Breathing

Original Article
Comparative evaluation of effect of two relaxation

breathing exercises on anxiety during buccal
Downloaded from http://journals.lww.com/jped by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AW
infiltration anesthesia in children aged 6‑12 years:

A randomized clinical study
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 10/06/2023
Seema Bargale, Jayesh Rupesh Khandelwal, Bhavna Haresh Dave, Anshula Neeraj Deshpande,
Susmita Shrenik Shah, Deepika Narasimha Chari
Department of Pediatric and Preventive Dentistry, KM Shah Dental College and Hospital, Sumandeep Vidyapeeth, Vadodara, Gujarat,
India
ABSTRACT Address for correspondence:

Dr. Seema Bargale,
Background: Dental procedures, especially local
anesthetic administration, are a source of great Department of Pediatric and Preventive Dentistry, KM
anxiety to children. Diaphragmatic breathing is Shah Dental College and Hospital, Sumandeep Vidyapeeth,
defined as an efficient integrative body–mind Vadodara, Gujarat, India.
training for dealing with stress and psychosomatic E‑mail: [email protected]
conditions. Pinwheel exercise is also a highly effective
technique of “play therapy.” Aim: This study
Access this article online
aimed to compare dental anxiety using pinwheel
Quick response code Website:
breathing exercise and diaphragmatic breathing
www.jisppd.com
exercise during buccal infiltration anesthesia.
Methodology: Sixty children in the age group of DOI:
6–12 years with Frankel’s behavior rating score of 10.4103/jisppd.jisppd_501_20
3 who required buccal infiltration local anesthesia PMID:
were selected. Subjects were divided randomly into ******
two groups, i.e., Group A: children who performed
pinwheel breathing exercise and Group B: children
who performed diaphragmatic breathing exercise.
Introduction
The level of anxiety of the patients was recorded
Dental anxiety is a dynamic condition in several
using an animated emoji scale. The data were
respects, and no single variable can account for its
analyzed using IBM SPSS version 20 software with
development exclusively. The literature has a series
paired t‑test and Chi‑square test. Results: There was
of factors which have always been linked to a higher
a significant reduction in dental anxiety score from
score 1 (before the anesthetic procedure) to score This is an open access journal, and articles are distributed under the terms
2 (after the anesthetic procedure) in both the groups. of the Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0
On intergroup analysis, children who performed License, which allows others to remix, tweak, and build upon the work
pinwheel breathing exercise (Group A) showed non‑commercially, as long as appropriate credit is given and the new
higher values than children who performed deep creations are licensed under the identical terms.
breathing exercise without pinwheel (Group B) with For reprints contact: [email protected]
a t value of 1.42 but was not statistically significant
with a P value of 0.161. Conclusion: Pinwheel How to cite this article: Bargale S, Khandelwal JR, Dave BH,
breathing exercise as well as diaphragmatic Deshpande AN, Shah SS, Chari DN. Comparative evaluation of
breathing exercise proved to be significantly effective effect of two relaxation breathing exercises on anxiety during
in reducing dental anxiety during local anesthesia. buccal infiltration anesthesia in children aged 6-12 years:
A randomized clinical study. J Indian Soc Pedod Prev Dent
KEYWORDS: Animated emoji scale, buccal 2021;39:284-90.
infiltration, dental anxiety, diaphragmatic breathing Submitted: 26‑Nov‑2020 Revised: 20-Feb-2021
exercise, pinwheel breathing exercise Accepted: 27‑Sep‑2021 Published: 22-Nov-2021
284 © 2021 Journal of Indian Society of Pedodontics and Preventive Dentistry | Published by Wolters Kluwer - Medknow
Bargale, et al.: Relaxation strategies in anxious children
incidence of dentistry, including characteristics of buccal infiltration anesthesia and whose parents gave
the individual; pain anxiety; past dental trauma, informed consent were selected for the study. Children
particularly in children (condition); and the influence of selected were with good systemic health and had no
family members of peers with dental anxieties, which allergy for local anesthesia. Children falling under
generate fear in one person (vicarial learning) and Frankl’s behavior rating scale 3,[17] i.e., (positive:
blood damage.[1] Dental anxiety prevalence is 5%–20% acceptance of treatment; cautious behavior at times;
in most populations, which is seen more in children, and willingness to comply with dentist, at times with
and this appears to decrease as the age progresses.[2,3] reservation, but patient follows dentist’s instruction
co‑operatively) were selected so as to standardize the
Children are particularly anxious about dental study subjects. Children suffering from any illness or
procedures and, in particular, about local requiring special medical care, presenting with acute
anesthetics (LAs). In children undergoing dental care, pain, and requiring emergency dental treatment were
the sight and feeling of the anesthetic needle have excluded from the study.
been identified as the most fear‑eliciting stimuli.[4] The
practitioner can therefore reduce anxiety in such a way Details of examination
that children are positively enthused for subsequent The clinical examination of the selected children was
dental visits. Therefore, behavior guidance is a core carried out expert by the principal investigator to
aspect of pediatric dental practice.[5] limit the variability of the examiner. The demographic
details such as name, age, and medical history were
Cognitive behavioral methods such as distraction, recorded.
relaxation strategies, and coping mechanisms are
frequently reported to alleviate dental procedural pain Methods of randomization
and anxiety.[6] Distraction is a strategy that reduces All the children were screened, and sixty children were
the child’s attention from painful stimuli through the carefully selected based on the inclusion and exclusion
engagement of other senses. The pinwheel is a deep criteria. The subjects were made to pick up a chit from
breathing exercise used to relieve pain in young children one fish bowl consisting of 60 chits that had either
as a distraction technique.[6,7] It is used for the control of Group A (30 chits) or Group B (30 chits) in the bowl. The
pediatric pain as an effective distraction technique during subject then handed over the chit to the administrator.
shorter operations such as immunizations,[8] dermal The administrator kept a record of it separately and
wart[9] cryotherapy, and for the reduction of experiences proceeded as per the allotted group [Figure 1].
of pain in children with chronic conditions such as • Group A: Children who performed pinwheel
epidermolysis bullosa and cancer.[10] The pinwheel acts breathing exercise
as a focal point that enhances concentration and can • Group B: Children who performed deep breathing
be productive when used before testing or other tasks exercise without pinwheel.
involving composure and coordination.[11]
Procedure
Breathing practice, also known as “diaphragmatic The subject was positioned in an erect position on the
breathing” or “deep breathing,” is defined as an dental chair. The subject and parents were explained
effective integrative body–mind training to deal with about the entire procedure. All the instruments were
stress and psychosomatic conditions.[12] In conjunction sterilized and arranged prior to the procedure.
with meditation and ancient east Asian religions (such
as the Buddhism) and martial arts, the benefits of
diaphragmatic breathing were investigated.[13] It is Administration of local anesthesia
regarded as a core part of yoga and Tai Chi Chuan, Topical anesthetic gel containing 2%
which aims to enhance social and emotional balance[14‑16] lignocaine (Easycainne®, Miraculus Pharama Pvt
as well as special rhythmic movements and positions. Ltd, Mumbai, Maharastra, India) was applied to
the injection site using a sterile cotton applicator tip
after drying with a cotton gauze. The benefit of using
Hence, this study was aimed to evaluate and compare
topical anesthetic was communicated to the child prior
dental anxiety using pinwheel breathing exercise and
to the application using appropriate euphemisms.
deep breathing exercise without pinwheel during buccal
The gel was applied after drying the injection site
infiltration anesthesia in children aged 6–12 years.
with a sterile cotton gauze. The gel was rubbed on
to the mucosa under moderate pressure for 30 s to
Methodology increase the depth of penetration. After 3 min, the
excess topical anesthetic was removed using a sterile
This study was conducted as a double‑blinded, cotton gauze. Then, the LA was administered by the
randomized clinical study at the Department of Pediatric buccal infiltration technique using a 27‑G short needle
and Preventive Dentistry and was initiated after the syringe (Dispovan, Hindustan Syringes & Medical
approval of ethical committee of institute (SVIEC/ Devices Ltd, Faridabad, Haryana, India). One milliliter
ON/DENT/RP/20002). Children between 6 and of 2% lignocaine with 1:200,000 units adrenaline was
12 years of age who required dental treatment under injected (Xylum‑A Regain Laboratories Ltd, Hisar,
Journal of Indian Society of Pedodontics and Preventive Dentistry | Volume 39 | Issue 3 | July-September 2021 | 285
Figure 1: The CONSORT diagram showing the flowchart for a randomized controlled study
Haryana, India). The standard technique of buccal

infiltration was followed keeping the rate of injection
as 0.8 mL/min. During injection, care was taken to
keep the needle out of direct sight of the child. The
lip/cheek was stretched to keep the tissue taut. At the
height of the mucobuccal fold above the target tooth,
the syringe was aligned along the long axis of the tooth
with the needle bevel facing the bone. The depth of
penetration was 2–3 mm. The needle was penetrated
slowly into the tissue using low‑speed continuous
injection, so as to minimize pain. The needle was
then withdrawn and made safe. A single investigator
carried out all infiltrations.
Group A (pinwheel breathing exercise)

Group A comprised thirty child patients who were
made to practice pinwheel breathing exercise before Figure 2: Subject performing pinwheel breathing exercise
and after the local anesthesia procedure. With a
pinwheel held in front of the child’s face, instruction child to feel the diaphragm move as he/she breathed.
was given to the child to take a deep, slow breath in. The subject was instructed to breathe in slowly
Then, the child was instructed to hold the breath in for through the nose so that the stomach would move
2 s. After this, the child slowly released the breath by out against his/her hand. The hand on the subject’s
blowing the pinwheel. Repetitions were done until the chest remained as still as possible. Then, the subject
child’s satisfaction[18] [Figure 2].
was instructed to exhale through the pursed lips. The
hand on the subject’s upper chest must remain as still
Group B (diaphragmatic breathing exercise) as possible[19] [Figure 3].
Group B comprised thirty child patients who were
made to practice diaphragmatic breathing exercise
before and after the local anesthesia procedure. The Method of blinding
subject was made to sit comfortably, with knees It was a double‑blinded study where the statistician
bent and the shoulders, head, and neck relaxed. The and the co‑investigator were blinded. He/she was
subject’s one hand was placed on the upper chest and unaware about which type of distraction method was
the other just below the rib cage. This allowed the used on the child patient in the study.
286 Journal of Indian Society of Pedodontics and Preventive Dentistry | Volume 39 | Issue 3 | July-September 2021 |
Figure 3: Subject performing diaphragmatic breathing exercise Figure 4: Dental anxiety assessment using an animated emoji scale
Anxiety assessment dental anxiety score after the anesthetic procedure

Dental anxiety was measured preoperatively, i.e., before was 1.5 ± 0.63. The mean values of dental anxiety
the anesthetic procedure and postoperatively, i.e., after before the anesthetic procedure were higher than the
the anesthetic procedure by a co‑investigator who was mean values of dental anxiety after the procedure
blinded for the remaining procedure of the study. An with a difference of 1.4 ± 0.77, which was statistically
animated emoji scale (AES) was used to assess dental significant (P < 0.001). In the diaphragmatic breathing
anxiety. The AES has five animated emoji face graphic exercise group, the mean value of dental anxiety score
exchange formats that show distinct feelings ranging before the anesthetic procedure was 2.8 ± 0.76 and the
from very happy/laughing to very unhappy/sad and dental anxiety score after the anesthetic procedure
crying (most positive to most negative feelings). The was 1.67 ± 0.48. The mean values of dental anxiety
child was asked to select one of these animated emojis before the anesthetic procedure were higher than the
that best suited their feelings at that moment on the mean values of dental anxiety after the procedure
electronic screen (laptop). As shown in Figure 4, the with a difference of 1.13 ± 0.68, which was statistically
scale had scores from 1 (very happy emoji) to 5 (very significant (P < 0.001).
unhappy emoji).[20]
Table 3 depicts the intergroup comparison of dental
anxiety scores using AES. The mean values of
Statistical analysis dental anxiety score before anesthetic procedure
Data collected were entered into a computer and for pinwheel breathing exercise and diaphragmatic
analyzed using the SPSS software version 16 (SPSS breathing exercise group were 2.9 ± 0.76 and 2.8 ± 0.76,
Inc., IBM, Chicago, USA). The results were presented respectively. This showed that dental anxiety score
as mean ± standard deviation on continuous before anesthetic procedure was higher in pinwheel
measurements and the results were presented in breathing exercise group, which was statistically not
number (percent) on categorical measurements. significant (P > 0.001). The mean values of dental
For intragroup comparison, the paired t‑test and an anxiety score after anesthetic procedure for pinwheel
independent t‑test for intergroup analysis were used. breathing exercise and diaphragmatic breathing
exercise group were 1.5 ± 0.63 and 1.67 ± 0.48,
Results respectively. This showed that dental anxiety score after
anesthetic procedure was higher in the diaphragmatic
A total of 60 children (29 males and 31 females) aged breathing exercise group, which was statistically not
6–12 years participated in the study. The mean age significant (P > 0.001). Comparison of the difference
of the participants in pinwheel breathing exercise of dental anxiety scores before and after the anesthetic
group (Group A) and diaphragmatic breathing exercise procedure between the pinwheel breathing exercise
group (Group B) was 8.53 ± 1.94 and 8.37 ± 1.85 years, group and diaphragmatic breathing exercise group
respectively. Data revealed that both groups were showed that the difference was higher in the pinwheel
similar in demographic characteristics including sex breathing exercise group, which was statistically not
and age range [Table 1]. significant (P > 0.001).
Table 2 depicts the intragroup comparison of dental Discussion

anxiety scores using AES. In pinwheel breathing
exercise group, the mean value of dental anxiety score Children’s dental anxiety is a very common problem
before the anesthetic procedure was 2.9 ± 0.76 and the that occurs primarily in childhood and adolescence[21,22]
Table 1: Age comparison of subjects between the two groups

Mean±SD t P
Pinwheel breathing exercise (Group A) (n=30) Diaphragmatic breathing exercise (Group B) (n=30)
Age 8.53±1.94 8.37±1.85 0.341 0.735
SD=Standard deviation
Table 2: Intragroup analysis of dental anxiety scores assessed using an animated emoji scale (paired t‑test)
Groups Dental anxiety score n Mean±SD Mean difference±SD t P
Pinwheel breathing Before the anesthetic procedure 30 2.9±0.76 1.4±0.77 9.96 <0.001
exercise (Group A) After the anesthetic procedure 1.5±0.63
Diaphragmatic breathing Before the anesthetic procedure 30 2.8±0.76 1.13±0.68 9.11 <0.001
exercise (Group B) After the anesthetic procedure 1.67±0.48
Table 3: Intergroup analysis of dental anxiety scores assessed using an animated emoji scale (independent t‑test)
Dental anxiety scores Mean±SD t P
Pinwheel breathing Diaphragmatic breathing
exercise (Group A) (n=30) exercise (Group B) (n=30)
Before the anesthetic procedure 2.9±0.76 2.8±0.76 0.51 0.612
After the anesthetic procedure 1.5±0.63 1.67±0.48 −1.153 0.254
Difference between dental anxiety scores 1.4±0.77 1.13±0.68 1.42 0.161
(before and after the anesthetic procedure)
and sometimes distresses the infant, parents, and minimal cognitive and linguistic abilities and should
dental practitioners. In this study, dental anxiety was include a scoring system. A new anxiety scale, AES,
measured in 6–12‑year‑old children, as there is a high was developed using motion emoticons/animojis by
level of prevalence of dental anxiety (84.5%) in this Setty et al.,[20] taking into account the abovementioned
age group of children, according to Kumar et al.[23] points. This was focused on the new generation’s
who evaluated dental anxiety among 6‑ to 12‑year‑old interest in multimedia and preference toward motion
children in South Indian population. These findings pictures on electronic devices rather than paper‑based
were in accordance with the study done by de Menezes cartoons. In 102 healthy children aged 4–14 years,
Abreu et al.[24] who investigated 302 children in the age whose dental anxiety during their first dental visit
group of 6–7 years. was evaluated using animated emoji scale (AES),
venham picture test (VPT), and facial image scale (FIS),
LAs are the most frequently used drugs in medicine and their scale preference was documented, Setty
and dentistry. The injection of LAs is sometimes the et al.[20] validated this new scale. Dental anxiety was
only perceived painful aspect of the medical or dental analogous to that measured with VPT and FIS when
operation, and fear associated with LA injection has measured with that of AES. AES has proven to be a
been identified as a factor that induces anxiety in straightforward, attractive, simple, easy, and efficient
children and prevents dental treatment.[25] There are method for measuring children’s dental anxiety during
numerous local anesthesia administration strategies their dental visit.
that include nerve block, local penetration, and
injection of periodontal ligament. Kaufman et al.[26] The pinwheel serves as a tool for opportunities.
found local infiltration technique for local anesthesia Almost every kid can remember watching the colors
administration to be least painful and causing less go around and around. The “toy” also makes this
discomfort. Hence, local infiltration technique was breath available because as an emphasis on the long
used in this study for local anesthesia administration slow exhale, it becomes a little more lighthearted
and buccal infiltration injection was selected for every pinwheel breathing. It is a releasing breath that helps
participant to standardize the treatment protocol and control the nervous system and relaxes anxieties.[11]
avoid further bias. Pinwheel breathing exercise is also a highly successful
“play therapy” method used by therapists to engage
Due to its difficulty, it is not easy to assess dental with intensely anxious kids and manage them. Play
anxiety, particularly in young children who still lack therapy methods have been used to ease anxiety and
the ability to either understand or interpret the signs guide children’s actions during elective surgery.[28]
of anxiety or answer questionnaires on this subject.[27] The pinwheel breathing exercise is an adaptation of
A clinically appropriate, time‑saving, appealing scale a deep breathing exercise intended to teach children
should be easily incorporated in younger children with synchronized breathing in the shape of a pinwheel
using a reinforcer, thereby fostering the nervous child’s In addition, the technique was easily adapted by
participation.[29] Hence, we used pinwheel breathing school‑aged children and thus was both clinician and
exercise as a novel method to reduce dental anxiety patient friendly.
in children during local anesthesia administration.
There was a signification reduction between dental Further studies are required in this field, particularly
anxiety scores after the local anesthesia administration involving children with high dental anxiety and dental
and dental anxiety scores before the local anesthesia behavior management problems. The results of this
administration. This exercise is a low‑cost, easy‑to‑use study suggest that the pinwheel exercise may be used
cognitive behavioral guidance technique that does as a relaxation as well as distraction therapy in the
not have any side effects. This was contrary to the management of procedural anxiety to ensure child’s
study conducted by Sridhar et al.[30] who evaluated psychological well‑being, which is an important goal
the effectiveness of bubble breath exercise which had of pediatric dentistry. Furthermore, diaphragmatic
a similar principle in reducing anxiety and found breathing exercise proved to be beneficial in managing
that this exercise was not effective in reducing dental procedural anxiety and can be used in routine pediatric
anxiety in children aged 7–11 years during maxillary dental practice.
buccal infiltration.
Relaxation exercises have been proven to improve

Conclusion
vagal function, increase the development of antipain
neurotransmitters such as serotonin, and reduce stress • Pinwheel breathing exercise and diaphragmatic
hormone levels. The “relaxation response” is known breathing exercise proved to be effective in
as this qualified physiological response of the body reducing dental anxiety after local anesthesia
to stressful conditions.[31] Diaphragmatic breathing is administration in children aged 6–12 years old
a technique of breath conditioning (mainly involving • When the efficacy of both the exercises was
diaphragm muscle involvement), characterized by compared, pinwheel breathing exercise proved to
an increased depth of both inhalation and exhalation be more effective than diaphragmatic breathing
and a decreased breath duration over an established exercise in reducing dental anxiety after local
period of time (e.g. 2–4 min). This form of respiration anesthesia administration, which was not found to
supplies the body with more oxygen, thus lowering the be statistically significant.
heart rate.[32] Breathing relaxation is easy to perform
and can be used by anxious patients in the dental Declaration of patient consent
chair immediately prior to treatment or at home.[33] The authors certify that they have obtained all
Psychological studies have shown that the practice appropriate patient consent forms. In the form the
of respiration is an important nonpharmacological patient(s) has/have given his/her/their consent for
response to emotional enhancement,[34] including his/her/their images and other clinical information
a decrease in anxiety, depression, and stress.[35] Ma to be reported in the journal. The patients understand
et al.[13] evaluated the effect of diaphragmatic breathing that their names and initials will not be published and
on cognition, affect, and cortisol responses to stress in due efforts will be made to conceal their identity, but
healthy adults and found that diaphragmatic breathing anonymity cannot be guaranteed.
practice improved cognitive performance and reduced
negative subjective and physiological consequences of Financial support and sponsorship
stress (anxiety) in healthy adults. Based on the evidence Nil.
showing the efficacy of diaphragmatic breathing in
reducing fear and anxiety in the general population,
we used as it as a breathing modification technique for
Conflicts of interest
There are no conflicts of interest.
reducing dental anxiety in children aged 6–12‑year‑old
for the first time. Children performing diaphragmatic
breathing exercise showed significant reduction in References
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Original Article

Comparative evaluation of effect of two relaxation

infiltration anesthesia in children aged 6‑12 years:

ABSTRACT Address for correspondence:

Haryana, India). The standard technique of buccal

Group A (pinwheel breathing exercise)

Anxiety assessment dental anxiety score after the anesthetic procedure

Table 2 depicts the intragroup comparison of dental Discussion

Table 1: Age comparison of subjects between the two groups

Relaxation exercises have been proven to improve

Community Dent Oral Epidemiol 1994;22:201‑5. 2018 Dec 19].

2014;31:757‑8. A birth cohort study. Community Dent Health 2001;18:99‑104.

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