Letter to the Editor: Semiotics of scrubs, children’s perceptions of dentist attire and implications for pediatric procedural anxiety

Abstract

In this article, we comment on the article by Kadiveti et al published in the World Journal of Clinical Cases. Interventions carried out by pediatric proceduralists, such as anesthetists, dentists, surgeons and even nurses, are usually high-stakes procedures in anxious pediatric patients, where non-verbal communication has the power to influence both patient cooperation and outcomes. The proceduralists attire, specifically operating theatre scrubs and related personal protective equipment function as nonverbal communication in pediatric procedural settings. Nonverbal elements comprise a significant proportion of emotional signalling in children and thus offer modifiable levers. There is gradual mounting evidence that proceduralist attire be treated as a modifiable signal within a broader communicative framework and can either reinforce or undermine softskill behaviours depending on their congruence with verbal tone, facial expression, and overall mannerisms. When implementing such finding into practice, practical implications need to be taken into account by pediatric proceduralists to ensure an evidence-driven approach that prioritizes measurable outcomes using validated anxiety scales, induction cooperation scores, time to induction, sedative requirements, and parental satisfaction, over preference alone. Ethical and infection control trade-offs need to be addressed, to ensure that any aesthetic adaptations comply with institutional safety standards and are culturally sensitive. Whether attire modifications translate into clinically meaningful benefits can only be determined after conducting large multi-centric studies that aid transition from mapping children’s preferences to drawing up outcome-oriented yet feasible practice changes.

Key Words: Attire; Communication; Nonverbal; Professional-patient relations; Clinical competence; Procedural sedation and analgesia; Non-verbal communication

Core Tip: Scrubs must be considered as tools of non-verbal communication, by proceduralists, particularly when aligned with age-appropriate communication, and a patient-centred approach can help allay pediatric anxiety, build trust, and improve cooperation and procedural outcomes.

TO THE EDITOR

This article aims at interpreting the findings from the dental attire preference study published in the World Journal of Clinical Cases by Kadiveti et al[1] as a lens through which, the conduct of pediatric procedural practice, can be reconsidered. The scope of our letter is translational, in that we wish to examine how choice of attire can impact peri-procedural care beyond dentistry, to include all across anaesthesia, endoscopy, radiology, and minor surgery. We strongly advocate that clinician attire functions as a highly visible cue within the broader non-verbal communication and can thus be leveraged by the healthcare providers to reduce patient anxiety and improve cooperation and eventually, procedural outcomes.

In pediatric healthcare practice, non-verbal communication assumes critical importance. The clinical setting itself, the clinician’s appearance, attire, body posture, gestures, tone of voice, and even the physical arrangement of the consultation room, conveys messages that patients consciously or unconsciously interpret[2]. Elements such as proximity, body movement, professional appearance, and vocal modulation gain heightened significance in face-to-face therapeutic encounters[3,4]. It is these cues that children use, to appraise the threat that unknown healthcare providers pose, and eventually, establish trust.

The dental procedures in particular, are inherently invasive, often requiring close physical proximity and the use of instruments within the patient’s mouth. The presence of masks and protective barriers can obscure facial expressions, potentially limiting emotional cues. Moreover, during procedures, patients are frequently unable to speak, which shifts the communicative balance toward non-verbal signals. In such moments, dentists must attentively observe subtle gestures, facial tension, eye contact, and changes in body posture or breathing patterns to assess discomfort, fear, or misunderstanding[5,6].

Thus, effective dental care relies heavily on the dentist’s ability to decode and respond appropriately to these nonverbal signals. Sensitivity to such cues strengthens rapport, preserves the human dimension of care, and ensures that the therapeutic relationship remains collaborative rather than purely technical. By consciously integrating both verbal and non-verbal communication skills, dentists safeguard the integrity of the doctor–patient relationship and enhance the overall quality and humanity of clinical practice[7].

Despite certain methodological limitations, the study by Kavideti et al[1] presents important evidence that contributes to the inconsistent literature currently available. They explore the impact of age, gender and previous experience on the children’s preferences regarding the dentists’ attire. A previously published systematic review and meta-analysis by Oliveira et al[8] analyzed 20 studies, which included 3706 children as participants, and concluded that child-friendly attire was not the most preferred choice. Some individual studies included in the systematic review and meta-analysis seemed to suggest that younger children might prefer child-friendly, coloured clothes but the available data to support such claims was scanty, hence, this sub-group analysis could not be carried out.

One of the most important considerations that limit the broad applicability of the findings by Kavideti et al[1] is that it includes only 4 participants in the 7-9 years age group, this markedly underpowered subgroup limits the reliability and interpretability of any subgroup analysis. Although the authors acknowledge it as a limitation, the question that arises is, if a methodologically more prudent approach would have been to exclude them from statistical analysis or combining it with an adjacent age category.

In research involving paediatric healthcare settings, children from diverse linguistic populations form an additional methodological challenge. To get credible data and reproducible findings, use of validated multilingual sets of questions, visual aids such as emojis or Likert scale, capturing parental assistance during answering, is crucial[9]. Thematic analysis of open-ended questions can provide in-depth analysis. In studies involving paediatric population with diverse literacy levels, simple standardized hand-drawn illustrations may enhance comprehensibility with reduced distractions whereas the use of real models or photographs are preferred where accurate perception of clothing details, realism and relatability is desired. The study by Kadiveti et al[1] incorporates these aspects in their methodology thus significantly strengthening the robustness of the study design.

While the importance of patient perception in the choice of attire cannot be diminished, the major considerations for healthcare providers hinge on the ability to prevent microbial contamination and user comfort. The skin of healthcare providers has been recognized as a major source of bacteria in healthcare settings. The pore sizes on standard cotton fabrics are 4-5 times larger than the epithelial fragments that carry the bacteria[10]. Hence, the recommendation from the Association of Peri-operative Registered Nurses (AORN), to prevent scrubs from being a source of infection, is to consider use of scrubs made of materials that are durable, tightly woven, low-linting and stain resistant[11]. Clinician comfort forms an important consideration in attire choice and hence, the AORN also recommends taking into consideration, the drapability, tactile comfort, thermal resistance and resistance to water vapour, while choosing the material to be used for clinical attire[11]. Even when informed, deliberate changes are made to the attire policies in hospital, several practical considerations need to be taken into account, such as gender equity and culture sensitivity, to truly make them implementable and sustainable.

Further explorations in the patient preferences should consider use of objective outcome measures such as validated anxiety scores like modified Yale Preoperative Anxiety Scale, induction cooperation scores, time to induction, need for premedication or sedation, parental satisfaction, and procedure completion rates, rather than patient interviews for preferences alone[12].

Clinicians across specialities must consider collaborations to design randomized trials with mixed method assessments in the form a combination of surveys, behavioural observation and stepped wedge-implementation. Stratifying the patients for age, inclusion of multiple centres and patients and their parents, belonging to varied ethnicities will unquestionably strengthen the investigative approach. However, the most crucial aspect to be considered, is understanding if attire modification to suit patient preferences has any clinically meaningful impact on patient outcomes. Until such times as this evidence is directly available, choice of attire must not be overemphasized as the most important tool in non-verbal communication, it must be recognized as complimentary, not substitutive to either technical competence or communication strategies. It must remain an important part of the broader communication eco-system, but no more.