The COVID-19 pandemic introduced significant changes to the dental clinical environment,
particularly due to the widespread use of personal protective equipment (PPE), which may
increase anxiety in pediatric patients. Dental anxiety is a common and multifactorial
condition in children and can negatively affect cooperation, treatment outcomes, and
overall oral health. Therefore, effective and non-invasive strategies to reduce
anticipatory anxiety are essential in pediatric dentistry.

This randomized controlled clinical trial aimed to evaluate the effectiveness of a
structured visual educational intervention in reducing anticipatory dental anxiety and
physiological responses in children aged 5 to 14 years undergoing restorative dental
treatment. The intervention was specifically designed to familiarize children with the
dental environment and the appearance of dental professionals during the COVID-19
pandemic.

Participants were randomly assigned in a 1:1 ratio to either an intervention group or a
control group using a computer-generated randomization sequence. Allocation concealment
was ensured through the use of sequentially numbered, opaque, sealed envelopes. Due to
the nature of the intervention, participant blinding was not feasible. However, outcome
assessment was performed by a trained pediatric dentist who was blinded to group
allocation.

The visual educational intervention consisted of a structured leaflet developed according
to visual pedagogy principles. The material included child-friendly images illustrating
dental professionals with and without PPE, common dental instruments, and the dental
clinical environment. The aim was to provide anticipatory guidance and reduce uncertainty
by presenting information in a simple and age-appropriate format.

Children in the intervention group received the visual educational material in the
waiting area prior to treatment and were given time to review it with their parents. The
control group received standard clinical care without additional preparatory
intervention.

Dental anxiety was assessed using validated self-report measures, including the faces
version of the Modified Child Dental Anxiety Scale (MCDASf) and the Facial Image Scale
(FIS). In addition, physiological response to anxiety was evaluated by measuring pulse
rate using a pulse oximeter. All outcome assessments were performed prior to the
initiation of dental treatment.

To explore potential differences in intervention effectiveness, subgroup analyses were
conducted based on age groups (5-7, 8-10, and 11-14 years) and sex. These groupings were
selected to reflect differences in cognitive development, which may influence how
children process and respond to visual information.

This study provides insight into the potential role of visual educational strategies as a
simple, low-cost, and non-invasive method to reduce anticipatory dental anxiety in
pediatric patients, particularly in the context of altered clinical environments such as
those observed during the COVID-19 pandemic.