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 Table of Contents  
Year : 2021  |  Volume : 6  |  Issue : 1  |  Page : 20-24

Evaluation of pain in children using animated emoji scale: A novel self-reporting pain assessment tool

Department of Pedodontics and Preventive Dentistry, University College of Medical Sciences, Guru Teg Bahadur Hospital (University of Delhi), Delhi, India

Date of Submission07-Oct-2020
Date of Acceptance21-Dec-2021
Date of Web Publication11-Jan-2022

Correspondence Address:
Amit Khatri
Department of Pedodontics and Preventive Dentistry, University College of Medical Sciences, Guru Teg Bahadur Hospital (University of Delhi), Delhi - 110 095
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijpr.ijpr_39_20

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Background: Pain perception of children in dental clinics is difficult to assess. Conventionally, visual analog scale (VAS) and Wong–Baker Faces Pain Scale (WBFPS) are used as self-reporting pain assessment tools in children. Novel animated emoji scale (AES) is recently introduced for pain assessment in pediatric patients. The aim of this study was to evaluate the pain using the novel AES in 3–14-year-old children and to compare it with frequently used VAS and WBFPS. Methods: A cross-sectional study recruited 266 patients in the 3–14-year age group with their first dental visit. Participants were divided into three groups on the basis of age: Group I–3–6 years, Group II–7–10 years, and Group III–11–14 years, and the pain was recorded using self-reporting tools, i.e., VAS, WBFPS, and recently introduced AES after the completion of dental procedure. Data were evaluated using the Pearson correlation test and Chi-square test. Results: A strong positive correlation among VAS, WBFPS, and AES in all the groups was observed (P < 0.05). AES was preferred more over VAS and WBFPS in all the groups for pain assessment (P < 0.001). Conclusions: AES as a self-reporting tool can be used frequently to assess the pain in children. AES was preferred over VAS and WBFPS due to its ease of understanding by children.

Keywords: Animated emoji scale, first dental visit, self-reporting tool, visual analog scale

How to cite this article:
Khatri A, Kalra N, Tyagi R, Sharma M, Yangdol P, Garg N. Evaluation of pain in children using animated emoji scale: A novel self-reporting pain assessment tool. Int J Pedod Rehabil 2021;6:20-4

How to cite this URL:
Khatri A, Kalra N, Tyagi R, Sharma M, Yangdol P, Garg N. Evaluation of pain in children using animated emoji scale: A novel self-reporting pain assessment tool. Int J Pedod Rehabil [serial online] 2021 [cited 2023 Dec 10];6:20-4. Available from: https://www.ijpedor.org/text.asp?2021/6/1/20/335496

  Introduction Top

Appropriate pain and anxiety control are important considerations in pediatric dentistry. Studies have demonstrated that clinicians often underestimate the child's pain. What may children describe as painful may seem merely unpleasant to the dental practitioner.[1] Pain remains the most common complaint presented to dentists, and it becomes the most crucial factor, with its intensity being one of the main factors which influence a person's sense of well-being.[2] The International Association for the Study of Pain has defined pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.”[3] Wong et al. stated that the pain sensation is not necessarily dependent on tissue damage. Since adults can elaborate the severity and nature of pain, it becomes much more challenging in children. Perceptions of pain in children are difficult to interpret, as they cannot adequately verbalize the pain and vary with his/her cognitive, emotional, and social experience.[4] In dentistry, it is initiated by conditioned stimuli such as the sound of the drill or the use of the needle during local anesthesia. Furthermore, dental fear, anxiety, and dental behavioral management problems have always been major obstacles faced by pediatric dentists toward various treatments.[5] Therefore, the etiology of fear and anxiety is mostly been due to painful dental treatments. Moreover, fear and anxiety can also increase the amount of perceived pain.[6]

Pain assessment in children in the dental clinic can be done by observer rating on pain assessment scale or by the child itself using self-reporting tool. Pain assessment through various pain rating scales helps us to accurately assess the extent of pain and enables us to understand the appropriate measures required for the management of pain.[7] Till date, there are various methods of assessing dental pain in young children. It should be clinically easy to use, appealing, with limited cognitive and linguistic skills to children.[8] Hence, in the present study, we used a newly developed novel animated emoji scale (AES) to assess the pain in the age group of 3–14 years and compared it with conventional pain scales, i.e., visual analog scale (VAS) and Wong–Baker Faces Pain Scale (WBFPS).

Aim and objective

The aim of this study was to evaluate the pain using the novel AES in 3–14-year-old children and to compare it with more frequently used VAS and WBFPS.

  Methods Top

Estimation of the sample size was done using the G*Power software (version; Heinrich-Heine-University, Dusseldorf, Germany); http://www.gpower.hhu.de/). Based on the previous research,[9] considering the VAS and WBFPS analysis of variance with P = 0.005 for each scale among the age groups, with power of the study at 80%, and margin of error at 5%, the minimum sample size was estimated to be 184.

A cross-sectional study was carried out in 266 children aged between 3 and 14 years who attended the Department of Pedodontics and Preventive Dentistry, UCMS and GTB Hospital, Dilshad Garden, Delhi, India.

The sample selection was done randomly and divided into three groups on the basis of age: Group I–3–6 years, Group II–7–10 years, and Group III–11–14 years.

The inclusion criteria were all healthy children of age group of 3–14 years, patients requiring procedures with any forms of local anesthesia such as extraction, or any endodontic therapy such as pulpotomy, pulpectomy, and root canal treatment, and only those who had first dental visit. The exclusion criteria were physically disabled children, medically compromised children, patients who did not give the assent, and parents who did not give informed consent. Informed consent was obtained from parents before enrolment of their children in this study and confidentiality of recorded data was maintained.

Each child's dental pain was measured using three different scales: VAS, WBFPS, and AES after the completion of the procedure. The order of presentation of the scales to each child was kept sequentially from VAS to WBFPS to AES; all the scales were presented to each patient by a single investigator, and the pain scores were immediately recorded to ensure reliability and avoid bias.

A VAS is a self-reporting instrument that measures a characteristic or attitude. It is believed to range across a continuum of values and cannot easily be directly measured. It is a simple assessment tool consisting of a 10-cm line with 0 on one end, representing no pain, and 10 on the other, representing the worst pain. It is determined by measuring in millimeters from the left-hand end of the line to the point that the patient marks. Children were asked to make a mark on the line that represented their level of perceived pain intensity, and the score was recorded after the treatment [Figure 1].[10]
Figure 1: Visual analog scale.

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The Wong–Baker Faces Pain Rating Scale is a pain scale that was developed by Donna Wong and Connie Baker. There are six faces in WBFPS showing different feelings ranging from “no hurt/hurts, a little bit/hurts, a little more/hurts, even more/hurts, a whole lot to hurts worst (most positive to most negative feelings)”. The children had to choose the face that best described how they felt [Figure 2].[9]
Figure 2: Wong–Baker Faces Pain Scale.

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Now, the novel AES was used to assess the pain intensity. A Japanese telecom company employee, Shigetaka Kurita, developed “picture word” or “image character” called Emoji in 1997. It was taken as a mechanism or tool through which it portrays emotions and context that abolish the language barrier. It depicts six animated emoji faces showing various facial expressions ranging from happy/laughing to unhappy/sad or crying. The child was asked to choose one of these animated emojis on the electronic display/paper that best matched their feelings at that moment [Figure 3].
Figure 3: Novel animated emoji scale.

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Once all the three scales were presented to the child and pain scores were collected, the information of the most preferred scale of the children was also recorded. Data collection was done over a period of 10-month study while patients were sitting on a dental chair after the treatment procedure. The data collected were tabulated and subjected to statistical analyses using SPSS statistical software package, version 20.0. Descriptive analysis of all the explanatory and outcome parameters was performed using frequency and proportions for categorical variables, and using mean and standard deviation for continuous variables. Independent Student's t-test and Kruskal–Wallis test were used to compare the mean age and the mean pain rating scores, respectively, of different rating scales between sexes. Pearson correlation test was used to correlate the pain rating scores between different rating scales. Chi-square test was used to compare the preference/liking of the different pain rating scales between sexes. The level of significance was set at P < 0.05.

  Results Top

The study included 266 participants with 219 males and 47 females who visited the dentist for the first time. Participants were divided into three groups based on age: Group 1 (3–6 years) with 48 children, Group 2 (7–10 years) with 155 children, and Group 3 (11–14 years) with 63 children, respectively. The mean age of the participants in Group 1, 2, and 3 was 5.50 ± 0.65, 8.47 ± 1.13, and 12.46 ± 1.11, respectively. The distribution of participants by age and gender was compared using independent Student's t-test, and there was no statistically significant difference in the mean age between males and females in each group was found [t values and P shown in [Table 1]]. The pain scores were recorded from each scale in all the participants. The mean of pain scores for VAS, WBFPS, and AES in all the groups was compared using Kruskal–Wallis test, and a significant difference was found with P, as shown in [Table 2].
Table 1: Distribution of samples by age and gender using Independent Student's t-test

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Table 2: Comparison of mean pain scores between different groups among the study subjects using Kruskal-Wallis test

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Correlation measurement for animated emoji scale versus visual analog scale, animated emoji scale versus Wong–Baker Faces Pain Scale, and visual analog scale versus Wong–Baker Faces Pain Scale using Pearson correlation test

Correlation between different pain rating scales was measured using Pearson correlation test for AES versus VAS, AES versus WBFPS, and VAS versus WBFPS in Group 1, Group 2, and Group 3 individually. A strong positive correlation was found between AES and VAS (Pearson correlation coefficient in Group 1, 2, and 3 was 0.486, 0.740, and 0.323, respectively). AES was also strongly positively correlated with WBFPS with the Pearson coefficient values of 0.626, 0.800, and 0.558 in Group 1, 2, and 3, respectively. VAS and WBFPS were also showed a strong positive correlation with Pearson coefficient values of 0.721, 0.793, and 0.754 in Group 1, 2, and 3, respectively [Table 3]. Hence, it can be inferred that AES showed the pain measurement similar to the VAS and WBFPS and can be frequently used for measuring the pain in children with the age of 3–14 years.
Table 3: Correlations between different pain rating scales using Pearson correlation test

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Liking/preferences among animated emoji scale, Wong–Baker Faces Pain Scale, and visual analog scale (age and gender wise)

In this study, the distribution of liking/preference was measured by Chi-square test. On comparing the preference among AES, WBFPS, and VAS, AES was most preferred in all the groups. In Group 1, 2, and 3, 95.8%, 92.3%, and 66.7%, respectively, of the participants preferred AES [Figure 4]. The order of liking/preference of different pain rating scales among children in all groups was AES>>WBFPS > VAS. On comparing the distribution of preference among pain scales between the groups using Chi-square test, a statistically significant difference was found (P < 0.0001). On comparing the preference of different pain rating scales between males and females in each group, no statistically significant difference was observed [Table 4]. Hence, it is indicated by these results that the AES is more preferred than VAS and WBFPS for the pain measurement by children in the age group of 3–14 years.
Figure 4: Patients pain scale preference among visual analog scale, Wong–Baker Faces Pain Scale, and animated emoji scale.

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Table 4: Age- and gender-wise comparison of liking/preference for different pain rating scales among study subjects using Chi-square test

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  Discussion Top

Interpretation of sensation such as pain is difficult to convey, especially in children. Appropriate pain management depends on the ability to precisely evaluate the level of pain using a valid tool. Self-reporting is known to be the main method of evaluation when pain is predominantly an emotional experience, and often children aged 3–4 years and older can give accurate assessments of pain severity using proper pain assessment tools since patient self-reporting is recognized as a gold standard for pain measurement and these methods should be easy and straightforward to use.[11] Right interpretation of the children's pain and its management helps to develop a positive relationship with the pediatric dentist.[12] Conventionally, VAS and WBFPS are being frequently used to assess the pain in children as a self-report tool.[10] A novel pain assessment tool AES was used in our study to assess pain in 266 children, and we compared it with frequently used VAS and WBFPS, and it was found that AES showed a strong correlation with both of these conventional self-reporting pain assessment tools and is almost equally effective in the children of the age group of 3–14 years. Furthermore, a significant relationship was found among all the scales used. These findings were consistent with most studies that consider these measures to be accurate and suitable for use in clinical practice.[10],[11],[12],[13] They further agree with Hjermstad et al., who observed in a systematic review that most of the articles analyzed were generally consistent on the association between scales.[14]

In response to unpleasant stimuli, cognitive development begins early in childhood, which can also be inferred by our study where there is a decrease in the mean pain score by children with increasing age.[15] The mean pain score for WBFPS and AES in our study was found similar to the mean pain score of (Facial Image Scale [FIS]) and (novel Animated Visual Facial Pain/Anxiety Rating Scale), respectively, after the extraction procedure, in the study by Prasad et al.[15] When age increases, the threshold for pain drops and the self-management of pain increases.[10] The decreasing trend of mean pain score with increasing age was found in our study which was similar to findings of Khatri et al., which supported the result of our study.[9] In our study, the mean pain score for AES was found almost twice as compared to that of a similar pain rating scale used, i.e., Chhota Bheem–Chutki Scale in the study by Prasad et al.[15] where it was recorded after extraction.

The choice or preference of the scale depends on the individual interest of the patients, and also on the potential of the patients to explain the feeling of pain they are undergoing.[16] In this study, majority of children in each group preferred the AES with a significant relationship with the age. 95.8% in Group 1, 92.3% in Group 2, and 66.7% in Group 3 preferred the AES with the highest preference percentage in the lower age group, i.e., 3–6 years. In the VAS scale, there was more difficulty in the understanding by the children and it took more time to explain it to them, which was comparatively less for the WBFPS and there was no difficulty observed in recording the AES by the children at all. Potential explanations for these preference results may be the widespread use of emojis in digital gadgets these days and cognitive development of children. Hence, it may be assumed that due to more familiarity of the children with emojis themselves, they have chosen AES over others. In the study conducted by Setty et al, when these scales were used to assess anxiety in the children of age group 4-14 years, the majority preferred AES over VPT and FIS, supporting the result of our study.[8]

Nonetheless, additional studies incorporating larger samples are indispensable in justifying the finding of this study. The result of this study suggested that children were able to express their pain experience more easily through AES. Thus, it is suggested that AES should be used as a pain assessment tool because AES was proven valid in assessing pain.

  Conclusions Top

AES showed a strong positive correlation with both conventional self-reporting pain assessment tools and is almost equally effective for measuring pain in the children of 3–14-year age group. AES was preferred significantly more in all the age groups, with maximum preference in the youngest age group as it was found to be easier to understand.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Murtomaa H, Milgrom P, Weinstein P, Vuopio T. Dentists' perceptions and management of pain experienced by children during treatment: A survey of groups of dentists in the USA and Finland. Int J Paediatr Dent 1996;6:25-30.  Back to cited text no. 1
Lim KH, Salahudin MS, Hariri F. Evaluating full cup study, numeric pain rating scale, and visual analogueue scale in assessing pain after surgical removal of lower third molar. Ann Dent Univ Malaya 2017;24:16-23.  Back to cited text no. 2
Merskey H, Albe Fessard D, Bonica JJ, Carmon A, Dubner R, Kerr FW, et al. Pain terms: A list with definitions and notes on usage. Recommended by the IASP subcommittee on taxonomy. Pain 1979;6:249-52.  Back to cited text no. 3
Wong C, Lau E, Palozzi L, Campbell F. Pain management in children: Part 1 – Pain assessment tools and a brief review of nonpharmacological and pharmacological treatment options. Can Pharm J (Ott) 2012;145:222-5.  Back to cited text no. 4
Townend E, Dimigen G, Fung D. A clinical study of child dental anxiety. Behav Res Ther 2000;38:31-46.  Back to cited text no. 5
Welbury R, Duggal MS, Hosey MT. Paediatric Dentistry. 5th ed. Oxford: OUP; 2012.  Back to cited text no. 6
Tsze DS, von Baeyer CL, Bulloch B, Dayan PS. Validation of self-report pain scales in children. Pediatrics 2013;132:e971-9.  Back to cited text no. 7
Setty JV, Srinivasan I, Radhakrishna S, Melwani AM, Dr MK. Use of an animated emoji scale as a novel tool for anxiety assessment in children. J Dent Anesth Pain Med 2019;19:227-33.  Back to cited text no. 8
Khatri A, Kalra N. A comparison of two pain scales in the assessment of dental pain in East Delhi children. ISRN Dent 2012;2012:247351.  Back to cited text no. 9
Chapman HR, Kirby-Turner N. Visual/verbal analogue scales: Examples of brief assessment methods to aid management of child and adult patients in clinical practice. Br Dent J 2002;193:447-50.  Back to cited text no. 10
Hendawy FA, Mahmoud S. Factors affecting self-reported pain in children receiving dental treatment. Eur J Soc Behav Sci 2017;19:2441-52.  Back to cited text no. 11
Kumar P, Tripathi L. Challenges in pain assessment: Pain intensity scales. Indian J Pain 2014;28:61-70.  Back to cited text no. 12
  [Full text]  
Williamson A, Hoggart B. Pain: A review of three commonly used pain rating scales. J Clin Nurs 2005;14:798-804.  Back to cited text no. 13
Hjermstad MJ, Fayers PM, Haugen DF, Caraceni A, Hanks GW, Loge JH, et al. Studies comparing numerical rating scales, verbal rating scales, and visual analogue scales for assessment of pain intensity in adults: A systematic literature review. J Pain Symptom Manage 2011;41:1073-93.  Back to cited text no. 14
Prasad MG, Nasreen A, Krishna AN, Devi GP. Novel animated visual facial anxiety/pain rating scale – Its reliability and validity in assessing dental pain/anxiety in children. Pediatr Dent J 2020;30:64-71.  Back to cited text no. 15
dos Santos Calderon P, Peixoto RF, Gomes VM, da Mota Corrêa AS, de Alencar EN, Rossetti LM, et al. Concordance among different pain scales in patients with dental pain. J Orofac Pain 2012;26:126-31.  Back to cited text no. 16


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

  [Table 1], [Table 2], [Table 3], [Table 4]

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