dental appointment is a stressful situation , which raises children 's anxiety level and avoidance behavior .
several communicative , advanced and pharmacological interventions have been developed to manage children 's anxious and cooperative behaviors .
the american academy of paediatric dentistry ( aapd ) recommended focusing more on non - pharmacologic intervention in future studies .
the first dental visit is crucial in the formation of the child 's attitude toward dentistry and future treatment success .
tell - show - do technique is commonly used by pediatric dentists in management of children 's anxiety at a pre - treatment visit .
it dictates that before anything is done , the child be told what will be done and then shown by some sort of simulation exactly what will happen before the procedure is started .
tell - show - do technique is based on principle of learning theory ; and is performed by the dentists themselves in the operatory room .
other methods such as desensitization , observational modeling and play therapy have also been recognized for the modification of children 's behavior .
modeling refers to learning by observation and children may reproduce behavior exhibited by the model in the same situation .
it was described by bandura in 1967 as a process which can reduce children 's fear and avoidance behavior .
studies on modeling have demonstrated its therapeutic effect in management of anxiety and educational effect in improving coping skills of children in medical stressful situations .
it has been suggested to use the live or filmed modeling technique as an effective intervention to prepare the child for a dental visit .
live models such as peers , siblings or parents are used for pre- appointment teaching of the expected behavior to the child patient .
several studies have evaluated the efficiency of the modeling through a film in the reduction of child 's dental anxiety .
it has been shown that filmed modeling can be effective as well as live modeling and also desensitization methods .
contrary to other social learning - based methods , filmed modeling does not take time by the dentist and dental team ; although it has not achieved its proper situation .
the aim of this study was to evaluate the effectiveness of filmed modeling in comparison with common and effective tell - show - do technique in a group of iranian children and to introduce an alternative time saving method to practitioners .
this randomized clinical trial study was approved by ethics committee of zahedan university of medical sciences and conducted in pediatric clinic of zahedan dental school in 2010 . among the patients referred to the clinic ,
46 children aged 4 - 6 years ( 2 months ) were enrolled in the study according to the inclusion criteria [ figure 1 ] .
they had caries lesion in one of the primary mandibular molars and needed a pulpotomy with restoration treatment .
the children with systemic diseases and developmental disorders were excluded from the study . the examination was completed and the necessary radiographs were prescribed .
flowchart of patient 's selection and randomization in two study groups ( tell - show- do and filmed modeling groups ) each child 's parent was asked to complete the informed consent and a questionnaire gathering demographic characteristics of the child and family .
then , the child was enrolled in one of the study groups based on balanced block randomization as follows : group i ( tell - show - do group ) ( control ) : children came in the operation room .
tell - show - do , prophylaxis with paste and rubber cap and fluoride therapy was performed by the dentist for each participant to increase their familiarity with dental procedures .
at the end of the first visit , the child was rewarded and the date of the second treatment visit was set for one week later . a child in the first group was excluded from the study because of his definitely negative behavior ( score i in frankl index ) . in the second session , the child entered the operating room alone . a video - camera located on the top of the dental unit light pole under a covering cloth
was focused on the child 's head and hands and started to record child 's behavior .
the required injection including the use of topical anesthesia and a mandibular alveolar nerve block technique was performed by the dentist .
the heart beat rate of each child was recorded manually before and following the injection by the dentist .
in all children , parameters such as the attending dentist , his assistant , the working environment , time and duration ( 30 minutes for each child ) of work , and the type of dialogues were all the same .
care was taken to make sure that the children were not tired , hungry , or did not have a common cold .
group ii ( filmed modeling group ) : the children were directed to a quiet and comfort room to watch a film presented by a dental assistant .
the film showed the same procedure consisting of tell - show - do , prophylaxis with paste and rubber cap and fluoride therapy on a 5-year - old child model with a time of 20 minutes .
the child in the film was cooperative and was reinforced by a reward at the end of the procedure .
dental procedures , measurement of the heart rate and recording of the behaviors were all performed as in group i. the recorded videotapes of all children were independently evaluated by 2 pediatric dentists who were blind to the grouping of the children .
children 's anxiety reactions and cooperative behaviors were scored based on venham scale and frankle index , respectively [ tables 1 and 2 ] .
the viewers were asked to rate the child 's responses in two stages : at the injection of local anesthesia and at the beginning of the tooth preparation .
venham 6-point index used to quantify the anxious behavior of 4 - 6-year - old children in the tell - show - do and filmed modeling groups frankle 4-point index used to quantify the cooperative behavior of 4 - 6 year old children in the tell - show - do and filmed modeling groups mean of heart rate measurements and behavioral ratings were used for statistical analyses .
data analysis was performed applying t - test method in software package of statistical analysis ( spss-15 , spss inc . ,
data analysis was performed applying t - test method in software package of statistical analysis ( spss-15 , spss inc . ,
a total number of 46 children , 22 boys and 24 girls , participated in the study and allocated between tell - show - do ( n = 23 ) and filmed modeling ( n = 23 ) groups . at the first visit , a child in group i showed definite negative behavior of score level i based on frankle index and was excluded from the study .
data revealed that both groups were the same in demographic characteristics including their sex , mean age , parental education and age , parental dental experiences , number of children in the family , and participation in kindergarten .
table 3 shows the mean and standard deviation ( sd ) for the heart beat rate , anxiety level , and cooperative behavior of children during treatment in two groups .
accordingly , heart rate mean scores ( before and after local anesthesia injection ) showed no significant differences between two groups ( p = 0.6 ) .
moreover , there were no statistically significant differences for the anxious and cooperative behavioral mean scores between two groups ( p > 0.05 ) .
comparison of heart rate measures , anxiety and cooperation level of 4 - 6-year - old children between tell - show - do and filmed modeling groups
based on piaget 's classification , children aged 4 - 6 years are in the pre - operational phase .
the increment in vocabulary , attention , and concentration abilities in this period are signs of their readiness for social communications such as a dental visit .
tell - show - do technique is the backbone of the child 's education and behavior guidance and is commonly used in the first appointment .
several epidemiological inquiries have revealed its positive effect on the reduction of dental anxiety ; but , performance of tell - show - do needs the time constraints of both the dentist and the parents .
this study was designed to evaluate the efficiency of the videotaped model to familiarize the child patient with the dental visit .
the results of this study showed that filmed modeling is as efficient as tell - show - do technique in the reduction of 4 - 6 years old children anxiety and increase their cooperative behavior during dental treatment .
it has been confirmed that a videotape showing a peer model coping with the similar dental procedures is more effective in reducing disruptive behavior and anxiety in comparison with an unrelated film .
it also prevents more information to be imparted and the child patients were sensitized to the procedures . it was attempted to prepare the film in conditions like that the children in group i experienced .
the operatory room and the dentist in the film were the same as in group i. in the film , model 's mother left the operatory room like the children in group i who experienced parental absence .
the parent 's absence / presence in the dentistry operation room has no impact on the cooperation and anxiety of the preschool children who have had no previous dental presentation .
hence , the mothers were asked to leave the room to prevent the child  parent interactions . at the end of the film
along with the presentation of proper information to the child , reinforcement of the appropriate behavior of the model is an important element of modeling procedure .
it prompts the learning and performance of that behavior in the child to receive the rewards .
studies by machen and johnson , melamed et al . and yahaya and salam have found the effectiveness of filmed modeling in comparison to desensitization in various patients .
fields and pinkham , and rouleau et al . performed the procedure of prophylaxis at the first visit and presented a videotaped model to children at the following visits .
they concluded that the presentation of a model through a film causes the children manifest relatively little negative verbalization and behavior and also request less parental presence .
it seems that the procedure of prophylaxis before the film presentation can have positive effects on the child 's familiarization and dental behaviors . in this study , for the evaluation of the specific effects of the modeling through a film , children in group ii did not experience the prophylaxis procedure before the film presentation .
furthermore , the operator dentist was absent throughout the film presentation and the treatment procedure was performed one week later after watching the film
. when the children visited the dentist at second appointment , they did nt exhibit signs of severe anxiety and negative verbalization or behavior more than the children who were familiarized to the dentist and experienced tell - show - do procedure .
it seems that the information presented in the film was efficient in the familiarization of the child to the dentist and the description about the procedure .
therefore , the children in group ii showed the behavior expected to do in a dental visit . in previous studies ,
the behavior of the child is not enough to detect the child 's anxiety . in evaluating anxiety and cooperation levels of children in this study ,
it has been shown that this index is more in line with the anxiety experienced in dental visits .
for assessing the child 's behavior in the dental visit , the treatment appointment was recorded through a video - camera , and then the child 's behavioral reactions were quantified by an unaware observer ( the blind method ) using two scales .
the scales used in our study were that of frankle scale for cooperative behaviors and venham scale for anxious behaviors .
these are very easy and quick methods with a reliability and validity for statistical analyses . at the first visit ,
a child in group i showed definite negative behavior with a score level i based on frankle index and was excluded from the study .
accordingly , further investigations are suggested to evaluate the effectiveness of filmed modeling on the children with negative behaviors including scores i and ii of frankle index .
filmed modeling is as efficient as tell - show - do technique to control 4 - 6 years old children anxiety and cooperative behavior during dental treatment and may be a proper alternative method for tell - show - do technique in some situations .
manifesting no more negative verbalization / behavior especially during child  mother separation and taking less time in comparison with tell - show - do technique are the advantages of providing a model through films .
 background : the aim of this study was to evaluate the effect of filmed modeling in comparison with commonly used tell - show - do technique ( t.s.d ) on the anxious and cooperative behavior of 4 - 6 years old children during dental practice.materials and methods : forty six children aged 4 - 6 years were enrolled in this study and randomly allocated into two groups . 
 group i : at the first visit , the procedure of tell - show - do , and at the second visit , the treatment procedures were performed by the dentist for the children . 
 group ii : at the first visit , children watched a film consisting of the procedure of tell - show - do performed on a child model . at the second visit , treatment procedures were performed . in both groups , during the treatment procedure , index of heart rate was measured and behaviors of children were recorded . 
 the children 's anxious and cooperative behaviors on the recordings were quantified according to venham and frankl rating scales , respectively . 
 the data were compared between two groups using t - test method . 
 all statistical references were made at 0.05.results:there were no statistically significant differences in heart rate measures , clinical anxiety and cooperative behavior scores of children between the two groups ( p = 0.6).conclusion : filmed modeling can be an efficient alternative method to tell - show - do technique in pre - appointment preparation of the 4 - 6 years old children during dental treatment . 
INTRODUCTION
MATERIALS AND METHODS
Statistical analysis
RESULTS
DISCUSSION
CONCLUSION