Dental anxiety, pain, behavior, and heart rate in anxious children
Eligible children were randomly allocated to the control or intervention group in a 1:1 ratio using a computer-generated random sequence. 1. Control arm Children receive conventional behavior guidance throughout the appointment: tell-show-do, positive reinforcement, and voice control, applied consistently by the researcher, followed by local anesthesia and completion of the required dental procedure. 2. Intervention arm Children receive the same conventional behavior guidance plus a guided deep breathing exercise. This diaphragmatic technique is used because slow, deep breathing augments parasympathetic (vagal) tone and reduces sympathetic arousal, thereby lowering heart rate and subjective anxiety and pain (Jerath et al., 2006; Levi et al., 2022). It requires no device, application, or timer and is delivered through verbal instruction and live modelling alone, which keeps it applicable in resource-limited settings (Levi et al., 2022). Before local anesthesia, each child is taught a simple, slow diaphragmatic breathing technique: inhale slowly and deeply through the nose, hold briefly, and exhale slowly through the mouth. Each cycle comprises an approximately 4-second nasal inhalation, an approximately 2-second breath-hold, and an approximately 6-second oral exhalation (about five breaths per minute); the child places one hand on the abdomen to feel it rise and fall so that a diaphragmatic (belly-breathing) pattern is reinforced (Levi et al., 2022; Bahrololoomi et al., 2022). The exercise is demonstrated by the investigator, a dentist trained in guiding paediatric breathing exercises, and rehearsed with the child until it can be performed correctly. While modelling, the operator breathes audibly in phase with the child and progressively lengthens the exhalation (Levi et al., 2022). Once the child performs the pattern correctly (about 3 minutes of teaching and rehearsal), a focused block of eight guided cycles (approximately two minutes) is completed immediately be
1. Aged 5-8 years 2. Good general health (ASA physical status I) 3. Moderate-to-high dental anxiety (CFSS-DS total score ≥ 32; range 15–75) 4. Requiring a dental procedure involving local anesthesia (pulpotomy of a primary molar) 5. Written parental/guardian consent and child assent
1. Any systemic, neurological, developmental, or respiratory condition that could affect cooperation or breathing 2. A History of severe or disabling dental anxiety requiring pharmacological management 3. Refusal to participate by the parent or the child 4. Presence of any contraindication to local anesthesia or the specific anesthetic agent used