1. Introduction

Dental clinic attendance is important behavior that should encourage in early child development since it has a clear positive association with dental health. As defined by the World Health Organization (WHO)[1], oral health means being free of chronic mouth and facial pain, oral and throat cancer, oral sores, birth defects such as cleft lip and palate, periodontal diseases, tooth decay and tooth loss, and other diseases and disorders that affect the mouth and oral cavity. However referring to the National Health Epidemiology Study (NOSHH) in 2007, approximately 74.5% Malaysian children age from 6 years old suffered oral problems. Thus, it is still considered as serious phenomena in the promoting dental hygiene as only 25.5% Malaysian children are free from dental problems; far behind WHO estimation which target 50% of children around the world should meet the dental health global standards. Dental anxiety is a major reason for patient avoidance of dental care which positively related to dental clinic attendance[2]. For most dental patients especially teenagers, dental treatment are painful and scary. Previous negative experienced may trigger internal conflicts such as tension, discomfort and distress that could lead to systematic complications. The most significant factors behind the dental fear among teenagers are patient’s beliefs and recalled negative experiences such as anticipatory anxiety and fear association with specific dental stimuli during dental treatment[3]. Listening to relaxing music during root canal treatment decreased the stress level of patients[4].

Based on existing literatures, it can be inferred that music can be considered as a therapeutic intervention in maintaining individual’s positive emotional outcomes. Numerous studies are being conducted on the value of water sounds as a therapy for various psychological treatments[5]. State Trait Anxiety Inventory (STAI) was used to further investigate the volunteer’s emotional condition[6].Research’ team expected that Volunteers will score lower in State Trait Anxiety Inventory (STAI) after listened to the Water Fountain melody and experimental groups will score lower in STAI as compared to the control group after listened to Water Fountain Melodies.

2. Objectives

1. To examine anxiety levels among the volunteers before and after melody intervention.

2. To investigate whether Water Fountain melodies could decrease anxiety levels among the volunteers before undergoing dental checkup.

3. To compare the effects of Water Fountain Melodies between Experimental groups and Control group

3. Methodologies

Volunteers age 12-16 years old were selected fulfill all the inclusions and exclusive criteria.

Inclusion criteria:

a. No previous anxious dental experience

b. Have no dentin sensitivity to air stimulation.

c. No hearing problem

Exclusion criteria:

a. If in a serious debilitating oral disease (acute periodontal pain, pulpits, abscess, or otheracute infections, attachment loss or gingival recession, root hypersensitivity that mightcause tooth hypersensitivity.

b. Patients with severe anxiety and non-cooperative

c. Not interested in music

d. Having medical or psychological disorder that might affect pain thresholds

e. Using pain or anxiety medication

Upon completing the inform consent, researchers had explained briefly about the experimental procedure to the volunteers. Consented volunteers were randomly assigned to Experimental group and Control group. Prior to the study, participants in each group underwent discussion session to make them more serious for the experiment and then asked to complete a self-rated questionnaire on their emotional regulation, State Trait Anxiety Inventory (STAI, bilingual version) (7), with no time restriction before and after the natural water fountain melody intervention for 10 minutes for the experimental group. The subjects in the control group were also used Mp3 for 10 minutes but with no music melody. After that, the volunteers were instructed to proceed to the dental room for checkup session.

4. Results

Table 1. Descriptive statistics about the level of anxiety Sessions Mean Standard Deviations Level anxiety after discussion 41.40000 10.81378 Level anxiety after listening to the water fountain 32.93332 9.417276

Table 1, Shows descriptive statistics of the level of anxiety after discussion sessions and level of anxiety after listening to water fountain melody sessions. It indicated that the mean of the level of anxiety after discussion sessions was higher than the mean of the level of anxiety after listening to the water fountain melody.

● Normality Assumption

In order to make further analysis, the normality assumption should be met because it is very important in analyzing and determine which method of analysis is actually suitable for this data.

Figure 1, shows the normal probability plot Level of Anxiety after Discussion Sessions. All the data were actually lying on the straight line which means that the normality assumption wasmet. So further analysis can be applied to this data.

Figure 1. Normal probability plot Level of Anxiety after Discussion Sessions

Figure 2. Normal probability plot Level of Anxiety after Listening Water Fountain’s Melody Sessions

Also Figure 2, shows the normal probability plot Level of Anxiety after listening Water Fountain’s Melody Sessions. All the data were actually lying on the straight line which means that the normality assumption was met. So further analysis can be applied to this data.

● Dependent Paired Sample T-test

Dependent sample t-test was conducted to evaluate the hypothesis that volunteers will score lower in State Trait Anxiety Inventory (STAI) after listening to the Water fountain melody. The analysis demonstrated that STAI scores decreased from (M=41. 40, SD=10. 84) to (M= 32.93, SD=9. 42) after the subjects listened to the water fountain melody before dental checkup.

Table 2. Dependent Paired Sample T-test

Table 2, demonstrated that there is significant differences level of anxiety after discussion session and level of anxiety after listening to the water fountain melody with mean difference 8.46667 and the P-values 0.00021 where it was less than 0.05. It indicated that the null hypothesis rejected and the level of anxiety was actually reduced after listening to the water fountain melody.

● Descriptive Statistics on Level of Anxiety after Listening to Water Fountain Melody in the experimental group:

Further analysis also supports second hypothesis, which showed that the experimental groups scored lower (M=31. 00, SD=1. 46) in STAI after listening to Water Fountain Melodies than the control group (M=40. 67, SD=5. 60) whom did not receive any melody intervention.

Table 3, Shows descriptive statistics on the level of anxiety after listening to water fountain melody sessions between the experimental group and control group. It indicated that the mean of the level of anxiety after listening to water fountain melody sessions in the experimental group was less than the mean of the level of anxiety in the control group.

Table 3. Descriptive statistics on the level of anxiety after listening to the water fountain melody Sessions Mean Standard Deviations Experimental Group 31.00000 10.81378 Control Group 40.66667 5.59563

● Independent Sample T-test to compare between the two groups:

Table 4, Independent Sample T-test to compare between the experimental group on the Level of Anxiety after Listening to Water Fountain Melody and a control group with no melody. The P-values 0.000213 less than 0.05, It indicated that the null hypothesis rejected and the level of anxiety was actually reduced after listening to the water fountain melody in the experimental group than in the control group with no melody.

Table 4. Independent Sample T-test to compare between the experimental group and control group Independent Sample T-test Mean Difference T-values P-values Conclusion Between Experimental and Comtrol groups -9.66667 -2.432 0.00213 Reject null hypothesis

5. Discussions

State-Trait Anxiety Inventory (STAI) in brief, it clearly differentiates between the temporary condition of state anxiety’ and the more general and long-standing quality of individual trait anxiety’[7]. STAI scores range from 20 to 80, higher scores are positively correlated with greater anxietylevel.Based on a psychophysiological theory synthesized from the literature, certain type of music induces relaxation and pleasure responses, which reduces activity in the neuroendocrine and sympathetic nervous systems; this result in decreasing anxiety, heart rate and respiratory rate.

Intervention of natural water fountain melodies before the dental checkup in the experimental group reduce teenagers worries and anxiety, thereby illustrate lower STAI scores as compared to the control group with no melody. There was a significant difference in anxiety scores. This finding is similar to the results of studies reported that soothing music lowered subjects’ anxiety[8].It can be assured that natural water fountain melodies might help volunteers to elicit the relaxation response by activating nervous systems while reducing heart rate and lowering blood pressure, at the same time recuperating body and mind towards resting mode with similar effects as soothing music[9].The findings provide evidence for nurses and dentists to use the natural water fountain melodies for anxiety reduction with dental patients undergoing a dental checkup procedure which is supported by the researchers.

6. Conclusions

Fear of dental treatment is a major reason for patient avoidance of dental care. The healing aspects of nature sounds therapy including water sound are beginning to get a lot of interest in the medical fields. Analysis of STAI collected data showed thatnatural water fountain music administered through Mp3 to teenagers before dental checkup decreased the procedure-related anxiety of the patients’ signs. Volunteers scored lower in State Trait Anxiety Inventory (STAI) after listening to the Water Fountain melody. Based on the current findings, it could be inferred that natural water fountain melodies are one of useful methods for practical dental settings especially in promoting positive anxiety management among youngster patients. Thus, it is hoped that natural water fountain melodies could possibly serve as preventative medicine to create ‘feels good’ dental clinic attendance among the dental community in the long run term. Also Further researches need to be done in this field using other techniques and newer strategies should be devised to manage anxious pediatric dental patient.