Professional Documents
Culture Documents
World Journal of
Clinical Pediatrics
World J Clin Pediatr 2016 February 8; 5(1): 102-111
ISSN 2219-2808 (online)
ORIGINAL ARTICLE
Retrospective Study
Abstract
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INTRODUCTION
Pain is an unpleasant combination of sensations and
emotions, which is difficult to describe. As the threshold
for the pain varies from person to person, only the
person experiencing the pain can explain its intensity
and nature. Childs pain is complex and varies with
[1,2]
his/her cognitive, emotional and social experience ,
necessitating an accurate assessment. Dentistry involves
numerous procedures, which may be perceived as
painful by a child; local anesthetic administrations and
extractions being the most painful of all, which can
[3,4]
cause psychological distress . Hence, a multilevel
approach of assessing the procedural pain in dentistry
is essential, as neglecting their experience can lead to
development of anxiety in the child, which becomes a
major barrier in accepting dental treatment during their
[5]
future visits . Thus, correct appraisal of pain helps in
understanding their interest in seeking treatment in the
future, assessing their behavior in succeeding visits as
well as customizing the guidance for the child.
Procedural pain can be assessed using behavioral
[faces, legs, activity, cry, consolability (FLACC) scale/
[6,7]
sound, eye, motor scale] , self report measures [facial
pain scale-revised (FPS-R)/pain thermometer/visual
[8-12]
analogue scale/colour analogue scale/finger span test]
and/or a combination of these approaches. However,
depending on the childs age and development, the
ability of these measures to quantify and qualify the pain
[13]
experience of a child varies . Thus, communication with
the child, in verbal/non-verbal/compounded means, plays
a vital role in evaluating their pain. However, children
may or may not have the ability and/or vocabulary to
[14]
express their feelings, fears and concerns verbally . Most
of the children disguise the inner fears of their painful
[15]
experience , which becomes another drawback of verbal
communication. Thus, there is a need to use some non-
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Sample
103
Interventions
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Statistical analysis
104
Figure 1 Samples of childrens drawings. A: Ages 11 years; gender: boy; Franki: 4. FLACC score (LA): 2 (mild discornfort), FLACC score (Ext): 2 (mild discornfort);
FPS-R score (LA): 6, FPS-R score (Ext): 2. Child drawing: Hospital score: 94 (average stress). The predominant colour in the drawing was black. The child included
dental equipment in the drawing (syninge and dental chair) represented himself crying in the dental chair. B: Ages 12 years; gender: boy; Franki: 4. FLACC score
(LA): 4 (moderate pain), FLACC score (Ext): 6 (moderate pain); FPS-R score (LA): 8, FPS-R score (Ext): 8. Child drawing: Hospital score: 67 (low stress). The
child used only black colour and included dental equipment in the drawing including cabin partitions. C: Ages 13 years; gender: boy; Franki: 4. FLACC score (LA):
2 (mild discornfort), FLACC score (Ext): 1 (mild discornfort); FPS-R score (LA): 8, FPS-R score (Ext): 0. Child drawing: Hospital score: 92 (low stress). The child
used only black colour and included dental equipment. It was an action picture showing extraction of his tooth by the doctor. Child omitted noses, ears and hair for
himself. D: Ages 11 years; gender: boy; Franki: 3. FLACC score (LA): 3 (mild discornfort), FLACC score (Ext): 0 (mild discornfort); FPS-R score (LA): 2, FPS-R score
(Ext): 0. Child drawing: Hospital score: 68 (low stress). The child used only small part of paper for his drawing and included dental equipment (syninge and dental
chair). However, the predominant colour used green. E: Ages 12 years; gender: boy; Franki: 4. FLACC score (LA): 2 (mild discornfort), FLACC score (Ext): 0 (mild
discornfort); FPS-R score (LA): 2, FPS-R score (Ext): 6. Child drawing: Hospital score: 49 (low stress). Child drew an action picture if he is undergoing extraction and
also included dental equipment (Try with instruments arranged on it). Note that the noses and ears are missing in his human figures. F: Ages 10 years; gender: boy;
Franki: 4. FLACC score (LA): 5 (mild discornfort), FLACC score (Ext): 0 (mild discornfort); FPS-R score (LA): 2, FPS-R score (Ext): 0. Child drawing: Hospital score:
64 (low stress). Child drew himself in a very happy mood, although he included dental equipment (extraction instrument and LA spray). FLACC: Faces, legs, activity,
cry, consolability scale; FPS-R: Facial pain scale-revised; LA: Local anaesthetic administration; Ext: Extractions.
correlation test.
RESULTS
A total of 107 children (58 boys and 49 girls) completed
the study, out of the 110 participants. Three children
willingly participated at the beginning of the study,
but, after extraction dissented to draw. The mean age
of the children who completed the study was 10.1
years (range: 4-13). The mode for the Frankl score of
participants was 4 (range: 2-4). The mean FLACC score
during LA administration was 2.8 1.7 (range: 0-10)
and during extractions it was 2.242.04 (range: 0-10).
The mode for FPS-R after LA administration was 2
(range: 0-10) and after extraction it was 0 (range 0-10).
The mean CD: H score of participants was 74.1 16.2
(range of 36-112). Some samples of childrens drawings
are presented in Figure 1.
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CD: H
Mean SD
Classification
43 44-83 84-129 130- > Mode
167 168
Age
Gender
4-6
76.43 16.08
> 6-9
76.06 15.36
> 9-13
72.87 16.75
Significance
Boys
78.03 15.29
Girls
Accompanying
person
69.41 16.18
Significance
Mother
72.55 15.61
Father
77.61 17.15
4
3.73%
0
21
19.6%
3
43
2.80% 40.18%
0.70NS
0
35
32.71%
3
33
2.80% 30.8%
0.08NS
1
39
0.93% 36.4%
1
16
0.93% 14.95%
1
13
0.93% 12.14%
0.47NS
3
2.80%
12
11.20%
21
19.60%
10
23
21.49%
13
12.14%
15
14.01%
14
13.08%
7
6.54%
2-4
6-8
1
0.93%
5
4.67%
6
5.60%
2
1.86%
11
10.28%
38
35.51%
2
1.86%
7
6.54%
17
15.88%
22
20.56%
29
27.10%
17
15.88%
9
8.41%
27
25.23%
14
13.08%
10
9.34%
14
13.08%
8
7.47%
4
3.73%
0.10NS
2
7
6.54%
2
5
4.67%
0.17NS
2
5
4.67%
2
5
4.67%
2
2
1.86%
0.90NS
FPS-R (extractions)
10
Mode
2
0
1.86%
10
0
9.34%
6
0
5.60%
0.44NS
12
0
11.2%
6
0
5.60%
0.97NS
9
0
8.41%
4
2
3.73%
5
8
4.67%
0.12NS
2-4
6-8
10
2
1.86%
8
7.47%
17
15.88%
3
2.8%
8
10
7.47% 9.34%
24
18
22.42% 16.82%
2
1.86%
7
6.54%
8
7.47%
14
13.08%
13
12.14%
17
15.88%
15
14.01%
17
15.88%
14
13.08%
10
9.34%
7
6.54%
13
12.14%
10
9.34%
4
3.73%
14
13.08%
15
14.01%
13
12.14%
15
14.01%
6
5.60%
10
9.34%
13
12.14%
3
2.80%
1
0.93%
CD: H: Children drawing: Hospital scale; FPS-R: Facial pain scale-revised; NS: Not significant, SD: Standard deviation.
Table 2 Distribution of faces, leg, activity, cry, consolability scale and frankl scores based on age, gender and accompanying person
Variables
Age
Gender
4-6
> 6-9
> 9-13
4
3.73%
< 0.011
2
1.86%
2
1.86%
0.95NS
1
0.93%
3
2.80%
0
Significance
Boys
Girls
Significance
Accompanying Mother
person
Father
Guardian
Significance
2
2
2
0.34NS
7-10
FLACC (extractions)
1-3
4-6
Mode
2
1.86%
16
14.95%
52
48.59%
5
4.67%
14
13.08%
11
10.28%
3
2.80%
0
37
34.57%
33
30.80%
17
15.88%
13
12.14%
2
1.86%
1
0.93%
34
31.77%
21
19.6%
15
14.01%
19
17.75%
6
5.60%
5
4.67%
1
0.93%
1
0.93%
1
0.93%
0
1
0.93%
4
3.73%
19
17.75%
< 0.011
2
14
13.08%
2
10
9.34%
0.82NS
2
9
8.41%
0
13
12.14%
2
2
1.86%
0.07NS
1-3
4-6
7-10
3
2.80%
14
13.08%
41
38.31%
1
0.93%
12
11.20%
7
6.54%
2
1.86%
3
2.80%
0
29
27.10%
29
27.10%
12
11.20%
8
7.47%
3
2.80%
2
1.86%
32
29.99%
14
13.08%
12
11.20%
11
10.28%
4
3.73%
5
4.67%
3
2.80%
0
2
1.86%
Mode
3
4
4
4
3.73%
4
5
3.73% 4.67%
7
9
6.54% 8.41%
0.06NS
4
3
2.80%
4
8
7.47%
0.16NS
4
7
6.54%
4
2
1.86%
4
2
1.86%
0.10NS
4
3
2.80%
24
22.42%
51
47.66%
11
10.28%
7
6.54%
44
41.12%
34
31.77%
9
8.41%
2
1.86%
7
6.54%
39
36.44%
27
25.23%
12
11.20%
Significant at 0.01 level. FLACC: Faces, leg, activity, cry, consolability scale; NS: Not significant.
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Correlations
106
Groups
CD: H
Mean SD
0.61NS
1.00NS
0.66NS
0.86NS
--
Mother vs father
Mother vs guardian
Father vs guardian
4-6 vs > 6-9
> 6-9 vs > 9-13
4-6 vs > 9-13
--
0.38NS
1.00NS
0.59NS
0.92NS
0.14NS
0.33NS
--
Mother vs father
Mother vs guardian
Father vs guardian
4-6 vs > 6-9
> 6-9 vs > 9-13
4-6 vs > 9-13
--
0.64NS
1.00NS
0.80NS
0.78NS
0.54NS
0.41NS
--
Mother vs father
Mother vs guardian
Father vs guardian
0.08NS
1.00NS
0.70NS
0.011
0.36NS
0.07NS
0.24NS
0.63NS
0.28NS
0.50NS
0.06NS
Significant at 0.01 level. CD: H: Children drawing: Hospital scale; FPS-R: Facial pain scale-revised; L.A: Local anaesthetic administration; Ext: Extractions;
NS: Not significant.
DISCUSSION
Drawing ability in children shows predictable, observable
and measurable stages that coincide with cognitive and
motor development; better representational and detailed
with age. By the age of 4 years, children drawings
emerge to have identifiable human figures and by the
end of 13 years they reach a stage where drawings
tend to become more natural, with true representation
of things. As CD: H is a manual based on human figure
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Mean SD
< 0.012
0.97NS
< 0.012
0.06NS
--
Mother vs father
Mother vs guardian
Father vs guardian
4-6 vs > 6-9
> 6-9 vs > 9-13
4-6 vs > 9-13
--
0.62NS
1.00NS
0.75NS
0.67NS
< 0.012
0.012
--
Mother vs father
Mother vs guardian
Father vs guardian
4-6 vs > 6-9
> 6-9 vs > 9-13
4-6 vs > 9-13
--
0.021
0.62NS
0.012
0.86NS
0.69NS
0.94NS
--
Mother vs father
Mother vs guardian
Father vs guardian
0.32NS
0.82NS
0.22NS
Variables
FLACC (LA)
0.61NS
0.60NS
< 0.012
0.93NS
< 0.012
0.68NS
0.17NS
0.17NS
Significant at 0.05 level; 2Significant at 0.01 level. FLACC: Faces, leg, activity, cry, consolability scale; LA: Local anaesthetic administration; Ext: Extractions;
NS: Not significant.
Table 5 Correlation of Children drawing: Hospital Scale with facial pain scale-revised, faces, leg, activity, cry, consolability scale and frankl
Variables
Groups
Age
4-6
> 6-9
> 9-13
Gender
Boys
Girls
Accompanying Mother
person
Father
Guardian
Total
CD:H
FPS-R (LA)
FPS-R (Ext)
FLACC (LA)
FLACC (Ext)
Frankl (Total)
Correlation
Significance
Correlation
Significance
Correlation
Significance
Correlation
Significance
Correlation
Significance
1
1
1
1
1
-
0.87
0.012
-0.09
0.63NS
0.21
0.09NS
0.11
0.40NS
0.18
0.22NS
-0.17
0.72NS
-0.24
0.19NS
0.17
0.17NS
-0.12
0.37NS
0.18
0.21NS
0.84
0.021
0.20
0.26NS
-0.08
0.53NS
0.12
0.38NS
0.11
0.46NS
0.71
0.07NS
-0.12
0.50NS
0.05
0.67NS
0.09
0.52NS
0.07
0.65NS
-0.14
0.76NS
0.27
0.63NS
0.07
0.56NS
0.01
0.94NS
0.15
0.32NS
Correlation
Significance
Correlation
Significance
1
1
-
0.18
0.20NS
-0.06
0.74NS
0.10
0.47NS
-0.01
0.97NS
0.19
0.17NS
0.02
0.91NS
0.28
0.041
0.08
0.68NS
0.01
0.98NS
0.1
0.60NS
Correlation
Significance
Correlation
Significance
1
1
-
0.55
0.012
0.17
0.09NS
0.11
0.65NS
0.04
0.72NS
0.20
0.38NS
0.12
0.21NS
-0.12
0.61NS
0.08
0.44NS
0.33
0.14NS
0.12
0.24NS
Significant at 0.05 level; 2Significant at 0.01 level. NS: Not significant; CD: H: Children drawing: Hospital Scale; FPS-R: Facial pain scale-revised; FLACC:
Faces, leg, activity, cry, consolability scale; L.A: Local anaesthetic administration; Ext: Extractions.
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ACKNOWLEDGMENTS
We acknowledge Dr. Baskar Naidu S, Clinical Psychologist,
for evaluating drawings and giving valuable suggestions.
COMMENTS
COMMENTS
Background
109
In pediatric settings, this is the second study in literature that determined the
procedural pain experienced by children during dental treatments, first being
the study done by Aminabadi et al in 2011. Aminabadi et al have tested the
procedural pain during pulp therapy and/or restorative treatments for carious
primary molars. However, in dentistry, out of the numerous procedures
perceived as painful by a child, local anesthetic (LA) administrations and
extractions are the most painful of all, which can cause psychological distress.
Hence, the present study is a breakthrough to know the efficacy of drawings
in depicting the experiences of children undergoing LA administration and
extraction of primary teeth.
10
11
12
Applications
13
14
15
Terminology
Pain drawings: Pain drawings are simple line drawings of the human figure
on which patients can indicate their pain for both clinical information and
research. Anxiety: Anxiety is a personality trait and is an apprehension, tension
or uneasiness that stems from anticipation of danger, the source of which is
largely unknown or unrecognized. Objective fear: It is acquired objectively or
produced by direct physical stimulation of the sense organs, but not of parental
origin, which are disagreeable and unpleasant in nature.
16
17
18
Peer-review
19
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