�� Vol. 43. No. 1 March 2010 Mozart effect on dental anxiety in �–�� year old children arlette Suzy Setiawan, hilma Zidnia, and inne Suherna Sasmita Department of Pediatric Dentistry Faculty of Dentistry, University of Padjadjaran Bandung - Indonesia abstract Background: C�ildren an�iety in dental treat�ent ��ten �ec��es a �arrier ��r dentist t� �er��r� ��ti��� dental treat�ent �r�ced�re. Vari��s �et��ds t� �anage an�iety and �ear in c�ildren �ave �een a��lied incl�ding listening t� classical ��sic d�ring dental treat�ent. One �� t�e classical ��sic �s�ally �sed is ��sic �y ��zart. Purpose: ��is st�dy is ai�ed t� disc�ver t�e r�le �� classical ��sic �y ��zart in dental an�iety c�anges. Method: ��is st�dy ��as a q�asi e��eri�ental st�dy �sing ��r��sive sa��ling �et��d. ��e sa��les c�nsist �� 30 c�ildren �et��een 6-12 years �ld gr��� ���� ��ere treated at t�e Pediatric Dentistry Clinic, Dental H�s�ital, Fac�lty �� Dentistry Padjadjaran University. ��e an�iety data ��as c�llected �sing Vis�al Anal�g�e Scale (VAS) �e��re and a�ter listening �n t�e classical ��sic d�ring treat�ent. result: ��e res�lt �� t�is st�dy s����ed t�at t�ere ��ere 23 c�ildren (76.67% �� s��jects) ���� �resent decreased an�iety, 7 c�ildren (23.33% �� s��jects) did n�t �resent decreased an�iety and n�ne �� �� s��jects s����ed increased an�iety. Conclusion: �t ��as c�ncl�ded t�at listening t� ��sic �y ��zart d�ring dental treat�ent can red�ce an�iety in 6–12 year �ld c�ildren. Key words: ��zart e��ect, dental an�iety, c�ildren abstrak latar belakang: Kece�asan �ada anak saat �era��atan gigi seringkali �er��akan �eng�alang �agi d�kter gigi �nt�k �elaksanakan �r�sed�r �era��atan gigi yang ��ti�al. Ber�agai �et�de �nt�k �engatasi kece�asan dan rasa tak�t �ada anak tela� dilak�kan ter�as�kBer�agai �et�de �nt�k �engatasi kece�asan dan rasa tak�t �ada anak tela� dilak�kan ter�as�k �endengarkan ��sik klasik sela�a �era��atan gigi. Sala� sat� ��sik klasik yang �anyak dig�nakan adala� ��sic �le� ��zart. tujuan: Penelitian ini dit�j�kan �nt�k �ene��kan �eran ��sic klasik ��zart dala� �er��a�an kece�asan �ada �era��atan gigi. Metode: Penelitian ini adala� k�asi eks�eri�ental �engg�nakan �et�de �enga��ilan sa��el ��r��si� . Sa��el terdiri dari 30 anak antara 6–12 ta��n yang dira��at di Klinik Ked�kteran Gigi Anak, R��a� Sakit Gigi dan ��l�t Fak�ltas Ked�kteran Gigi Universitas Padjadjaran. Data kece�asan dia��il dengan Vis�al Anal�g�e Scale (VAS) se�el�� dan setela� �endengarkan ��sic klasik sela�a �era��atan. hasil: Hasil �en�nj�kkan �a���a terda�at 23 anak (76,67% dari s��jek) yang �en�nj�kkan �en�r�nan kece�asan, 7 anak (23,33%) tidak �en�nj�kan �er��a�an kece�asan dan tidak ada (0 anak ata� 0%) yang �en�nj�kkan �eningkatan kece�asan. Kesimpulan: Disi���lkan �a���a �endengarkan ��sik ��zart sela�a �era��atan gigi da�at �en�r�nkan kece�asan di antara anak- anak �sia 6–12 ta��n. Kata kunci: E�ek ��zart, kece�asan, anak-anak C�rres��ndence: Arlette Suzy Setiawan, c/o: Bagian Kedokteran Gigi Anak, Fakultas Kedokteran Gigi Universitas Padjadjaran. Jl. Sekeloa Selatan I Bandung, Indonesia. E-mail: arlettesuzy@yahoo.com Research Report introduction Anxiety related to dental treatment is frequently found, especially in children. This often becomes a direct reason why a child reluctantly goes to a dentist.1,2 A study of Milgrom and Weinstein in 1993 has proven that anxiety during dental treatment occupies the fourth rank among other anxieties.1 Anxiety is an individual normal �� Dent. J. (Maj. Ked. Gigi), Vol. 43. No. 1 March 2010: 17-20 emotional reaction that appears when facing dangerous or life threatening situation because basically each person wants comfort in his or her life. Dental treatment in clinics can create anxiety leading to non cooperative behavior of the patient during the treatment that may interfere the medical procedures causing longer chair time. Uncooperative patient will cause difficulties in treatment leading to non-optimum treatment result.1 According to a study performed by Kartono and Sartono in 1992 at Sutadi,3 the factors of anxiety include the sound of a bur, 81.46%, sitting on dental chair 50.72%, needle 39.13%, dental instruments 39.13%, and negative story on dental treatment 33.33%. Anxiety and fear in children during dental treatment is not a new phenomenon in dentistry. The child anxiety in dental treatment often becomes a barrier for the dentist to perform optimum dental treatment procedure.1,2 Anxiety is become severe by unpleasant experiences during the previous visit that make the child refuses to continue dental treatment. One of the factors that cause anxiety during dental treatment is the sound of dental bur. Based on the study done by Wardle 1982 as mentioned by Budiman,4 anxiety during dental preparation using bur occupies the second place after dental extraction. The sound of bur instrument often creates anxiety in children.3 One of the methods to deal with anxiety and fear in children during dental treatment is by using distraction technique, i.e. distracting the child’s attention away from the source of anxiety.4 One of the ways to distract patient’s attention is by listening to the music.5 Pediatric patients who are afraid of the sound and the vibration of handpiece can be managed by simple audio technology, i.e. installing stereo music instrument in the dental clinic. This can reduce and cover unpleasant sounds. Therefore, music can help reducing stress and make the patient relax.6 A soft and gentle music can reduce fear and anxiety in children. A soft classical music can neutralize the sharp noise of bur used by the dentist. A study by Campbell5 has proven that listening to classical music during treatment is very effective for relaxation, especially in reducing discomfort in pediatric patients. Six to twelve year is a transitional age from the childhood to teenage which is also often called the end period of childhood. In this period the child’s attention to the surrounding environment increases. In terms of dental treatment, the children in 6–12 years old group are generally cooperative and have the ability to accept the treatment. With better cognitive development the child will enable to absorb abstract explanation. However, some still cannot accept it, which will leading to be anxious.7 The aim of this study is describing the effect of the classical music on anxiety changes in children aged 6 to 12 years old before and after listening to classical music at the Pediatric Dentistry Clinic, Dental Hospital, Faculty of Dentistry Padjadjaran University by using the visual analogue scale (VAS).7 material and method The type of this study is a quasi-experimental method. The study population were pediatric patients which will receive dental treatment at Pediatric Dentistry Clinic, Dental Hospital, Faculty of Dentistry Padjadjaran University. The purposive sampling technique is used with the following criteria: 30 children age 6–12 years old, male and female, come for a class one cavity preparation for dentin caries in lower first molar and with a good general health condition. A walkman and a Mozart’s song (Andantino Grazioso from Symphony No.18) was used as an instrument to listen. Visual Analogue Scale sheet is used to assess the anxiety level with a scale from 1 to 7 which shows the expression degree of increased anxiety (Figure 1). The anxiety changes are measured from VAS pictures. The anxiety was stable when there was no change in VAS scale. The anxiety was reduced when there was reduction in VAS scale and it was increased when there was increase in VAS scale. figure 1. Visual Analogue Scale.7 figure 2. Distribution of VAS scale before treatment and during treatment without and with listening to Mozart music. The study was started by asking the child to select a picture in VAS that represented his/her emotion before the treatment procedure was applied. Next, the child’s tooth was prepared using round diamond bur for two minutes. During the first two minutes the child is asked to mark the picture in VAS that he or she considered as representing his or her anxiety. After that, the child listened to the music using walkman through an earphone. The preparation work using bur is continued while the child was listening to the classical music. After the preparation was finished the ��Setiawan, et al.: Mozart effect on dental anxiety child was asked to mark the picture in VAS that he or she considered as representing his or her anxiety. result Based on the study results of 30 children, data on the anxiety during treatment is represented in the following tables. The child anxiety change before the treatment and after the treatment without listening to Mozart music showing 40% of the children reduced anxiety, 23.33% increased anxiety and 36.67% showed no decrease or increase in anxiety (Table 1). table 1. Anxiety change before dental treatment and duringAnxiety change before dental treatment and during dental treatment without Mozart music Condition f % Reduced anxiety Increased anxiety No change 12 7 11 40.00 23.33 36.67 The child’s anxiety change before the treatment and during the treatment by listening to Mozart music. It showed that there was 70% of the children reduced the anxiety, 10.00% increased the anxiety and 20.00% with no anxiety increase or decrease (Table 2). table 2. Anxiety changes before dental treatment and during treatment while listening to Mozart music Condition f % Reduced anxiety Increased anxiety No change 21 3 6 70.00 10.00 20.00 The child’s anxiety change before listening to the classical music during treatment and after listening to Mozart music. A reduction in anxiety was found in 76.67% and 23.3% of the samples do not show increase or decrease in anxiety. No sample shows any increase in anxiety (Table 3). table 3. Anxiety change during dental treatment while listening to Mozart music after the previous condition I and II Condition f % Reduced anxiety Increased anxiety No change 23 0 7 76.67 0.00 23.33 Overall, the data collected is grouped based on the three conditions when the anxiety is measured and the VAS scale selected by the respondents. Table 4 show the scale distribution in the Visual Analogue Scale marked by respondents in each treatment, i.e. before treatment (condition I), during preparation without listening to Mozart music (condition II) and during preparation while listening to Mozart music (condition III). table 4. Distribution of VAS scale before treatment and during treatment without and with listening to Mozart music. VAS Scale Condition I % II % III % 1 2 3 4 5 6 7 6 8 5 10 1 0 0 20.00 26.67 16.67 33.33 3.33 0.00 0.00 4 9 9 8 0 0 0 13.33 30.00 30.00 26.67 0.00 0.00 0.00 14 11 3 2 0 0 0 46.67 36.67 10.00 6.67 0.00 0.00 0.00 Note: I: Before treatment II: During treatment, before listening to classical music III: During treatment while listening to classical music discussion Anxiety is a manifestation of fear without clear cause.8 The anxiety that is related to the dentist and dental treatment is generally triggered by the lack of knowledge of the patient on the treatment that he or she is going to receive. Information from friends about unpleasant dental treatments can increase the anxiety. The condition that triggers anxiety during dental treatment is various, including dental preparation using bur. Another factor that may affect patient’s anxiety level is the dentist is skill to communicate with the patient.9 Generally anxiety experiences by patient who visit the dental practices for the first time because the patient could not predict what the dentist will do on him/she. The study sample generally includes patients who have visited the dentist before to treat his or her teeth periodically at Pediatric Dentistry Clinic, Dental Hospital, Faculty of Dentistry Padjadjaran University. Patients tend to be cooperative because they are used to the instruments and equipments used by the operator. The communication between the operator and the patient is good that patient tends to be not anxious. The patient knows about the treatment to be because it has informed by the operator beforehand. They also have heard stories from their school friends who have received dental treatment that the dental treatment at this clinic is quite pleasant. Music is a universal language that encompasses status, age, religion, and race borders. Classical music can calm, soothe and heal. It can also give joy and joy is a kind of therapy. Calm classical music can function as emotional barrier. In the medical field, music is used for treatment �0 Dent. J. (Maj. Ked. Gigi), Vol. 43. No. 1 March 2010: 17-20 just like medicine.5 It has been reported that the pulse, respiration, electromyogram and electroenchepalogram are changed when the patient listens to music.11 Changes in the form of increased anxiety level in this study are seen mostly during before treatment and during treatment without music (Table 1). Reduced anxiety level in this study is mostly seen during before and after listening to the classical music during dental treatment (Table 2). Subjects who did not experience increased or reduced anxiety are mostly found during before and during treatment without music (Table 1). Increased anxiety during listening to the classical music in the treatment may be triggered by the loud volume of the walkman or the volume was too weak that the patients unable to hear the music. No changes in anxiety level may be caused by the condition where the children have never listened to the classical music before or because the child’s psychological nature showed no response to situation change or uneasiness in using headphones. Reduced anxiety during dental treatment by listening to classical music was caused by the distraction ability of the classical music or because listening to classical music may trigger relaxation effect and analgesia. The study shows that the anxiety experienced by the subject during dental drilling was reduced if the drilling is performed while the patient listens to the classical music. This is according to previous study showing positive response in dental patients who receive treatment while listening to the music.5 Reduced anxiety during dental treatment with classical music is caused by the fact that children like and able to enjoy music that make the children feel more relax. According to Marzuky,6 music for relaxation can reduce hart beat up to beat per second that the heartbeat becomes calmer. The slower heartbeat and pulse create lower stress and physical tension level. One of the efforts of the dentist to reduce anxiety and making the patient relax is by providing relaxing music. Classical music has sedative effect that anxiety and tension can be lowered making the patients feel calmer. Slow classical music makes the patient’s emotion low and relax that the anxiety level during dental treatment will be reduced. Not all classical music can be used for anxiety therapy. Classical music used for therapy includes music with 60 beats per minute or less tempo that will affect physiological and psychological aspects. According to Campbell5 slow music such as Andantino Grazioso from Symphony No. 18 of Wolfgang Amadeus Mozart can be used as musical therapy for children who experience stress to make them more relax. Gentle sound and soft beat will be perceived by the brain that a person becomes relax. In relax individual, there is reduced sympathetic nerve activity in autonomic nervous system part that will lead to reduced epinephrine (adrenaline) secretion. Adrenalin plays a role in one of the anxiety clinical symptom, i.e. pulse and blood pressure. Reduced adrenalin release will reduce pulse and blood pressure.12 Based on this study, patiens who listen to classical music while recovering dental treatment feel more relax than those who did not listen to the music. It can be concluded that classical music reduces anxiety in dental treatment of children aged 6–12 years old at this clinic. references 1. Al-Madi EM, Hoda AL. Assesment of dental fear and anxiety among adolescent females in Riyadh Saudi Arabia. Saudi Dental JournalSaudi Dental Journal 2002; 14(2): 77–80. 2. Engkling N, Marwinski G, Johren P. Dental anxiety in a representative sample of residents of a large German city. Clin Oral Invest 2006; 10: 84–91. 3. Sutadi H. Rasa takut dan cemas terhadap perawatan gigi. Kumpulan Makalah Ilmiah Kongres PDGI XVIII 1992; 135–42. 4. Budiman JA. Pengelolaan tingkah laku pasien pada praktek dokter gigi. Edisi ke-2. Jakarta: EGC; 1994. p. 63–86, 106–7. 5. Campbell D. 2000. Efek Mozart bagi anak-anak. Widodo ATK, editor. Jakarta: PT Gramedia Pustaka Utama; 2001. p. 331. 6. Fung HC. Medicine and music. Lifestyle 2006: 11(6): 24–5. 7. Latifa W, Soemartono SH, Sutadi H. Pengaruh musik terhadap perubahan kecemasan dalam perawatan gigi pada anak usia 8-10 tahun. JITEKGI FKG UPDM(B) 2006; 3: 125–8. 8. Chaplin JP. 1999. Kamus psikologi. Kartono K, editor. 10th ed. Jakarta: PT Raja Grafindo Persada; 2005. p. 32–3. 9. Peretz B, Katz J, Elda A. Behavior of dental phobic residents of large and small communities. Braz Dent J 2000; 10(1): 1–3. 10. Murabayashi N. Psychosomatic medicine and music therapy. Asian Med J 2000; 43(11): 538–42. 11. Marwah N, Prabhakar AR, Raju OS. Music distraction-its efficacy in management anxious pediatric dental patient. J Indian Soc Pedod Prev 2005; December: 168–70. 12. Chafin S, Roy M, GerinW, Christenfeld N. Music can facilitate blood pressure recovery from stress. British Journal of Health and Pscycology 2004; 9: 393–403. 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