ORIGINAL RESEARCH

A Comparative Study of the CARD™ System and

Tell-show-do Technique in the Behavior Management of
6–10-year-old Children
Asvitha Babu1 , Senthil Eagappan AR2 , Daya Srinivasan3 , Lavanya Mangala Valli4
Received on: 26 July 2024; Accepted on: 09 October 2024; Published on: 14 February 2025

A b s t r ac t
Background: Dental fear and anxiety are common issues affecting pediatric dental care, leading to challenges in treatment delivery and patient
compliance. Nonpharmacological techniques such as the tell-show-do (TSD) method and CARD™ system have emerged as effective strategies
for managing child dental anxiety.
Aim: This study aims to compare the effectiveness of the CARD™ system and TSD technique in managing the behavior of 6–10-year-old children
during dental procedures.
Methods: Forty children requiring invasive dental treatments were randomly assigned to either the TSD technique (group 1, n = 20) or CARD™
system (group 2, n = 20) groups. Physiological parameters (oxygen saturation and pulse rate) and behavioral responses (evaluated using the
Facial Image Scale) were assessed before and after procedures. Data were analyzed using t-tests and Mann–Whitney U tests as appropriate.
Results: No statistically significant differences were found between the techniques regarding physiological parameters or behavioral responses.
Both groups exhibited comparable oxygen saturation levels (CARD™: 98.00 ± 1.02; TSD: 98.00 ± 1.12) and pulse rates (CARD™: 87.45 ± 7.28 bpm;
TSD: 90.30 ± 10.26 bpm) before procedures, with minimal changes observed postprocedure. Similarly, there were no significant differences in
emotional responses assessed by the Facial Image Scale before (CARD™: 1.90 ± 0.85; TSD: 1.80 ± 0.76) or after procedures (CARD™: 2.80 ± 1.60;
TSD: 2.95 ± 1.50).
Conclusion: This study suggests that the CARD™ system and TSD technique are equally effective in managing child dental anxiety. Both methods
offer viable options for reducing anxiety and enhancing cooperation during dental procedures.
Keywords: Behavior management, CARD™ system, Dental anxiety, Pediatric dentistry, Tell-show-do technique.
International Journal of Clinical Pediatric Dentistry (2025): 10.5005/jp-journals-10005-3023

Introduction 1–4
Department of Pedodontics & Preventive Dentistry, Chettinad Dental
Dental fear and anxiety are prevalent psychological issues that College and Research Institute, Kelambakkam, Tamil Nadu, India
significantly impact the provision of dental care, particularly in Corresponding Author: Asvitha Babu, Department of Pedodontics &
pediatric patients.1 These reactions can interfere with daily activities Preventive Dentistry, Chettinad Dental College and Research Institute,
and present considerable challenges in delivering adequate dental Kelambakkam, Tamil Nadu, India, Phone: +91 9843578112, e-mail:
treatments. 2 Several factors contribute to the development of [email protected]
dental fear and anxiety in children, including previous negative How to cite this article: Babu A, Eagappan SAR, Srinivasan D, et al.
experiences, parental anxiety, and the child’s temperament. Fear of A Comparative Study of the CARD™ System and Tell-show-do Technique
the unknown, sight and sound of dental instruments, and potential in the Behavior Management of 6–10-year-old Children. Int J Clin Pediatr
for pain are common triggers. Dental fear can lead to avoidance of Dent 2025;18(1):53–57.
dental care, which exacerbates oral health problems and creates a Source of support: Nil
cycle of increasing anxiety and deteriorating oral health.3 Therefore, Conflict of interest: None
addressing dental fear and anxiety in children is essential for their
overall well-being and successful dental treatment outcomes.4
Various methods have been developed to manage children’s is one of the most widely used techniques in pediatric dentistry.8
behavior during dental visits, with nonpharmacological techniques TSD involves explaining the dental procedures to the child (tell),
gaining popularity due to their safety and effectiveness.5,6 These demonstrating the procedures using models or instruments (show),
methods include parental presence and reassurance, distraction, and then performing the procedure (do). This step-by-step approach
relaxation techniques, systematic desensitization, modeling, and the aims to familiarize children with dental procedures, reduce their fear
use of music or light physical contact. Previous studies have shown through clear communication, and build trust between the dentist
that these nonpharmacological techniques can effectively reduce and child. The effectiveness of the TSD technique has been well
anxiety and improve cooperation in pediatric patients, offering a documented in previous studies,9,10 which have shown that it can
safer and more holistic approach for managing child dental anxiety significantly reduce anxiety and improve cooperative behavior in
compared to pharmacological interventions.7 Among the various children. Its simplicity and efficacy have made it a popular choice
nonpharmacological techniques, the tell-show-do (TSD) technique among pediatric dentists for managing child dental anxiety.

© The Author(s). 2025 Open Access. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons.
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 A Comparative Study of the CARD™ System

The CARD™ system represents a newer approach that Exclusion criteria included children with prior dental treatment
empowers children by involving them in managing their dental experience, history of unpleasant dental visits, acute painful
anxiety. This system educates children on various evidence-based oral conditions, known systemic diseases, recent prolonged
coping strategies, categorized into four letters: Comfort, Ask, Relax, hospitalization, or physical disabilities. Participants who did not
and Distract.11 During dental treatment, children can choose their provide informed consent were also excluded from the study.
preferred coping interventions from these categories, fostering
a sense of control and participation in their care. The limited Intervention Groups
literature on the CARD™ system is available compared to the Group 1: TSD Technique
extensive research on the TSD technique.12 However, preliminary The TSD technique involved explaining the procedure,
studies suggest that involving children in selecting coping demonstrating it, and then performing it to familiarize children
strategies can enhance their sense of agency and reduce anxiety.13 with the process.
The need for this study arises from the lack of comprehensive
research comparing the effectiveness of the CARD™ system to Group 2: CARD™ System
the well-established TSD technique. This study aims to fill this Participants in the CARD™ system group were introduced to
gap by systematically evaluating the anxiety levels, physiological coping strategies categorized under Comfort, Ask, Relax, and
parameters, and behavioral responses of children managed with Distract. For children to understand the CARD™ system, strategies
these two techniques, with the primary objective being to find were prepared in simple English and in regional language from
the effectiveness of the CARD™ system technique in managing which children chose one from each segment (Fig. 1). They
the behavior of 6–10-year-old children during dental procedures. selected strategies they preferred, which were then employed
Specifically, the study aims to determine which method is more during their treatment.
effective in reducing anxiety and enhancing cooperation among
pediatric patients. The null hypothesis is that there is no significant Randomization and Allocation
difference in the effectiveness of the CARD™ system and TSD For randomization, a stratified approach was adopted to ensure an
technique in managing child dental anxiety. By systematically equitable distribution of participants across intervention groups.
assessing anxiety levels and physiological and behavioral Allocation concealment was maintained using an open list of
parameters before and after the procedures, this study will provide random numbers. Both participants and outcome assessors were
a comprehensive comparison of the two techniques. blinded to group assignments to minimize bias.

Outcome Measurements
M at e r ia l s and Methods Primary Outcome
Study Design and Sample Size Estimation The primary outcome measured the effectiveness of both
This cross-sectional prevalence study aims to compare the behavior management techniques in reducing pain and
effectiveness of the CARD™ system and TSD technique in managing anxiety levels among children undergoing dental procedures.
the behavior of 6–10-year-old children during dental procedures. Physiological parameters such as pulse rate (PR) [beats per
Conducted at the Department of Pedodontics & Preventive minute (bpm)] and oxygen saturation (SpO2) were recorded
Dentistry, the study received approval from the Institutional using a pulse oximeter. Behavioral responses were evaluated
Review Board and ethical clearance from the Institutional Human using the Facial Image Scale (FIS) (comprising five faces ranging
Ethics Committee (IHEC) and the sub-board (approval number: from very happy to very unhappy) by an observer not involved in
IHEC-CDCRI/2024/STU-0012). This detailed methodology adhered the treatment process. Children indicated their feelings before
to the CONSORT guidelines for reporting clinical trials, ensuring and after the procedure, with scores from 1 (most positive) to
transparency and reproducibility. All procedures followed the 5 (most negative).
ethical standards outlined in the Declaration of Helsinki (1964)
and its subsequent amendments. Sample size estimation using Randomization and Allocation
G*Power software (version 3.1.9.2) with a priori power analysis For randomization, a stratified approach was adopted to ensure an
for t-tests of independent means yielded a total sample size of 40 equitable distribution of participants across intervention groups.
(20 participants per group), with parameters set at α error of 0.05, Allocation concealment was maintained using an open list of
β error of 0.02, power of the test at 98%, and effect size (Cohen’s random numbers. Both participants and outcome assessors were
d statistic) of 1.3463 (determined from Raseena et al., 2020).14 blinded to group assignments to minimize bias.

Participants Statistical Analysis

Children aged 6–10 years were recruited from the Department of Data about SpO2, PR (bpm), and FIS in the CARD™ system and TSD
Pedodontics & Preventive Dentistry for procedures requiring local groups were entered into Microsoft Excel and analyzed using IBM
anesthesia. Participants were selected based on specific inclusion SPSS Statistics for Windows, version 29.0 (IBM Corp., Armonk, NY,
and exclusion criteria to ensure group homogeneity. Inclusion USA). The normality of the data for SpO2 and PR was assessed
criteria encompassed should be children who are visiting dental using the Kolmogorov–Smirnov test, indicating that both variables
setup for the first time, physically and mentally healthy children followed a normal distribution. Descriptive statistics, including
demonstrating positive behavior according to Wright’s modification mean, standard deviation, frequencies, and percentages, was
of Frankl’s Behavior Rating Scale, necessitating an inferior alveolar calculated. Intergroup comparisons of SpO2 and PR were conducted
nerve block for dental procedures such as extractions, pulpotomies, using independent t-tests, while the Mann–Whitney U test was
or restorations. Informed consent was obtained from children to utilized to analyze differences in the FIS scores between groups.
their parents or guardians for participation. Statistical significance was set at p < 0.05.

54 International Journal of Clinical Pediatric Dentistry, Volume 18 Issue 1 (January 2025)

 A Comparative Study of the CARD™ System

Fig. 1: Intervention groups

Table 1: Intergroup comparison of physiological parameters

95% confidence interval of the
Mean mean difference Independent t-test
Physiological parameters Groups n Mean + SD difference Lower Upper value (p-value)
Oxygen saturation (SpO2)
Before CARD 20 98.00 ± 1.02 0.000 –0.688 0.688 0.00 (1.000) (NS)
TSD 20 98.00 ± 1.12
After CARD 20 98.35 ± 0.74 0.050 –0.399 0.499 0.225 (0.823) (NS)
TSD 20 98.30 ± 0.65
PR (bpm)
Before CARD 20 87.45 ± 7.28 –2.850 –8.548 2.848 –1.012 (0.318) (NS)
TSD 20 90.30 ± 10.26
After CARD 20 87.70 ± 5.96 –2.400 –6.988 2.188 –1.059 (0.296) (NS)
TSD 20 90.10 ± 8.19

R e s u lts 90.30 ± 10.26 bpm; p = 0.318). After the procedure, mean SpO2
Physiological parameters, (including SpO2) and PR, were assessed levels showed a slight increase in both groups (CARD™: 98.35 ± 0.74;
before and after the procedures (Table 1). Before the procedure, TSD: 98.30 ± 0.65), with no significant intergroup difference found
both the CARD™ system and TSD method groups demonstrated (p = 0.823) (Fig. 2). Likewise, there was no significant difference in
comparable mean SpO2 levels (CARD™: 98.00 ± 1.02; TSD: 98.00 ± mean PR after the procedure (CARD™: 87.70 ± 5.96 bpm; TSD: 90.10 ±
1.12) with no statistically significant difference observed (p = 1.000). 8.19 bpm; p = 0.296) (Fig. 3).
Similarly, there was no significant difference in mean PR before the Behavioral responses were evaluated using the FIS, which
procedure between the groups (CARD™: 87.45 ± 7.28 bpm; TSD: assesses the child’s emotional state before and after the procedure

International Journal of Clinical Pediatric Dentistry, Volume 18 Issue 1 (January 2025) 55

 A Comparative Study of the CARD™ System

Table 2: Intergroup comparison of behavioral parameters

Facial Image Scale Groups n Mean + SD Mean rank Sum of rank Mann–Whitney U test value (p-value)
Before CARD 20 1.90 ± 0.85 21.10 422.00 188.000 (0.729) (NS)
TSD 20 1.80 ± 0.76 19.90 398.00
After CARD 20 2.80 ± 1.60 19.93 398.50 188.500 (0.750) (NS)
TSD 20 2.95 ± 1.50 21.08 421.50

Fig. 2: Oxygen saturation between the CARDTM system and TSD Fig. 4: Facial Image Scale between CARDTM system and TSD

suggest that both the CARD™ system and TSD technique are
similarly effective in mitigating anxiety and improving cooperation
among pediatric patients undergoing dental treatment. Therefore,
our study accepts the null hypothesis that there is no discernible
difference in the behavioral management efficacy between the
CARD™ system and TSD technique in this population.
The TSD technique was selected due to its widespread
acceptance and established efficacy in pediatric dental practice.
Previous studies have consistently demonstrated that TSD
effectively reduces anxiety by familiarizing children with
procedures through verbal explanation, demonstration, and then
execution.15 This method is widely recommended for its simplicity
and effectiveness in preparing children for dental treatment,
fostering a positive dental experience, and reducing the likelihood
of disruptive behaviors.
Similarly, the CARD™ system was chosen for its structured
approach to engaging children in their dental care through
Fig. 3: Pulse rate between CARDTM system and TSD educational preparation and active participation in coping
strategies during procedures.16 Previous literature supports the use
(Table 2). Before the procedure, both groups exhibited similar FIS of similar structured approaches in pediatric dentistry, emphasizing
scores (CARD™: 1.90 ± 0.85; TSD: 1.80 ± 0.76), indicating comparable the importance of empowering children to manage their anxiety
emotional states (Mann–Whitney U test, p = 0.729). After the through informed decision-making and coping skills.17 Studies
procedure, FIS scores slightly increased in both groups (CARD™: have shown that such patient-centered approaches can enhance
2.80 ± 1.60; TSD: 2.95 ± 1.50), with no significant difference observed children’s cooperation and reduce dental fear, contributing to better
between the groups (Mann–Whitney U test, p = 0.750) (Fig. 4). treatment outcomes and overall patient satisfaction.16,17
In this study, the selection of physiological parameters such
as SpO2 and PR, along with the FIS, was deliberate in assessing
Discussion the efficacy of both techniques in managing pediatric dental
This study aims to compare the effectiveness of the CARD™ system anxiety. SpO2 and PR are objective measures commonly used to
and TSD technique in managing the behavior of 6–10-year-old gauge physiological stress responses during medical and dental
children during dental procedures. The results indicated no procedures.18-21 By monitoring these parameters, the authors aim
statistically significant differences between the two techniques to quantify the immediate physiological impact of anxiety-reducing
in terms of physiological parameters (SpO2 and PR) or behavioral interventions on children undergoing dental treatments. The
responses (FIS) before and after dental procedures. These findings negligible differences observed in SpO2 and PR between the CARD™

56 International Journal of Clinical Pediatric Dentistry, Volume 18 Issue 1 (January 2025)

 A Comparative Study of the CARD™ System

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The FIS was employed to subjectively evaluate the emotional
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This study contributes to the growing body of evidence supporting technique with and without the aid of a virtual tool in the behavior
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