INTRODUCTION

Anxiety is a response to a supposed threat or danger from multiple systems. This involved a mixture of physiological changes in the body. Anxiety can occur without a reason, or it could be related to a specific occurrence that resulted in a reaction out to what would probably be expected1).

For many years the dental anxiety of the child has been a real barri-er to dental procedures2). Dental anxiety may prevent patients from cooperating fully during treatment3), and its often caused by a sense of pain and discomfort that associated with the dental environment4).

Dentists must be able to assess anxiety in their patients as there is a significant relationship between dental anxiety and negative behavior5). The changes in endocrine are commonly used measures for identifying these patients1). Emotional stress increases the activity of the hypothala-mus-pituitary-adrenal axis (HPA-axis) in various human studies, result-ing in increased cortisol secretion6). Cortisol has been used as an indica-tor in stress studies, also called the stress hormone7).

Although the dental team has various approaches to support effec-tive management of a dentally anxious child usually involved signifi-cant additional time, extra effort, and professional expertise, it has been recognized that behavioral therapy and psychological interventions can relieve the anxiety of the patient without the need for pharmacological assistance8,9).

Colors are commonly accepted to have a significant effect on both emotions and thoughts, this probably refers to children who may be extra color sensitive10). The application of colors that are child friendly in the dental attire and practice may build a positive dental atmosphere for children and could help to relieve dental stress and help to improve

communication11). There's a gap in the base of information about how child-friendly colors can aid in a child’s comfort and minimize dental anxiety in pediatric dental practice. Thus, it was encouraging to estab-lish a study to assess the effects of colors in the dental environment on the children’s anxiety to create a positive dental environment for chil-dren.

MATERIALS AND METHODS

Study designThis case controlled intervention clinical trial began after the

approval of the ethical and scientific committee was obtained at the College of Dentistry/ University of Baghdad. The children were collect-ed from four primary schools, aged 8-9 years based on the following inclusion criteria:

Good general health, without any history of current episodes of medications, any systemic or mental disorders and without any previous dental experience.

Inclusion criteria for teethCarious lesions (class I) in primary lower molars, without pain, pul-

pal exposure, fistula, mobility, or abscess of the tooth adjacent to the selected tooth.

The sample size was comprised of eighty healthy children, aged 8-9 years, including boys and girls. Patients were randomly divided into 2

International Medical Journal Vol. 28, Supplement No. 1, pp. 58 - 60 , June 2021

DENTISTRY

Evaluation of Children's Dental Anxiety in Colorful Versus Conventional Dental Clinic

Rasha Khalaf Zighair1), Zainab Juma Jafar2)

ABSTRACTObjective: Dental anxiety is a widespread problem that can occur at any age. The color of dental clinic affects children's

behavior, and may contribute to a child's comfort and reduce dental anxiety. The purpose of this study was to evaluate the effect of a colorful dental environment on children's anxiety.

Materials and Methods: Eighty children between 8 and 9 years of age have been split into two groups: group A were treated in the conventional dental clinic and group B were treated in the colorful dental clinic. The dental procedure employed was restorative treatment for both groups. The anxiety was measured by using salivary cortisol level in the waiting room as a base-line, after local anesthesia, and after finishing dental procedure.

Results: In general, the children in group B showed less dental anxiety in the salivary cortisol level in comparison to the chil-dren in group A after local anesthesia and after the dental procedure.

Conclusion: The current study suggests that introducing pleasant colors to the clinical environment and the attire of the den-tist would increase positive feelings and help decrease dental anxiety.

KEY WORDSdental clinic, colors, salivary cortisol, dental anxiety.

Received on March 31, 2021 and accepted on April 30, 20211) Department of Anbar Health, Fallujah Sector Iraq2) Department of Pedodontic and Preventive Dentistry, College of Dentistry, University of Baghdad IraqCorrespondence to: Rasha Khalaf Zighair(e-mail: znbjma1977@codental.uobaghdad.edu.iq)

58

C 2021 Japan University of Health Sciences & Japan International Cultural Exchange Foundation

Zighair R. K. et al. 59

groups, matched by age and gender, use a Microsoft excel program to create a random allocation list. The first group (group A) which was the control group, consisted of forty children, that was treated in the con-ventional dental clinic and the second group (group B) as the interven-tion group, consisted of forty children, that was treated in the colorful dental clinic.

Study measuresThe dental anxiety was recorded at three stages: In the waiting room

as a baseline, after local anesthetic injection, and then after finishing the treatment.

Saliva cortisol kits (Roche / Germany), were used for in vitro corti-sol immunoassay for human saliva.

Materials used in colorful dental clinic The Children's friendly colors blue, green, pink, yellow, purple, and

orange have been used12,13) (Figure 1).

1. A dental clinic with colorful sidewalls and the floor is distin-guished by chromatic color combinations was standard for all patients.

2. Dental chair unit with child-friendly colored disposable dental chair cover.

3. Child-friendly colored lab coat.4. Child-friendly colored disposable masks and gloves.

The selection of colors in points 2, 3, and 4 was according to patients' preferences.

Procedure Parents were clarified on the methodology and objectives of the

study, oral and signed permission was obtained for approval of their children's study participation.

For at least thirty minutes before saliva collection, the participants were instructed not to either drink, eat, or clean their teeth14,15). The first Salivary samples were collected at the waiting room according to previ-ous strategies16,17).

All children in both groups were treated by a traditional dental pro-cedure (Figure 1), after 10 minutes of local anesthesia, the second sali-vary samples were collected. The cavity was prepared in a conventional way. After 10 minutes of completion of dental procedure the third sali-vary samples were collected.

STATISTICAL ANALYSIS

Data analyzes were carried out using SPSS version 22. Descriptive Analysis for quantitative variables were expressed a minimum, maxi-mum, mean and standard deviation (SD). As well as repeated Measure One Way ANOVA that is used to detect the differences between K relat-ed means of the quantitative variable with Bonferroni post hoc test.

Figure 1: The dental procedure in the colorful dental clinic with colored lab coat and in the conventional dental clinic with white coat.

Table 1: Distribution of salivary cortisol level by groups and time.

Salivary cortisol level (μg/dl)

Groups Statistics In Waiting After local After finishing room anesthesia treatment

Minimum 0.080 0.070 0.050

A

Maximum 0.630 0.790 0.920

Mean 0.249 0.359 0.301

± SD 0.142 0.202 0.165

Minimum 0.110 0.050 0.050

B

Maximum 0.800 0.780 0.680

Mean 0.340 0.328 0.216

± SD 0.212 0.200 0.126

Table 2: Comparisons of salivary cortisol level (μg/dl) among different times by groups.

(Intra Comparison) (Pairwise Comparisons)

Measure: Salivary cortisol level (μg/dl)

Groups (I) Time (J) Time Mean Difference (I-J) P Value

After local -0.110 0.000*

A

In the waiting anesthesia

room After finishing -0.052 0.079

treatment

After local 0.012 0.691

B

In the waiting anesthesia

room After finishing 0.123 0.000*

treatment

* Highly significant at P value < 0.01.

Table 3: Comparisons of salivary cortisol level (μg/dl) between groups by time.

(Inter Comparison) Pairwise Comparisons

Measure: Salivary cortisol level (μg/dl)

(I) Groups (J) Groups Mean F P Effect Difference Value Size (I-J)

In the Waiting A B -0.090 4.998 0.028 0.060

room

After local A B 0.031 0.481 0.490 0.006

anesthesia

After finishing A B 0.085 6.661 0.012 0.079

treatment

Evaluation of Children's Dental Anxiety in Colorful Versus Conventional Dental Clinic60

RESULTS

The scores in Table 1 depict and evaluate the change in salivary cor-tisol level (μg/dl), in both groups. In group A: there were increased scores of salivary cortisol after local anesthesia and after finishing treat-ment to be higher than the baseline in the waiting room. While in group B: there were decreased scores of salivary cortisol after local anesthesia and after finishing treatment to be lower than the baseline in the waiting room.

The intra-comparison of salivary cortisol level among different times by groups is shown in Table 2. In group A: there was statistically highly significant difference between salivary cortisol level in the wait-ing room and after local anesthesia, whereas non-significant difference was found between the means in the waiting room and after finishing treatment. While, in group B: there was non-significant difference between the level of cortisol in the waiting room and after local anesthe-sia, and the highly significant difference between its level in the waiting room and after finishing treatment.

One way ANOVA statistical test was performed to evaluate the dif-ferences between groups, in the salivary cortisol level, as Table 3 dis-plays. A significant intergroup difference was found in the waiting room, and after finishing treatment.

DISCUSSION

Dental procedures, especially the administration of local anesthesia, frequently cause anxiety and discomfort in children, and an increase in pain reactivity18). Since colors are important in children's lives19) conse-quently, one of the purposes of this research was to assess the efficacy of diversion using colors on anxiety levels of children undergoing dental procedures.

Cortisol levels in both Saliva and serum are correlated to each other, and the collection of a salivary sample provides the simple and non-in-vasive method that does not cause pain or discomfort as blood sample collection20). In this study, the findings showed elevation of the salivary cortisol levels in group A relative to the baseline in the waiting room. There are different stimuli such as; dental setting characteristics, dentist attire which can trigger dental anxiety, either individually or synchro-nously. It has been also noticed that dental procedures including local anesthetic injections had increased cortisol levels in saliva21,22).

Comparatively, in group B, the level of salivary cortisol decreases, after local anesthesia and after completion of the dental procedure, so less dental anxiety. No previous research in the colorful dental clinic on child's anxiety is available however, this outcome could be explained through different possible reasons; creating a friendly dental environ-ment through using colors to minimize children's anxiety and improve healthcare quality23). Additionally, this can be interpreted by that the pediatric dental clinic should be designed to give children a feeling of relaxation and a space for respecting their choices. The children favored a painted dental environment rather than a plain clinic24). Furthermore, the dental office can give a comfortable environment for children by using friendly color13).

It is highly recommended according to the result of the current study, that reveal the significant effect of the application of colored den-tal clinic and reduced child’s dental anxiety, it is wise for both dentists and health institutions to apply the colored dental clinic in their practice which will give a positive and helpful feedback for both patients and health professionals. Moreover, the presence of children-friendly colors dentist attire has a positive effect on the children’s attitude and the qual-ity of dental clinic service.

CONCLUSION

Adding attractive colors to the pediatric dental clinic and the incor-poration of different colors in the dental clinic and dentist's attire can help to reduce dental anxiety.

CONFLICT OF INTEREST

This study does not have any conflicts of interests.

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