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Original Article

A cross‑sectional survey on children perception of isolation

methods for restorative procedures and influence of
cognitive development

Anupam Saha, Rekhalakshmi Kamatham, Sreekanth Kumar Mallineni, Sivakumar Nuvvula

Department of Paedodontics and Preventive Dentistry, Narayana Dental College and Hospital, Nellore, Andhra Pradesh, India

ABSTRACT
Aim: The aim of this study was to ascertain whether the cognitive level of a child
affects the preference of isolation methods commonly employed in pediatric dentistry.
Materials and Methods: Children from 4 to 16 years with no previous dental experience
were recruited. Based on Piaget’s stages of cognitive development, they were divided
into three age groups, namely, Group I: 2–7 years, Group II: 7–11 years, and Group III:
>11 years. Three videos demonstrating operative procedures performed under one of the
isolation methods (1) rubber dam, (2) cotton rolls, and (3) saliva ejector were displayed
and asked about their preference. The data were tabulated and statistically analyzed
using Chi‑square test for the difference in their preferences based on cognitive level of
children. Results: A  total of 360 children participated in the survey. Both 8–11 years
and >11 years age group children preferred saliva ejector while 2–7 years group preferred
rubber dam. Statistically, significant difference was observed (P < 0.001) among different
age groups. No significant difference was observed between boys and girls regarding
the preference to isolation techniques (P = 0.821). Most of the children preferred saliva
ejector (P < 0.05). Conclusions: Children’s perceptions and preferences are strongly
influenced by the level of their cognitive development with children age 2–7 years preferred
rubber dam whereas other age groups preferred saliva ejector.

Key words: Cognition, cotton rolls, isolation, rubber dam, saliva ejector

INTRODUCTION complexity of oral environment presents many obstacles

in performing dental treatment procedures. To minimize
Isolation of the operating field is a fundamental aspect them, proper isolation is required to control operating field
in pediatric dentistry. Rubber dam, cotton roll, and saliva as well as provide safe and quality treatment. Moreover,
ejectors are commonly employed for this purpose. The good isolation is an important precondition to guarantee the
long‑term survival of any dental treatment.[1] Rubber dam is
Address for correspondence:
Dr. Sreekanth Kumar Mallineni, This is an open access article distributed under the terms of the
Department of Paedodontics and Preventive Dentistry, Narayana Creative Commons Attribution‑NonCommercial‑ShareAlike 3.0
Dental College and Hospital, Nellore, Andhra Pradesh, India.
License, which allows others to remix, tweak, and build upon the
E‑mail: drmallineni@gmail.com
work non‑commercially, as long as the author is credited and the
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Website:
For reprints contact: reprints@medknow.com
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How to cite this article: Saha A, Kamatham R, Mallineni SK, Nuvvula S.

DOI: A cross-sectional survey on children perception of isolation methods for
10.4103/0976-433X.195623 restorative procedures and influence of cognitive development. SRM J
Res Dent Sci 2016;7:219-21.

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Saha, et al.: Influence of cognitive development on children’s preference of isolation procedures

considered the optimum isolation technique due to several Group III (115). Among them, most children (n = 159)
advantages, such as providing an aseptic environment, preferred saliva ejector followed by cotton rolls (n = 102)
minimizing the potential risk of transferring infective and rubber dam (n = 99) for isolation. Children of
microbes between the operator and the patient, and prevents Group I (2–7 years) preferred rubber dam, whereas other
any possible ingestion or aspiration of dental instruments two groups (Group II and Group III) preferred saliva
during a dental procedure.[2] Children may feel that the ejector as their primary choice. No statistically significant
treatment takes place outside of their mouth.[1] Nevertheless, difference (P = 0.821) was found among boys and girls as
children indeed tolerate longer treatments once the rubber most of the boys and girls preferred saliva ejector as their
dam has been applied. Other techniques such as cotton rolls choice. When age and children’s preferences were compared,
and saliva ejectors are routinely used in pediatric dentistry a statistical significant difference (P < 0.001) was found with
besides rubber dam due to their ease of usage. participants of Group I preferring rubber dam, and Group II
and III selecting saliva ejector, respectively [Table 1].
Anxiety and fear, originated from a previous traumatic Correlation between age and gender in each group was not
experience in dental office or due to hospitalization for significant [Table 2].
general health problems, might exhibit an emotional upset for
most of the children.[3] Hence, it is important for the pediatric DISCUSSION
dentist to maintain a friendly relationship with children to
reduce anxiety and fear toward dental treatment. Giving Piaget[5] believed that in every child, the same sequence of
priority to the children’s preference of treatment will help development occurs and divided them into different stages
them cope with their dental fear and anxiety.[4] However, the (1: sensorimotor period [18 months to 2 years], 2: period of
influences of cognitive levels of children on the preference of conceptual intelligence [2 years and above], a: preoperational
these methods have not been given much attention. Hitherto, period [2–7 years], i: preconceptual [2–4 years], ii: intuitive
studies on isolation primarily emphasized on children’s stage [4–7 years], b: period of concrete operation [7–11 years],
satisfaction after treatment, and influence of cognitive level of c: period of formal operational [11 years and beyond]). Among
children on their preference was given little attention. Hence, them, preoperational stage (2–7 years) is the second stage of
the aim of this study was to ascertain, whether the cognitive cognitive development during which children think symbolically
level of a child affects the preference of isolation methods about objects, but reason is based on the appearance rather
commonly employed in pediatric dentistry. than the logic. Hallmarks of this stage include egocentrism,
centration, irreversibility, and lack of conservation.[6] Based on
MATERIALS AND METHODS the observations, age plays a major role in children’s preferences
rather than gender because age might have direct impact on
A cross‑sectional survey was conducted in the Department the cognitive levels of a child. Cognition refers to knowing
of Pedodontics and preventive dentistry. After obtaining and understanding, cognitive development involves changes
the institutional ethical clearance, consent was obtained in cognitive process and abilities.[7]
from the schools as well as parent and ascent of the children
to participate before the study. Three hundred and sixty Group 1 children would have preferred rubber dam because
healthy children of 2–16 years with no previous dental of the “centration” which will be present at this level of
experience were included in the study. All the participants
were divided into three groups based on the Piaget’s theory Table 1: Correlation of age of child with isolation techniques
of cognitive development, namely, Group I: (2–7 years), Age of Cotton Rubber Saliva Total P
the child roll, n (%) dam, n (%) ejector, n (%)
Group II: (7–11 years), and Group III: (>11 years). Children
(years)
of all three age groups were shown videos regarding pediatric 2-7 36 (30) 49 (40.83) 35 (29.17) 120 <0.001***
operative procedure performed under different isolation 8-11 35 (28) 20 (16) 70 (56) 125
methods: (1) Cotton roll, (2) rubber dam, and (3) saliva >11 31 (26.95) 30 (26.1) 54 (46.95) 115
ejector (video modeling), and age appropriate explanation ***Highly significant. N: Number of participants
was given to all the participants about the importance of
isolation and the armamentarium used (tell‑show). Later, Table 2: Correlation of age of child and gender with
each child was asked individually about their preference of Isolation techniques
particular isolation method. On completion of the survey, Age of the Gender Cotton Rubber Saliva P
data were formulated and statistically analyzed using child (years) roll dam ejector
(SPSS version 17.0) Chi‑square test. 2-7 Boys 23 (29.87) 29 (37.66) 25 (32.46) 0.513NS
Girls 13 (30.23) 20 (46.51) 10 (23.25)
8-11 Boys 17 (26.15) 12 (18.46) 36 (55.38) 0.709NS
RESULTS Girls 18 (30) 8 (13.33) 34 (56.66)
>11 Boys 16 (25.8) 14 (22.58) 32 (51.61) 0.517NS
A total of 360 children participated in the study with mean Girls 15 (28.30) 16 (30.18) 22 (41.5)
age of 9.34 years with Group I (120), Group II (125), and NS
: Not significant

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Saha, et al.: Influence of cognitive development on children’s preference of isolation procedures
cognitive development. Child’s understanding is mostly
based on what they see and their reaction or comprehension
of an object or situation is based on the most compelling
and striking feature of the stimulus. Their thoughts are
centered only on one salient aspect of the problem or one
feature of a multifaceted experience is emphasized in
the child’s perception.[7] Children, when they are young,
show an over‑reliance on visual stimuli and tend to focus
on that and less on what they “know” or heard.[8] In the
present study, children might have centered on the color of
the rubber dam shown as well as the feeling of treatment
outside the mouth and would have preferred rubber dam
as their choice.
Majority of the children from other two groups (Group II and
Group III) preferred saliva ejectors, which could be due to
the development of logical reasoning from 7 years onward.
During this period, they will understand logical concepts
and no longer make judgments solely on the basis of how
things appear. At this age, the child’s thinking will be more
stable and reasonable. Children could understand many
relationships with the cause and effect.[5] As saliva ejector
takes away all the saliva, making the operative field clear
along with the feeling of control over situation, most of the
children would have preferred saliva ejector. This might be
because of the use of inductive logic, means making broad
generalizations from specific observations, by the children
of this age group. Clinically, studies have shown successful
retention rates of adhesive restorations when used with
rubber dam than any other isolation technique.[9] Ammann
et al.[1] stated that isolation with rubber dam causes less stress
in children and adolescents compared to cotton rolls. In the
present study, most of the children overruled cotton rolls as
they would have thought that it might not be as effective
as saliva ejector in isolation, and moreover, they have to be
replaced with new one consistently, which makes the child
feel uncomfortable.
Miller[10] postulated that there is need to reduce children’s
anxiety and fear toward dentistry as much as possible
before dental treatment. The present study was planned, to
know the preferences of children before the start of dental
treatment, with the purpose of making children familiar with
the dental settings. Several studies have been investigated
physiological and psychological responses of children during
dental procedures and it has been noted that behavior
may vary with the type of dental procedure, the frequency
of visits, and during the process of a visit itself.[11] This
present study elicited the benefit of the knowledge related
to the child’s preferences before the dental procedures and
implementing them to create a comfortable atmosphere in
which the child does not feel helpless.[4] Common problems
that are encountered by pediatric dentists are behavior
prediction, oral health education, and motivation.[6] Further
researches on the cognitive development of a child help a
pediatric dentist in better understanding, approach, and
SRM Journal of Research in Dental Sciences | Vol. 7 | Issue 4 | October-December 2016
deliver quality care to the children, and also its application
to dental health care.
Limitations of the present study include generalizability of
the results due to smaller sample size, and the participated
population was an institutional sample. Preferences may
be differed, once the child has experienced with different
isolation techniques; however, application of all the isolation
methods in one child may not be practically possible. Hence,
the results of the present study would not very different from
other clinical studies conducted on isolation techniques.
CONCLUSIONS
This study provides an insight to the classical characteristics
of a child’s cognitive levels as described by Piaget, among
children of three different age groups. Cognitive levels of
child are primarily dependent on the age, which in turn might
have influence their preferences during dental treatment.
Knowledge on the child’s preferences and implementing
them will help the pediatric dentist in behavior shaping and
oral health education of the child.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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