Asian Journal of Dental Sciences

Background: Dental anxiety and uncooperative behaviour in children aged 4–9 years remain significant challenges in paediatric dental practice. Non-pharmacological distraction techniques have gained increasing recognition as safe and effective behaviour management strategies.

Aim: The present study aimed to compare the effectiveness of four distraction techniques: Tell-Show-Do (TSD), Virtual Reality (VR) immersion, Crocodile Teeth play therapy, and Magic Trick distraction in managing anxiety and behaviour during dental restorative procedures in children aged 4–9 years.

Materials and Methods: A cross-sectional comparative study was conducted at the Department of Paediatric Dentistry, Adhiparasakthi Dental College and Hospital, Chengalpattu, Tamil Nadu, India. A total of 40 children aged 4–9 years requiring dental restorative treatment were enrolled and allocated into four equal groups of 10 each. Behavioural and anxiety responses were assessed at three stages — pre-assessment, during procedure, and post-assessment using the Facial Image Scale (FIS), Root Mean Square (RMS) Scale, Chhota Bheem and Chutki Scale (CCS), and Dental Anxiety Scale (DAS). Inter-group comparisons were performed using the Kruskal-Wallis test, with statistical significance set at p ≤ 0.05.

Results: Statistically significant inter-group differences were observed at the pre-assessment and post-assessment stages across all four outcome scales, while intra-procedural comparisons were non-significant. On the FIS, significant differences were observed at pre-assessment (p = 0.034) and post-assessment (p = 0.000). The Control (TSD) group consistently recorded the lowest post-assessment scores across all scales (FIS: 1.00 ± 0.000; RMS: 1.00 ± 0.000; CCS: 1.00 ± 0.000; DAS: 0.00 ± 0.000). Among distraction groups, Crocodile Teeth recorded the highest post-assessment scores on FIS (2.60 ± 0.516), RMS (2.40 ± 0.699), and CCS (2.00 ± 0.471), while Magic Trick and Crocodile Teeth groups recorded equal DAS post-assessment scores (1.50 ± 0.527 each). On the RMS scale, significant differences were noted at pre-assessment (p = 0.001) and post-assessment (p = 0.000). The CCS demonstrated significant inter-group differences at pre-assessment (p = 0.009) and post-assessment (p = 0.001). The DAS showed significant differences at all three stages, including during the procedure (pre-assessment p = 0.003; during procedure p = 0.017; post-assessment p = 0.000). The VR group recorded the highest DAS score during the procedure (2.60 ± 1.074), while the Control group recorded the lowest (1.40 ± 0.516).

Conclusion: All four non-pharmacological behaviour management techniques demonstrated varying degrees of effectiveness in reducing dental anxiety in children aged 4–9 years. The Tell-Show-Do technique achieved the most consistent post-procedural anxiety reduction across all outcome measures, affirming its role as the cornerstone of paediatric behaviour management. Among the distraction techniques, Virtual Reality and Magic Trick distraction demonstrated comparable and clinically meaningful anxiety attenuation at post-assessment, while Crocodile Teeth play therapy showed greater utility in reducing anticipatory anxiety. The choice of distraction technique should be individualised based on the child's age, temperament, and baseline anxiety level.