Comparison and evaluation of two play therapy breathing exercises to reduce anxiety in children receiving local anaesthesia: A randomized clinical study

Background: Children are anxious about dental procedures and the anaesthetic needle’s sight and feeling have been identified as the most fear-eliciting stimuli. Psychologists have used ‘play therapy’ to modify child behaviour to alleviate pain and anxiety during elective surgery in children. The pinwheel and bubble blower have been used in play therapy for children to bring about deep breathing which in turn brings about relaxation and anxiety reduction. Objectives: To evaluate and compare the use of two relaxation breathing exercises for anxiety reduction before and after administration of local anaesthesia for 6–12-year-old children undergoing dental treatment. Method: Forty-five children were divided into 3 groups as control, pinwheel breathing exercise and bubble blowing breathing exercise. The children were given a demonstration of the breathing exercise before local anaesthesia administration and asked to perform the exercise for 3 to 5 minutes. Anxiety was measured before and after administration of local anaesthesia with pulse rate and Venham’s picture scale score. Results: Post-operative rise in pulse rate was seen in all groups but was statistically significant in the control group and the bubble blowing breathing exercise group (p<0.05). The least rise was seen in the pinwheel breathing exercise group. The post-injection Venham’s picture test score was the same as the pre-injection score in the pinwheel exercise group but had increased for the other two groups which was statistically not significant. Conclusions: The play therapy relaxation breathing exercises can be successfully used for anxiety reduction in children receiving local anaesthesia. ____________________________


Introduction
The most essential components of paediatric dental care are pain and anxiety control.Increased sensitivity and responsiveness to painful stimuli can be seen with high levels of anxiety and fear 1 .Children display anxiety about dental procedures and particularly about local anaesthesia administration.In children undergoing dental treatment, the anaesthetic needle's sight as well as feeling have been identified as a stimulus that elicits the most fear.Therefore, paediatric dental practice largely depends on behaviour guidance 2 .In order to reduce procedural pain and anxiety, cognitive behavioural techniques like distraction, relaxation strategies and coping mechanisms have been widely studied and used.Another method that has been used by therapists is 'play therapy' used to communicate with and manage child behaviour.It establishes communication and relaxation of the child by providing objects or situations in the form of games.It has also been used to alleviate pain and anxiety during elective surgery in children.
The pinwheel breathing exercise incorporates deep breathing to relieve anxiety in young children.It is a form of play therapy used to bring about relaxation for the child.Concentration is enhanced by the pinwheel which acts as a focal point and can produce composure and coordination in tasks that require it 1 .The bubble blowing exercise, which is also a form of deep breathing exercise and a type of play therapy, is designed to teach children controlled breathing with the aid of a reinforcer which is the bubble blower 3 .Blowing soap bubbles can be powerfully calming and evolve into a relaxation technique with slow rhythmic breathing 4 .Hence, both these exercises may find application in a child patient undergoing dental treatment for anxiety reduction.There is a lack of literature that studies the use of play therapy relaxation breathing exercises for anxiety reduction in children undergoing dental treatment.

Objectives
To evaluate and compare the anxiety reduction in children after the bubble blowing and pinwheel breathing exercise during local anaesthesia administration.

Method
This is an in vivo, randomized control, parallel group study that was conducted over a period of 3 months on the patients who reported to the Department of Paediatric and Preventive Dentistry's outpatient department at KAHER's KLE Vishwanath Katti Institute of Dental Sciences, Belagavi, India.

Sample size:
With the alpha error as 5%, effect size of 0.96, p value set at 0.05 and power of 80%, a sample size (n) of 15 in each group was calculated using the following formula: Inclusion and exclusion criteria: Children between the ages of 6 to 12 years who required dental treatment under local anaesthesia in their 1 st appointment except those with special healthcare needs, with medical conditions contraindicating use of local anaesthetics containing adrenaline, respiratory conditions and history of allergy to anaesthetic drugs were included in the study.
Ethical issues: Ethical approval to conduct the study was obtained from the Institutional Review Board of KAHER's KLE Vishwanath Katti Institute of Dental Sciences, Belagavi, India [No: IEC/KLE VKIDS/ 2022/ 37].The study was registered at the Clinical Trial Registry India (CTRI/2023/01/048689).Written informed consent was obtained from the parents of the children participating in the study and assent from the children.
The children were randomly allotted into three groups using the lottery method: Group A (Control group), Group B (Pinwheel breathing exercise group) and Group C (Bubble blowing exercise group).The randomization was performed by the primary investigator (Figure 1).The child's pre-operative anxiety measurement was done using the Venham's picture test score and the pulse rate.(Figure 2 a and b) The participants belonging to Groups B and C were then given a demonstration and asked to perform the breathing exercise while participants in Group A did not perform any breathing exercise.In Group B (Pinwheel breathing exercise group), the child was asked to take a deep breath in and breathe out in such a way that the pinwheel rotated for as long as possible.(Figure 3 a) In Group C (Bubble blowing exercise group), the child was asked to take a deep breath in and breathe out to make the largest soap bubble possible.In both groups, the child was asked to perform the exercise till he learnt the deep breathing pattern and then continue the exercise for 3 to 5 minutes.(Figure 3 b).
Topical anaesthetic gel containing 2% lignocaine (LOX* 2% Jelly, Neon Laboratories Ltd, Mumbai, Maharashtra, India) was applied to the injection site with a sterile cotton swab after drying the area with gauze.To increase the depth of penetration, the gel was rubbed on the mucosa for 30 seconds.After 3 minutes, the excess gel was wiped off with cotton 1 .A 2cc disposable syringe with 26-gauge, 1.5inch needle (UNOLOK Single use hypodermic syringe with needle, Luer lock 3 ml (3 ml), Hindustan syringes and medical devices, Faridabad, Haryana, India) was used for administration of local infiltration with 2% lignocaine with 1:80,000 adrenaline (Lidayn, Lignocaine & Adrenaline Injection IP 2% Adrenaline 1:80,000 30 ml, Global Dent Aids Pvt Ltd, Noida, Uttar Pradesh, India).The mucosa was made taut, and the needle was inserted 2 to 3 mm at the height of the muco-buccal fold adjacent to the tooth concerned.1 ml of anaesthetic solution was injected at the standard rate of 0.8 ml/min to minimize pain 3 .The post-operative anxiety measurement was immediately carried out with pulse rate measurement and Venham's picture test score.The pre-operative and postoperative data were tabulated in Excel and entered using the IBM SPSS software (version 22.0 Chicago IL, USA) and subjected to statistical analysis (Figure 1).

Results
The participants were divided into 3 equal groups of 15 each.There were no dropouts or exclusions.The mean age of the participants in this study was 8.96 years; 62.2% of them were males while 37.8% were females.The preoperative and post-operative Venham's picture test scores in all the three groups do not follow a normal distribution.Therefore, the non-parametric tests were applied.Parametric tests were applied for pre-operative and postoperative pulse rate scores as they follow a normal distribution.For the Venham's picture test, the preoperative and post-operative scores of all 3 groups were compared with Kruskal Wallis ANOVA while pairwise comparison of the groups was done using the Mann-Whitney U test (Table 1).No significant difference was observed in these scores.Pre-operative and post-operative comparison of pulse rates between the three groups was done by one way ANOVA test while the pairwise comparison was done by Tukey's multiple post-hoc test (Table 3).The intragroup pre-operative and post-operative pulse rate comparison was done using the dependent t-test.The rise in the pulse rates was seen in all groups post-operatively and was statistically significant in Group A (p=0.0070) and Group C (p=0.0500).The least rise in the pulse rate was seen in Group B. (Table 4).

Discussion
Dental anxiety is a global phenomenon that impacts people of all age groups and impacts their oral-health related quality of life.It is a state of apprehension where a patient feels something dreadful might happen during dental treatment and is observed commonly in 3-18-yearolds worldwide 6 .In paediatric patients, local anaesthetic needles produce the greatest negative responses.Children become sensitized with repeated exposure to the injection procedures causing increasing negative responses 7 .
Kumar V, et al 8 , reported high level dental anxiety prevalence (84.5%) among 6-12-year-old children of South India; 6-12-year-old children were hence recruited for the present study.Additionally, children younger than 5 years of age do not have sufficient cognitive development to rate pain or anxiety with self-reporting scales such as the Venham's picture test used in this study 2 .The anxiety was reported using subjective and objective measurements using the Venham's picture test and pulse rate respectively.Rise in anxiety leads to sympathetic stimulation and increases the heart rate and hence, the pulse rate 9 .The Venham's picture test is a selfmeasure test which is projective as well as psychometric, the reliability of which has been previously tested 10 .
An anxious child might perceive pain to be of a more severe, or longer lasting kind as compared to the pain perceived by a less anxious child 11 .Meditation, relaxation, and breathing techniques have been shown to counteract the detrimental effects of stress, anxiety, and the autonomic nervous system's sympathetic dominance.Breathing techniques could be used as first-line as well as supplemental treatment for stress and anxiety 12 .A study by Busch V, et al 13 showed that modulation of sympathetic arousal and pain reduction can be brought about by deep and slow breathing.Relaxation breathing exercises cause an active distraction inducing stimulation of the vagus nerve, cortisol reduction and secretion of antidepressant neurotransmitters such as serotonin 2 .
'Play therapy' is a newer technique successfully used by therapists to help engage with and manage intensely anxious kids 1 .The pinwheel breathing exercise and the bubble blowing exercise incorporate relaxation deep breathing along with the play therapy, where the pinwheel and the bubble blower are the reinforcers 1,2 .They are easy to learn and perform and enjoyable to children.
The results of this study revealed a spike in post-operative pulse rates in all 3 groups, the maximum rise being in the control group (statistically significant with p=0.0070), followed by the bubble blowing exercise group (statistically significant with p=0.0500) and the least rise being in the pinwheel breathing exercise group.This rise in the pulse rates can be due to the endogenous epinephrine release caused because of emotional stress 14 .The pain experienced is however, not just dependent on the dental anxiety but also modulated by psychological factors or the coping mechanisms of the individual 15 .Similar findings of post-operative rise in the pulse rate and the rise in Venham's picture test scores of the present study in the control and bubble blowing exercise group have been reported in existing literature 1,2,5 .
Even though the dental anxiety among all 3 groups seems to be comparable in this study, it can be said that the pinwheel exercise was slightly efficacious in terms of the least rise in the post-injection pulse rate and an almost unchanged Venham's picture test score.The findings of a study by Kohli N, et al 16 that evaluated anxiety and pain perception during local anaesthesia administration using insulin syringes and deception syringes showed a statistically significant anxiety reduction implying that hiding or camouflaging of threatening stimuli is of core importance to manage an anxious patient.Hence, the occasional circumstantial and inevitable sight of the needle in the present study could have resulted in a bias.
This study has scope to be carried out with a larger sample size, in a wider age group while using more methods of anxiety assessments at varying time intervals throughout the process of local anaesthesia administration.These methods of relaxation could also be implemented for anxiety reduction in children undergoing other dental treatments.

Conclusions
The study revealed that post-injection rise in the pulse rate in the pinwheel group and the bubble blowing exercise group was less than that seen in the control group.The Venham's picture test scores also remained the same postinjection in the pinwheel breathing exercise group.Hence, it can be concluded that these relaxation breathing exercises can be successfully used for anxiety reduction in children receiving local anaesthesia.

Table 1 : Pre-operative and post-operative Venham's picture scale scores of groups A, B, and C compared pairwise by Mann-Whitney U test
Intra-group comparison of pre-operative and postoperative Venham's picture test scores was done using the Wilcoxon-matched pair test.Though not statistically significant, it revealed that while the Venham's picture test score had increased in Groups A (Control) and C (Bubble blowing breathing exercise) post-operatively it remained unchanged for Group B (pinwheel breathing exercise) (Table2).