety Scale at 5 minutes Study group 7.46 89.5 0.000*
Venham Anxiety Scale at the end Study group 6.67 80 0.000*
Control group 18.33 220
Table 3: Intragroup comparison of Study group based on pulse rate, systolic and
diastolic blood pressure at various time intervals
Parameter Mean Std. Wilks'
Deviation Lambda Sig.
Pulse rate at baseline 92.42 14.28 0.35 0.006*
Pulse rate at 5 minutes 80.50 8.48
Pulse rate at the end 83.25 9.25
Systolic Blood Pressure at baseline 129.00 9.39 0.20 0.000*
Systolic Blood Pressure at 5 minutes 126.25 9.96
Systolic Blood Pressure at the end 118.08 14.77
Diastolic Blood Pressure at baseline 73.58 15.76 0.24 0.001*
Diastolic Blood Pressure at 5 minutes 69.42 16.95
Diastolic Blood Pressure at the end 66.58 16.95
49
Results
Table 4: Intragroup pairwise mean difference of Study group based on pulse rate,
systolic and diastolic blood pressure at various time intervals
(I) Time (J) Time Mean Sig.
Difference
(I-J)
Pulse rate at baseline Pulse rate at 5 minutes 11.92 0.003*
Pulse rate at baseline Pulse rate at the end 9.17 0.01*
Pulse rate at 5 minutes Pulse rate at the end -2.75 0.53
Systolic Blood Pressure at baseline Systolic Blood Pressure at 5 minutes 2.75 1.00
Systolic Blood Pressure at baseline Systolic Blood Pressure at the end 10.92 0.001*
Systolic Blood Pressure at 5 minutes Systolic Blood Pressure at the end 8.17 0.28
Diastolic Blood Pressure at baseline Diastolic Blood Pressure at 5

4.17 0.20
minutes
Diastolic Blood Pressure at baseline Diastolic Blood Pressure at the end 7.00 0.01*
Diastolic Blood Pressure at 5 Diastolic Blood Pressure at the end
minutes 2.83 0.005*
Table 5: Intragroup comparison of Study group based on Venham Anxiety Scale at
various time intervals
Parameter Mean Sig.
Rank
Venham Anxiety Scale at baseline 2.79 0.000*
Venham Anxiety Scale at 5 minutes 1.79
Venham Anxiety Scale at the end 1.42
50
Results
Table 6: Intragroup comparison of Control group based on pulse rate, systolic and
diastolic blood pressure at various time intervals
Parameter Mean Std. Wilks'
Deviation Lambda Sig.
Pulse rate at baseline 94.00 15.89 0.65 0.118
Pulse rate at 5 minutes 99.00 21.83
Pulse rate at the end 108.50 26.03
Systolic Blood Pressure at baseline 130.00 11.28 0.25 0.001*
Systolic Blood Pressure at 5 minutes 133.67 13.53
Systolic Blood Pressure at the end 136.67 13.73
Diastolic Blood Pressure at baseline 67.75 17.61 0.94 0.715
Diastolic Blood Pressure at 5 minutes 69.83 12.48
Diastolic Blood Pressure at the end 71.92 13.91
51
Results
Table 7: Intragroup pairwise mean difference of Control group based on pulse
rate, systolic and diastolic blood pressure at various time intervals
(I) Time (J) Time Mean Sig.
Difference
(I-J)
Pulse rate at baseline Pulse rate at 5 minutes -5 0.66
Pulse rate at baseline Pulse rate at the end -14.5 0.22
Pulse rate at 5 minutes Pulse rate at the end -9.5 0.85
Systolic Blood Pressure at baseline Systolic Blood Pressure at 5 minutes -3.67 0.03*
Systolic Blood Pressure at baseline Systolic Blood Pressure at the end -6.67 0.31
Systolic Blood Pressure at 5 minutes Systolic Blood Pressure at the end -3 1.00
Diastolic Blood Pressure at baseline Diastolic Blood Pressure at 5 minutes -2.08 1.00
Diastolic Blood Pressure at baseline Diastolic Blood Pressure at the end -4.17 1.00
Diastolic Blood Pressure at 5 minutes Diastolic Blood Pressure at the end -2.08 1.00
Table 8: Intragroup comparison of Control group based on Venham Anxiety Scale
at various time intervals
Parameter Mean Sig.
Rank
Venham Anxiety Scale at baseline 1.42 0.000*
Venham Anxiety Scale at 5 minutes 1.88
Venham Anxiety Scale at the end 2.71
52
Results
GRAPHS
Graph 1: Intergroup comparison based on pulse rate

120.00
100.00
80.00
Mean
60.00
40.00
20.00
0.00
Pulse rate at 5
Pulse rate at baseline Pulse rate at the end
minutes
Study group 92.42 80.50 83.25
Control group 94.00 99.00 108.50
Graph 2: Intergroup comparison based on systolic blood pressure

140.00
135.00
130.00
125.00
Mean
120.00
115.00
110.00
105.00
Systolic Blood Systolic Blood Systolic Blood
Pressure at baseline Pressure at 5 minutes Pressure at the end
Study group 129.00 126.25 118.08
Control group 130.00 133.67 136.67
53
Results
Graph 3: Intergroup comparison based on diastolic blood pressure

76.00
74.00
72.00
70.00
Mean
68.00
66.00
64.00
62.00
Diastolic Blood Diastolic Blood Diastolic Blood
Pressure at baseline Pressure at 5 minutes Pressure at the end
Study group 73.58 69.42 66.58
Control group 67.75 69.83 71.92
Graph 4: Intergroup comparison based on Venham's Anxiety

Scale
20
18
16
14
Mean Rank
12
10
8
6
4
2
0
Venham Anxiety Scale Venham Anxiety Scale Venham Anxiety Scale
at baseline at 5 minutes at the end
Study group 10.29 7.46 6.67
Control group 14.71 17.54 18.33
54
Results
Graph 5: Mean difference in the study group for pulse rate, systolic and
diastolic blood pressure at the various time intervals
14.00
12.00
10.00
Mean difference
8.00
6.00
4.00
2.00
0.00
-2.00
-4.00
Systolic Systolic Systolic Diastolic Diastolic Diastolic
Pulse Pulse Pulse Blood Blood Blood Blood Blood Blood
rate at rate at rate at 5 Pressure Pressure Pressure Pressure Pressure Pressure
baseline baseline minutes at at at 5 at at at 5
baseline baseline minutes baseline baseline minutes
rate at 5 rate at rate at Pressure Pressure Pressure Pressure Pressure Pressure
minutes the end the end at 5 at the at the at 5 at the at the
minutes end end minutes end end
Mean Difference (I-J) 11.92 9.17 -2.75 2.75 10.92 8.17 4.17 7.00 2.83
Graph 6: Mean rank of study group for Venham Anxiety Scale

3
2.5
2
Mean Rank
1.5
0.5
0
Mean Rank 2.79 1.79 1.42
55
Results
Graph 7: Mean difference in the control group for pulse rate, systolic and
diastolic blood pressure at the various time intervals
0
-2
-4
Mean difference
-6
-8
-10
-12
-14
-16
rate at rate at rate at 5 Pressure Pressure Pressure Pressure Pressure Pressure
baseline baseline minutes at at at 5 at at at 5
baseline baseline minutes baseline baseline minutes
rate at 5 rate at rate at Pressure Pressure Pressure Pressure Pressure Pressure
minutes the end the end at 5 at the at the at 5 at the at the
minutes end end minutes end end
Mean Difference (I-J) -5 -14.5 -9.5 -3.67 -6.67 -3 -2.08 -4.17 -2.08
Graph 8: Mean rank of control group for Venham Anxiety Scale

3
2.5
2
Mean Rank
1.5
0.5
0
Mean Rank 1.42 1.88 2.71
56
Discussion
DISCUSSION
Hallmarks of intellectual disability include the deficiencies in both intellectual and
adaptive functioning. With the progression in research and comprehension on
importance of cultural and social elements for an individual's intellectual functioning,
the term has evolved from idiocy to mental retardation to intellectual disability.
Intellectual disability has overall impact in all functional domains on a person’s growth
and development. They need a variable degree of guidance in education, support to
access health care, community participation as well as encouragement. By the
definitional criteria, intellectual disability must be recognized during developmental
years of the child. In children with severe intellectual disability, the signs and symptoms
are recognized clinically at an early age during the first 3 years of life, however the
children with mild intellectual disability are difficult to recognize and may not be
identified until later age of 4–6 years and up to 9 years new cases could be identified.
Therefore, in this present study, children with mild intellectual disability were included
who were aged between 8-13 years. The assessment of intellectual disability using
standardized tools is important as it is difficult to infer an individual’s intellectual
functioning solely based on conversation and observation.20
Thus, in this study we utilized the developmental screening test (DST) by Bharat Raj,
as it is a highly reliable and valid test to assess and evaluate the IQ level of children
with intellectual disability and categorize those with IQ scores of 52-67 under mild form
of disability and include them in the study.
Children with special needs, due to constraints imposed by their disabled condition have
increased chances of developing caries and periodontal diseases leading to pain,
premature exfoliation and further consequences affecting their overall quality of life.
57
Discussion
They face challenges to maintain proper oral hygiene due to lack of manual dexterity
that hinder day to day oral health practice thereby exhibiting a poor oral hygiene
status.52 Burtner et al reported that the other major obstacles faced by the dentists were
lack of adequate knowledge, skills and training to provide dental care to these
individuals.53
Most of these children with developmental disabilities exhibit extreme anxiety which
makes dental intervention aversive for this population.43 Martin et al (2002) showed
that 43.2% of this population reported dental fear as a major barrier to obtain
comprehensive oral health care among them.54
There are several nonpharmacological therapies for managing these children in dental
setting and to reduce maladaptive behaviours and improve oral health care. Among
those various techniques, there is a distinct therapy method which is now gaining much
emphasis is the multisensory stimulation (Sensory adapted dental environment). This
multisensory-stimulating environment is generally presented in a relaxing and
pleasurable space known as the “Snoezelen room”. This has been proven effective in
managing individuals with learning disabilities as well. The term “Snoezelen” is a
derived from two Dutch words; ‘Snuffles’ which means to sniff out or discover one’s
environment, and “doezelen,” means to doze or relax. So primarily, the Snoezelen
multisensory environment is a well-illuminated room comprising of slow-moving
lighting, calming sound, along with precise tactile sensation.52
These particular multisensory stimuli were utilized to serve various purposes. Firstly,
the room was partially dimmed, curtailing any disturbing visual stimuli. Direct
fluorescent lighting has been reported as flashing and extremely disturbing to eyes. So,
this lighting in the dental chair was switched off and was substituted with soft-coloured,
58
Discussion
slowly repetitive moving lights. Previous reports have documented the negative effects
of noise, showing that higher noise levels may elevate blood pressure, and increase heart
and respiration rates. Therefore, in order to camouflage the second sensory stimuli, that
is the ‘noise’, soft music was played in the background to distract the children from the
regular loud sounds of the dental equipment (e.g:- airotor, suction etc).The third
sensation was the deep pressure. Somatic sensation was provided by means of deep
pressure via the butterfly wrap in this study.47 The wings of the butterfly were wrapped
around the child from shoulders to ankles which provided deep “hugging” pressure
input designed to produce a calming effect.17 Research by Fertel-Daly et al and
Vandenberg support the use of weighted vests (an effect similar to the “butterfly”) for
reducing maladaptive behaviours and calming and improving attention in special needs
children.47 The main difference between the butterfly and a traditional papoose board is
that the main body of the butterfly slips over the dental chair, thereby not requiring the
child be strapped to a board such as that used for the papoose.17
Butterfly wrap provided a sort of protective stabilization to the child in this study, so as
any discomfort arises, we had a protocol that the children could request to keep open
the butterfly wings or ask to close it during the scaling procedure.
A.K.Khoshali (2011) in his study observed that children with mild mentally retardation
appear to make greater use of toys than children with moderate mentally challenged.55
In this study, elimination of visual input of scaling instruments was done in order to
conceal the child’s sight by camouflaging them with colourful child friendly toys to
reduce anxiety during the procedure.
Since Sensory adapted dental environment is one of the novel techniques to manage
disabled children in dental clinic, the present study utilized this technique to evaluate
59
Discussion
the efficacy of SADE compared to a RDE on anxiety levels of these children and to
reduce the sensory-aversive characteristics of the environment, during a dental scaling
procedure. The estimated sample size for this in-vivo study was 24 children with mild
ID, aged between 8-13 years that were randomly allocated into two groups comprising
a regular dental setup and a sensory adapted dental set up.
Previous study done by Shapiro et al showed the potential role of the sensory adapted
environment modification in creating a calming effect among children with
developmental disabilities which was demonstrated by evaluation of both behavioural
and physiological parameters.47
Contemporary ways of assessment of dental anxiety includes the objective and the
subjective measures. Objective assessment is a record of physiological functions of the
body. The psychophysiological responses produced by anxiety are related to increased
activity of the sympathetic branch of the autonomic nervous system consequently
leading to changes that occur in the cardiovascular system such as increased pulse rate
and blood pressure, changes in the sweat glands such as increased electrical
conductivity of the skin, in the muscles such as increased muscle tone, spasmodic
movements, etc., in the respiratory system such as increased respiratory rate and in the
digestive system such as dry mouth, constipation etc. Various studies done by Myers et
al (1972), Messer (1977), Beck and Weaver (1981) have demonstrated that these
physiological changes occurring in the body are very useful assessment tool as they are
due to anxiety and stress experienced by the patients during dental procedures. The
results of these studies were in conjunction with studies done by Laufer and Chosack
(1964) and McCarthy (1957) which concluded that heart rate and blood pressure can be
used as safe and reliable indicators of anxiety, as they increase simultaneously with
stress and anxiety during dental procedures.56

60
Discussion
Pulse oximeter device is one of the most acceptable methods for measuring the
physiological changes as it gives pulse rate values continuously.57 Pulse oximeter
functions by positioning any pulsating arterial vascular bed between two-wavelength
light sources and a detector. The magnitude of the light is dependent on change in the
arterial pulse, the wavelength of light and oxygen saturation of the arterial haemoglobin.
Therefore, a pulsatile waveform corresponding to the pulse rate and oxygen saturation
levels of the patient is detected on the device.58 Aughey et al found that the heart rate
displayed by the pulse oximeter closely approximated the heart rate displayed by the
ECG monitor.59 Hence, in this study dental anxiety was objectively measured by
recording of pulse rate values before, during and after the procedure using a pulse
oximeter device.
In reference to a study conducted by Potter et al, the mean scores of heart rate, systolic
and diastolic blood pressure were lower during the dental cleaning under Sensory
adapted dental environment when compared to Regular dental environment.48 Similar
findings were observed in this study where in the mean value of pulse rate at 5 minutes,
at the end and systolic blood pressure at the end were lower during oral prophylaxis
showing a statistically significant results with a p-value of 0.012, 0.004 and 0.004
respectively. In relation to values of diastolic blood pressure in this present study, there
was no statistically significant results found at baseline, 5minutes and at the end of the
procedure.
The intragroup comparison in the study group (i.e. Sensory adapted dental environment)
also showed statistically significant decrease in pulse rate, systolic and diastolic blood
pressure from baseline to the end of the procedure when compared to regular dental
environment where in the readings increased consistently from baseline to the end of
61
Discussion
the procedure indicating increased dental anxiety among these children in the regular
dental environment.
Another way to evaluate children’s dental anxiety is by observational-based assessment.
This is facilitated by relying on a descriptive rating scale, where the evaluator observes
the child throughout the dental procedure and gives a score apt for the child’s
behavioural response.60 Therefore in this present study, the child’s dental anxiety was
assessed by using the Venham’s anxiety rating scale. This scale is an interval rating
scale, wherein a rank order relationship exists and the distance between any two
neighbouring scale points are of known size. Therefore, a truly quantitative
measurement of dental anxiety is possible with the Venham’s anxiety rating scale.40
The results of the comparison of Venham’s anxiety rating scale among the study group
before, during and after the procedure showed a statistically significant reduction in
dental anxiety. The intergroup comparison showed statistically significant decrease in
anxiety at five minutes and at the end of the procedure in the SADE, and significant
increase in anxiety in regular dental environment. These results showed similar findings
to studies conducted by Shapiro et al which reported shorter duration of anxious
behaviours in the adapted environment when compared to control group as assessed by
NDBC(negative dental behaviour checklist).16 The results were also in agreement with
previous study done by Cermak et al where the children were relaxed and cooperative
during the dental procedure in SADE compared to control group as assessed by
Venham’s anxiety rating scale.17 Our study results were also identical to the results
obtained by Shapiro et al where there was decreased anxious behaviours and increased
cooperation levels as evaluated by Venham’s rating scale in normal children and also
children with developmental disability.47,49
62
Discussion
This study shows the possible significance of sensory-adapted environment
modification in providing a soothing effect among children with developmental
disabilities undergoing a dental procedure. This was proven through the analysis of both
behavioural and physiological characteristics. Majority of these children have extreme
general anxiety. This helps to explain why this group finds dental intervention aversive.
A major assumption underlying this study was that the sensory alteration of a potentially
frightening environment, along with a shift in sensory inputs, leading to increased
comfort and reduction in anxiety. The sensory environment is thought to cushion and
hence shield the individual from harsh stimuli by lowering the intensity of visual,
auditory, and tactile inputs. Furthermore, the altered sensory environment causes the
participants attention to be focused solely on the moving visual and auditory stimuli, as
well as the deep pressure, resulting in a "altered state" with the inevitable reduction in
awareness of unpleasant stimuli. In SADE, the room was dimmed to reduce any
distracting visual cues. Williams backs this viewpoint, claiming that individuals who
are too sensitive to visual stimuli have trouble filtering out distinct wavelengths of light.
As a result, visual perception becomes overloaded, and it becomes difficult to make
sense of visual inputs. Furthermore, one of the observations made during the present
research was that significantly less anxious behaviours were noted among the children
due to the soft, relaxing music played in the background which distracted the child from
harsh stimuli involving regular loud sounds of the dental equipment. Another reason for
decreased anxiety was produced by a butterfly wrap swaddled around the child which
created a sensation of deep pressure.47
In the SADE, several participants reacted positively to the multisensory equipment. Few
participants liked the multi colour projection on the wall, while others reciprocated in a
positive way to the relaxing and calming music played in the background. There were
63
Discussion
no negative comments about the SADE. This indicated that this novel behaviour
management technique was effective in handling children with mild intellectual
disability by reducing their anxiety levels while undergoing dental treatment.
The results of this study were also in agreement with a systematic review done by Ismail
et al (2021) which emphasized the importance of multisensory-adapted dental
environment in improving oral health behaviour among special needs children in terms
of physiological changes, behaviours, pain, and sensory discomfort.52
This study exclusively tried to assess the dental anxiety of children when subjected to
routine dental scaling procedures in two different dental environments before, during
and at the end of the procedure using observational assessment of Venham’s anxiety
rating scale, along with two physiological parameters which are known indicators of
dental anxiety that were the blood pressure and pulse rate. Assessing these physiological
parameters in children with mild intellectual disability during the scaling procedure to
evaluate their anxiety levels for effective behaviour management was not done in
previous studies, hence this study was attempted.
64
Conclusion
CONCLUSION
The following conclusions can be drawn from the study:
• There was a statistically significant reduction in dental anxiety in the sensory
adapted dental environment compared to regular dental environment when
assessed using Venham’s Anxiety Rating Scale, pulse rate and blood pressure
values.
• The sensory adapted dental environment utilized in this research is a innovative,
non-pharmacological, noninvasive approach to induce relaxation and decrease
anxiety during the dental treatment.
• It proved to be effective in reducing sensory stimuli, increase cooperation and
has potential to significantly provide oral health care for all children, specifically
for those with developmental disabilities.
Recommendations:
Within the limitations of the present study, further studies with larger sample
size should be carried out. Also, a multi-visit assessment of dental anxiety using
the objective measures and subjective measures, involving various other dental
treatment procedures should be undertaken.
65
Summary
SUMMARY
This present invivo, randomized clinical trial was conducted on 24 children with mild
intellectual disability with an age range of 8-13 years in the Department of Paedodontics
and Preventive Dentistry, Bapuji Dental college and hospital, Davangere, Karnataka,
India, for oral prophylaxis procedure. The study was approved by Ethical Committee
(Ref.No.BDC/Exam/ 509 / 2019-20) from the Institutional Review Board, Bapuji
Dental College and Hospital, Davangere and written informed consent from the legal
guardian/care taker of patients willing to participate in the study was taken after
explaining the whole procedure.
SELECTION CRITERIA
Inclusion criteria:
• Children with the age group of 8-13 years.
• Children with mild intellectual disability with IQ level between 50-69.
• Children who are systemically healthy.
Exclusion criteria:
• Children with moderate to severe intellectual disability.
• Children with any other concomitant diseases or syndromes.
Methodology:
A general examination of children after taking consent from the legal guardian/care
taker was done prior to the study, to assess if he/she comes under selection criteria.
66
Summary
Developmental screening test was utilized to categorize and include the children in the
study with mild intellectual disability with IQ score between 52-67.Then the children
were randomly allocated and subjected to routine dental prophylaxis into two different
dental environments
GROUP 1- Intellectually disabled Children treated under regular dental environment.
GROUP 2- Intellectually disabled Children treated under sensory adapted dental
environment.
Dental anxiety levels for both the groups, were assessed at baseline, 5 minutes,and at
the end of the procedure using the Venham’s anxiety rating scale, pulse rate and
blood pressure values.
Results: The data was coded and analyzed using software SPSS (IBM version 22.0) for
statistical analysis. Comparison between groups was done using Independent T- test
and repeated measured ANOVA for objective assessment of intergroup and intragroup
anxiety levels respectively, and using Mann Whitney U test and Friedman’s test for
subjective assessment of intergroup and intragroup anxiety levels respectively.
Interpretation and Conclusion: The current study suggests that SADE significantly
decreased anxiety levels and cooperative behaviour in children with mild intellectual
disability and SADE can be used as an alternative behaviour management technique
in effectively handling children with intellectual disability when compared to
conventional behaviour management techniques.
67
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75
Annexures
ANNEXURE 3
INFORMED CONSENT FORM
Bapuji Dental College & Hospital, Davangere, Karnataka
Department of Paedodontics and Preventive Dentistry
Patient name:
Date:
Age in years:
Sex: M/F
Mobile number:
In relation to patient, I hereby confirm that I have been informed in detail about
the procedure of cleaning the teeth of child in two different dental setups. I was
given an opportunity to ask questions and all of them have been answered to my
satisfaction. I therefore give my consent for the procedure to be performed.
Signature of Parent/Guardian
Date and Time
Signature of the doctor in charge
79
Annexures
ಒಪ್ಪಿ ಗೆ ಪತ್ರ
ಬಾಪುಜಿ ದಂತ್ ಕಾಲೇಜು ಮತ್ತು ಆಸ್ಿ ತ್ರರ , ದಾವಣಗೆರೆ, ಕರ್ನಾಟಕ
ಡಿಪಾರ್ಟ್ ಾೆಂಟ್ ಆಫ್ ಪ್ಪಡೊಡೆಂಟಿಕ್ಸ್ ಮತ್ತು ಪ್ಪರ ವೆಂಟಿವ್ ಡೆಂಟಿಸ್ಟ್ರ ರ
ಹೆಸರು: ದಿನಾಂಕ:
ವಯಸ್ಸು :
ಲಾಂಗ:
ಮೊಬೈಲ್ ನಂಬರ:
ರೋಗಿಗೆ ಸಂಬಂಧಿಸಿದಂತೆ, ಎರಡು ವಿಭಿನ್ನ ದಂತ ಚಿಕಿತ್ಸೆ ಯ ಪರಿಸರಗಳಲಿ ಮಗುವಿನ್
ಹಲ್ಲಿ ಗಳನ್ನನ
ಸವ ಚ್ಛ ಗೊಳಿಸ್ಸವ ವಿಧಾನ್ದ ಬಗೆೆ ನ್ನ್ಗೆ ವಿವರವಾಗಿ ತಿಳಿಸಲಾಗಿದೆ ಎಾಂದು ನನ್ನ ಈ
ಮೂಲಕ ಒಪ್ಪಿ ಗೆ ವಯ ಕತ ಪಡಿಸ್ಸತೆತ ೋನೆ. ನ್ನ್ಗೆ ಪರ ಶ್ನನ ಗಳನ್ನನ ಕೇಳಲ್ಲ ಅವಕಾಶ ನೋಡಲಾಯಿತು
ಮತುತ ಅವರೆಲಿ ಕ್ಕೂ ನ್ನ್ಗೆ ತೃಪ್ಪತ ಯಿಾಂದ ಉತ್ತ ರಿಸಲಾಗಿದೆ. ಆದದ ರಿಾಂದ ಕಾಯಯವಿಧಾನ್ವನ್ನನ
ನವಯಹಿಸಲ್ಲ ನನ್ನ ನ್ನ್ನ ಒಪ್ಪಿ ಗೆಯನ್ನನ ನೋಡುತೆತ ೋನೆ.
ರೋಗಿಯ /ಪೋಷಕರ / ರಕ್ಷಕರ ಸಹಿ:
ದಿನಾಂಕ ಮತುತ ಸಮಯ:
ಉಸ್ಸತ ವಾರಿ ವೈದಯ ರ ಸಹಿ:
80
Annexure
ANNEXURE 1
ETHICAL COMMITTEE APPROVAL LETTER
76
Annexures
ANNEXURE 4
STUDY PROFORMA
“COMPARATIVE EVALUATION OF SENSORY ADAPTED DENTAL

ENVIRONMENT AND REGULAR DENTAL ENVIRONMENT IN
REDUCING ANXIETY LEVELS IN CHILDREN WITH INTELLECTUAL
DISABILITY”
NAME: OPD
NO:
AGE: years SEX:
M/F
MOBILE NO:
Parameters Regular dental environment Sensory adapted dental environment
Baseline 5 mins At the end Baseline 5 mins At the end
Pulse rate
Systolic blood
pressure
Diastolic
blood
pressure
Venhams
anxiety scale
81
Annexures
I] ARMAMENTARIUM FOR SENSORY ADAPTED DENTAL ENVIRONMENT
Figure 1: HEAD LAMP
Figure 2: SLOW MOVING COLOURED LIGHTS
31
Annexures
Figure 3: PORTABLE SPEAKER
Figure 4: CUSTOMIZED MOUTH MASK
32
Annexures
Figure 5: CAMOUFLAGED INSTRUMENTS
Figure 6: BUTTERFLY WRAP
33
Annexures
II] ARMAMENTARIUM FOR EVALUATION OF ANXIETY LEVELS
Figure 7: DIGITAL SPHYGMOMANOMETER
Figure 8: PULSE OXIMETER DEVICE
34
Annexures
SENSORY ADAPTED DENTAL ENVIRONMENT
Figure 9: Representative photograph showing multisensory environment with coloured lights,

butterfly wrap, and camouflaged instruments
DEVICE
35
Annexures
Figure 10: Representative photograph showing butterfly wrap being wrapped around
child in Sensory Adapted Dental Environment
Figure 11: Representative photograph showing treatment of child in Sensory Adapted Dental
Environment
36
Annexures
III] ARMAMENTARIUM FOR REGULAR DENTAL ENVIRONMENT
Figure 12: SCALERS AND MOUTH MASK
Figure 13: MISCELLANEOUS INSTRUMENTS
37
Annexures
Figure 14: Representative Photograph Showing Treatment Of Child In

Regular Dental Environment
38

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ABSTRACT

1. To evaluate the efficacy of sensory adapted dental environment (SADE) on

cooperation and anxiety levels in children with intellectual disability.

2. To evaluate the efficacy of regular dental environment on cooperation and anxiety

levels in children with intellectual disability.

environment on cooperation and anxiety levels in children with intellectual

rate and blood pressure values.

assessment of intergroup and intragroup anxiety levels respectively

disability and SADE can be used as an alternative behaviour management technique in

effectively handling children with intellectual disability when compared to conventional

behaviour management techniques.

dental care is neglected primarily because of insufficient encouragement and awareness

Development Programme in 2006, about 80% of people having disabilities reside in

below 10 years of age. Intellectual disability(ID), in former times referred as mental

retardation, is a condition involving significantly sub-average intellectual development from

birth to early childhood.6

Features of this condition comprise of substantial impediments in intellectual functioning

variety of everyday social and practical abilities.7

moderate intellectual disability,severe and profound intellectual disability, in which majority

of the population (about 85%) with intellectual disabilities is mildly disabled.6

associated with mental retardation like Phenol ketonuria, Cretinism, Microcephaly,

Neurofibromatosis, and Huntington’s chorea. The environmental aspect of causation

incompatibility, fetal irradiation and infections in peri-natal periods such as bacterial

communication, socialization, as well as looking after themselves. They experience

difficulties with fundamental activities, including eating, dressing, communicating and

children who do not have intellectual disability.6

parent/caregiver, socioeconomic status, their nutrition, eating pattern, medication, physical

providing dental care.10,11

was suggested to be the predominant cause of periodontal disease in these individuals.9

reactions which can be difficult to manage them resulting in a reduction in access to or

changes in the manner in which dental care is offered.12

can be caused by unpredictable or unfamiliar circumstances, medical treatment, or an

vulnerability to environmental demands.12 Anxiety related to dental treatment is one such

disabilities,14 as these behaviour management strategies can be costly, often necessitating

reasonably inferior. Furthermore, as acceptance of restraint techniques decrease, behavioural

reinforcement and remodelling without the utilization of restraint procedures. There is a

desensitization, differential reinforcement, a more extensive acknowledgment by patients,

caretakers as well as by the dental practitioners would be accomplished.14

and taste of prophylaxis paste.15 This altered neurophysiological predisposition of

individuals with developmental disability encountered in regular dental set up could

sensory over-responsivity and uncooperative behaviours in the dental office.17

Health professionals have studied sensory-based treatment in dental management of people

with developmental disability. This Sensory-based treatments are intended to give

individualized, regulated sensory experiences in order to modulate responses to external

universally accepted protocol for implementing sensory-based treatment into practice.

reduce dental anxiety in children.15

environment helped a lot to facilitate dental care.18

The sensory-adapted dental environment (SADE) comprises of a specialised room with

However, the efficacy of sensory-based treatments are yet to be conclusive.

instruments aiming to additionally supplement decreased anxiety during dental procedures

camouflaging instruments during a routine scaling procedure in children with mild

levels in children with intellectual disability.

AIM AND OBJECTIVES

1. AIM OF THE STUDY:

regular dental environment in reducing anxiety levels in children with intellectual

2. OBJECTIVES OF THE STUDY:

• To evaluate the efficacy of sensory adapted dental environment on cooperation and

anxiety levels in children with intellectual disability.