Projective Indicators of Underlying Dental Anxiety in Children with Positive Frankl Behavior: A Draw-a-Person...

Background: Positive behavior during dental treatment does not necessarily indicate the absence of anxiety in children. Behavioral assessment scales, such as the Frankl Behavior Rating Scale, evaluate observable behavior but may fail to identify underlying emotional tension that may accompany dental treatment. Objectives: To evaluate indicators of underlying emotional tension in children classified as cooperative based on the Frankl Behavior Rating Scale (scores 3 and 4) undergoing conventional caries removal or chemo-mechanical excavation with Brix 3000. Methods: Sixty children aged 4-6 years with positive (score 3) or definitely positive (score 4) Frankl behavior were assigned to two treatment groups: conventional caries removal using rotary instruments (n = 30) and chemo-mechanical excavation with Brix 3000 (n = 30). Projective indicators potentially associated with emotional tension were indirectly assessed using the Draw-a-Person Test. Drawings were obtained at home (baseline), immediately before treatment, and immediately after treatment. Figure height was used as a projective indicator that may reflect emotional tension. Results: A marked reduction in figure height was observed immediately before treatment in both groups, consistent with increased emotional tension despite cooperative behavior. Baseline comparison revealed no statistically significant difference between the treatment groups (p = 0.842). Following treatment, figure height increased significantly in both groups. Children treated with Brix 3000 demonstrated significantly greater post-treatment figure heights than those treated with rotary instruments (p = 0.002), suggesting more favorable projective indicators that may reflect lower emotional tension and improved psychological comfort. Conclusions: Cooperative behavior classified by the Frankl Behavior Rating Scale does not exclude the presence of underlying emotional tension that may be associated with anxiety in children undergoing dental treatment. The findings suggest that chemo-mechanical excavation with Brix 3000 may provide greater psychological comfort and potential reduction in indicators consistent with projective indicators of emotional tension than conventional rotary instrumentation. Behavioral assessment alone may not fully capture emotional responses to fully evaluate the emotional state of pediatric dental patients.