Pro-Activeness of Parents in Accepting Behavior Management Techniques: A Cross-Sectional Evaluative Study
Karthik Venkataraghavan1, Jolly Shah2, Manpreet Kaur3, Krishna Trivedi4, Shalin Shah5, Mira Virda6
1 Professor and Head, Department of Pedodontics and Preventive Dentistry, College of Dental Sciences and Research Centre, Ahmedabad, Gujarat, India.
2 Postgraduate Student, Department of Pedodontics and Preventive Dentistry, College of Dental Sciences and Research Centre, Ahmedabad, Gujarat, India.
3 Reader, Department of Pedodontics and Preventive Dentistry, College of Dental Sciences and Research Centre, Ahmedabad, Gujarat, India.
4 Senior Lecturer, Department of Pedodontics and Preventive Dentistry, College of Dental Sciences and Research Centre, Ahmedabad, Gujarat, India.
5 Senior Lecturer, Department of Pedodontics and Preventive Dentistry, College of Dental Sciences and Research Centre, Ahmedabad, Gujarat, India.
6 Senior Lecturer, Department of Pedodontics and Preventive Dentistry, College of Dental Sciences and Research Centre, Ahmedabad, Gujarat, India.
NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR: Dr. Karthik Venkataraghavan, Professor and Head, Department of Pedodontics and Preventive Dentistry, College of Dental Sciences and Research Centre, Ahmedabad-382115, Gujarat, India.
E-mail: veekart@yahoo.co.in
Introduction
The contemporary parents are more active and participate in the decision making during dental treatment.
Aim
To assess the parents’ acceptance towards behavior management techniques commonly used in the pediatric dentistry in different dental situation.
Materials and Methods
Fifty-one parents participated in the study. Children’s dental fear was assessed by the parents before attending power point presentation using Dental Subscale of the Children’s Fear Survey Schedule (CFSS-DS). Parents viewed power point presentation of eight behavior management techniques being used during pediatric dental treatment. The techniques were: 1) Voice control; 2) Tell-Show-Do; 3) Positive reinforcement; 4) Parental presence or absence; 5) HOME; 6) Physical restraint; 7) N2O-O2 sedation; 8) General anesthesia. Parents were asked to arrange various behavior management techniques from most accepted technique to least accepted technique in various dental situations according to their view.
Results
All the parents completed the questionnaire. Most children show increased anxiety related to dental component of CFSS-DS scale particularly during the administration of local anesthetic. In present study most preferred behavior management technique was Tell-Show-Do followed by positive reinforcement and least preferred behavior management technique was general anesthesia followed by physical restraint.
Conclusion
Children’s anxiety level increases during the condition related to dentistry which can be overcome by developing positive approach in children and parents towards dentistry and by utilizing various behaviour management strategies. A generalized low parental tolerance level for firm management techniques was seen in the present study population.
Introduction
The “pedodontic triangle” is equally divided between the child, the parents and the dentist, and there should be a permanent dialogue between all parts of the triangle for better delivery of dental care [1]. Behavior management techniques control and alter the behavior of the child and help to build relationship between child, parent and doctor, at the same time eliminate fear and anxiety provoked by dental visit and ultimately building trust.
To be a successful pediatric dentist, managing uncooperative children is an important part of the practice and it depends on the dentist’s ability to acquire and maintain cooperation. To accomplish treatment successfully, variety of techniques can be used. Tell-Show-Do (TSD), positive reinforcement, modeling, voice control, physical restraint, N2O-O2 sedation and general anesthesia are some of the techniques used in practice to manage the behavior of the child patient.
One of the core concepts of child dental care is to provide prior information of behavior management techniques to the parents. This information help parents to participate in treatment decisions with the understanding of factors related to their child’s proposed dental care. This helps in reducing situational parental anxiety. Thus, awareness of factors that influence parental perception is necessary [2].
Child’s needs at the time of treatment and the type and urgency of treatment determine the acceptability of a behavior management technique by parents. There has been a nationwide trend in the law toward expansion of patient’s right and the growing demand for informed consent from the parents, dentists can no longer assume that parents will approve any form of behavior management technique without prior informed consent.
The aim of the present study was to assess the parents’ attitude toward behavior management techniques commonly used in the pediatric dentistry in different dental situations.
Materials and Methods
The present study was designed as a cross-sectional study to evaluate the parental participation in accepting behavior management technique for their child’s oral care. Permission to carry out study was obtained from the Smartkidz School, Ahmedabad and Kidz Kingdom School, Ahmedabad, Gujarat, India. Informed consent was obtained from the parents after outlining the goal of the study.
Total 51 parents (age 20 to 40 years) who accompanied their children (age 2 to 4 years) to the Smartkidz School and Kidz Kingdom School were invited to participate in the study. A Power Point presentation and questionnaire were used to examine parents’ attitudes toward certain behavior management techniques. Attitude toward the following behavior management techniques were examined. 1) Voice control, 2) Tell-Show-Do, 3) Positive reinforcement, 4) Parental presence or absence, 5) HOME, 6) Physical restraint, 7) N2O-O2 sedation, 8) General anesthesia.
Each of the behavior management techniques used in this study has been approved by the American Academy of Pediatric Dentistry (AAPD). According to the AAPD guidelines of behavior management techniques, techniques were divided into two broad categories: (1) Basic behavior management and (2) Advanced behavior management [3].
Children’s dental fear was assessed by the parents before attending power point presentation using CFSS-DS - a fear scale for young children, designed by Scherer and Nakamura later revised to include specific dental fear items as one of its subscales by Cuthbert and Melamed [4]. CFSS-DS scale in present study contained total 14 questions. The response format ranged from one (not afraid at all) to five (very afraid), gave a score range from 14 to 70. The parents were asked to complete the CFSS-DS scale first.
Various behavior management techniques were explained to parents through power point presentation in a group. Parents were given a questionnaire form. Questionnaire included various dental situations like intra-oral examination, taking X-ray, fluoride application, restoration of carious tooth, administration of local anesthesia and emergency extraction. Parents were asked to arrange various behavior management techniques from most accepted technique to least accepted technique in various dental situations according to their view. Questionnaire also included giving preferences for behavior management technique that is most acceptable as well as least acceptable to parents in any kind of dental situation.
All statistical analyses were done with the SPSS (Statistical Package for the Social Sciences) software program 15.0. Difference between the response related to general condition and dental condition was evaluated using Mann Whitney test.
Results
All of the parents who were invited to participate agreed to complete the questionnaires (100% compliance). Among 51 children, 30 children (N = 58.8%) ranged in the age from 2 – 3 years and 21 children (N = 41.2%) ranged in the age from 3 – 4 years. Among 51 parents, 33 (N = 64.7%) parents ranged in the age from 20 to 30 years and 18 (N = 35.3%) parents ranged in the age from 30 to 40 years.
Children’s anxiety levels were assessed using CFSS-DS scale. Component of CFSS-DS scale was categorized in general situation and situation related to dentistry. Most children showed increased anxiety related to dental component of CFSS-DS scale particularly during the administration of local anesthetic [Table/Fig-1]. Difference in anxiety level between general component and dental component of CFSS-DS scale was statistically significant [Table/Fig-2].
Frequency distribution of anxiety level of study population.
| Anxiety level | Frequency N (%) |
|---|
| Dentist | Doctor | Injection | Somebodyexamine | Openmouth | Strangertouch | Look at you | drill | Sight of drill | Noise of drill | Instrument in mouth | Go to Hospital | White uniform | Dr clean your teeth |
|---|
| Relaxed | 13 (25.5) | 19 (37.3) | 15 (29.4) | 10 (19.6) | 20 (39.2) | 27 (52.9) | 34 (66.7) | 2 (3.9) | 2 (3.9) | 6 (11.8) | 7 (13.7) | 2 (3.9) | 21 (41.2) | 2 (3.9) |
| A little uneasy | 23 (45.1) | 18 (35.3) | 0 | 15 (29.4) | 16 (31.4) | 14 (27.5) | 4 (7.8) | 6 (11.8) | 0 | 6 (11.8) | 10 (19.6) | 34 (66.7) | 19 (37.3) | 6 (11.8) |
| Tense | 9 (17.6) | 8 (15.7) | 0 | 18 (35.3) | 8 (15.7) | 2 (3.9) | 7 (13.7) | 32 (62.7) | 21 (41.2) | 14 (27.5) | 15 (29.4) | 12 (23.5) | 8 (15.7) | 13 (25.5) |
| Anxious | 6 (11.8) | 6 (11.8) | 14 (27.5) | 0 | 7 (13.7) | 7 (13.7) | 5 (9.8) | 7 (13.7) | 25 (5.0) | 20 (39.2) | 11 (21.6) | 3 (5.9) | 3 (5.9) | 19 (37.3) |
| Very anxious | 0 | 0 | 22 (43.1) | 8 (15.7) | 0 | 1 (2) | 1 (2) | 4 (7.8) | 3 (6.9) | 5 (9.8) | 8 (15.7) | 00 | 0 | 11 (21.6) |
| Total | 51 (100) | 51 (100) | 51 (100) | 51 (100) | 51 (100) | 51 (100) | 51 (100) | 51 (100) | 51 (100) | 51 (100) | 51 (100) | 51 (100) | 51 (100) | 51 (100) |
Difference between components of CFSS-DS scale.
| Mean | Mean rank | SD | p-value |
|---|
| Dental condition | 4.37 | 60.07 | 0.720 | 0.002* |
| General condition | 3.84 | 42.93 | 0.903 |
- Mann Whitney test used as the test of significance
In different dental situation parents ranked the behavior management technique for their children. In present study population most preferred behavior management technique was Tell-Show-Do followed by positive reinforcement and least preferred behavior management technique was general anesthesia followed by physical restraint [Table/Fig-3].
Question wise distribution of behavior management (BM) among study subjects.
| Questions | Behaviour Management (BM) |
|---|
| Voice Control | Tell – Show -Do | Physical Restraint | Positive Reinforcement | Parental Presence / Absence | HOME | N2O – O2 sedation | GA | Total |
|---|
| Examination (most) | 0 | 39 (76.5) | 0 | 8 (15.7) | 4 (7.8) | 0 | 0 | 0 | 51 (100) |
| Examination (least) | 2 (3.9) | 0 | 0 | 0 | 0 | 4 (7.8) | 0 | 45 (88.2) | 51 (100) |
| X ray (most) | 0 | 37 (72.5) | 2 (3.9) | 8 (15.7) | 4 (7.8) | 0 | 0 | 0 | 51 (100) |
| X ray (least) | 2 (3.9) | 0 | 0 | 2 (3.9) | 0 | 4 (7.8) | 0 | 43 (84.3) | 51 (100) |
| Fluoride (most) | 0 | 41 (80.4) | 0 | 6 (11.8) | 4 (7.8) | 0 | 0 | 0 | 51 (100) |
| Fluoride (least) | 2 (3.9) | 0 | 0 | | 0 | 4 (7.8) | 0 | 45 (88.2) | 51 (100) |
| Caries removal (most) | 2 (3.9) | 43 (84.3) | 0 | 6 (11.8) | 0 | 0 | 0 | 0 | 51 (100) |
| Caries removal (least0) | 0 | 0 | 0 | | 3 (5.9) | 0 | 0 | 48 (94.2) | 51 (100) |
| LA (most) | 0 | 43 (84.3) | 2 (3.9) | 6 (11.8) | 0 | 0 | 0 | 0 | 51 (100) |
| LA (least) | 0 | 0 | 0 | | 0 | 6 (11.8) | 0 | 45 (88.2) | 51 (100) |
| Emergency (most) | 0 | 44 (86.3) | 3 (5.9) | 4 (7.8) | 0 | 0 | 0 | 0 | 51 (100) |
| Emergency (least) | 0 | 0 | 4 (7.8) | | 0 | 10 (19.6) | 1 (2) | 36 (70.6) | 51 (100) |
- Most – most preferred technique by the parents
- Least – least preferred technique by the parents
Discussion
In the present study to assess the child’s dental fear, CFSS-DS scale was used. Reliability of scale in Indian subjects was found to be 0.92. Thus the scale was found to be reliable [4]. The high reliability of the scale can be attributed to its focal characteristics and highly specific yet easily understandable questions.
The numbers of factors emerging in the present study were - fear of injection, fear of the dentist’s drill and fear of the dental procedure. A pediatric dentist must firstly try to build a rapport with the patient before starting the treatment and try to instill a positive behavior.
Most parents in present study preferred Tell – Show – Do followed by Positive Reinforcement to be employed on their children. This finding was consistent with the study by Abushal, Adenubl in which most preferred techniques were Tell-Show-Do, Positive Reinforcement and Distraction [5]. Findings were also consistent with the study by Benjamin Peretz et al., they found that most parents preferred an explanation as proper approach for treating their children [6].
Most parents in present study did not prefer GA followed by physical restraint and HOME. These findings were consistent with the study by Henry W. Fields in which physical restraint technique was unacceptable by parents but the parents accepted GA in emergency dental situation [7]. This finding was inconsistent with present study.
In the present study parents were explained various behavior management techniques that dentist intend to use. This is why parents showed general acceptability towards various behavior management techniques. This finding is consistent with the finding of the study by Scott M. Lawrence et al., and Carole Havelka [8,9].
In the present study we hypothesize that parents in dental condition which required LA or emergency treatment preferred the firm management techniques to be employed by the dentist but these findings suggest a generalized low parental tolerance level for firm management techniques in our study population. Due to increasing number of working parents and smaller nuclear families parental attitudes had changed and parents showed increased anxieties towards their children [10].
Tell-Show-Do technique was most acceptable and GA was least acceptable by the contemporary parents in the present study. Jonathan J. Eaton et al., showed high level of acceptance of general anesthesia compared to earlier studies may suggest that parental acceptance of this technique is increasing [11]. [Table/Fig-4] summarizes the results of similar studies.
List of published reports of studies regarding acceptance of behavior management techniques by the parents.
| S. No. | Behaviour Management (BM) |
|---|
| Author, Year | Place | Sample Size | Mode of Presentation | Results |
|---|
| 1 | Marilyn Goodwin Murphy et al., 1984 [12] | North Carolina, USA | 67 | Videotaped segment of actual treatment | Most acceptable techniques - Tell-Show-Do, Positive reinforcement Least acceptable techniques – General anesthesia, Papoose board. |
| 2 | Henry W. Fields et al., 1984 [7] | North Carolina, USA | 67 | Videotaped segment of actual treatment | HOME – unacceptable technique regardless of dental treatment needed Papoose board, General anesthesia and sedation – unacceptable except when used for emergency extraction Physical restraint by the assistant or dentist – acceptable for gaining co-operation of child for injection Positive reinforcement and Tell-Show-Do – consistently acceptable except for dental injection or emergency extraction. |
| 3 | Scott M. Lawrence et al., 1991 [8] | Columbus children’s hospital | 80 | Videotaped presentation Group 1: provide prior explanation for each technique Group 2: did not provide prior explanation for any technique videotape with description of and rationale for the | Parents in the experimental group who viewed the behavior management techniques rated each of the management techniques as more acceptable than the parents in the control group who received no explanation of the techniques. |
| 4 | Carole Havelka et al., 1992 [9] | Private offices of two pediatric dentists in Columbus, Ohio, the dental clinic at the Columbus Children’s Hospital | 122 According to social status divided in 2 groups High and Low | Videotaped presentation Group 1: provide prior explanation for each technique Group 2: did not provide prior explanation for any technique | Prior explanation to high group – increase acceptability of HOM and GA Prior explanation to low group – increase acceptability to HOM Least acceptable techniques – HOM, GA, Papoose board, Oral premedication. |
| 5 | Benjamin Peretz et al, 1999 [6] | Hebrew University, Israel | 104 | Verbal explanation | Relaxation with explanation is the most acceptable method followed by explanation and then sedation if the child did not cooperate. |
| 6 | Manal Sharaf Abushal et al., 2003 [5] | Saudi Arabia | 133 | Videotaped presentation Group 1: provide prior explanation for each technique Group 2: did not provide prior explanation for any technique | Group 1: least acceptable technique were HOM and voice control and most acceptable method were distraction, Tell-Show-Do and positive reinforcement Group 2: least acceptable technique was HOM and most acceptable techniques were positive reinforcement and distraction. |
| 7 | Jonathan J. Eaton et al., 2005 [11] | Columbus Children’s Hospital | 55 | Videotaped presentation | Most acceptable technique – Tell-Show-Do followed by nitrous oxide oxygen sedation Least acceptable techniques – HOM followed by passive restraint. |
| 8 | Mahmoud Alammouri, 2006 [13] | Jordan University of Science and Technology | 138 | Videotaped presentation | Most acceptable techniques – Tell-Show-Do, positive reinforcement and distraction Least acceptable techniques – HOM, conscious sedation, GA. |
| 9 | J. Luis de Leon et al., 2010 [14] | Spain | 50 | Videotaped presentation | Most acceptable technique – Tel-Show-Do Least acceptable technique – HOM. |
| 10 | Saleh Muhammad et al., 2011 [15] | Kuwait | 118 | Videotaped presentation | Positive reinforcement, effective communication, Tell-Show-Do, distraction, modeling and nonverbal communication were considered as the most approved techniques. Voice control, nitrous oxide sedation, protective stabilization (physical restraint), general anesthesia, hand-over-mouth technique and conscious sedation were the least approved techniques. |
| 11 | Elango I et al., 2012 [2] | Bagalkot, Hubli, Karnataka, India | 204 Group A: healthy children Group B: special children | Videotaped presentation | Group B parents were less accepting to techniques than group A parents Most acceptable technique Group A: contingent escape Group B: live modeling Least acceptable techniques – HOM and voice control in both group |
| 12 | Peretz B et al., 2013 [1] | Tel Aviv | 90 | Written brochure | Most acceptable techniques – positive reinforcement followed by Tell-Show-Do Least acceptable techniques – restraint followed by voice control |
| 13 | Mahdi Jafarzadeh et al., 2015 [16] | Isfahan University, Iran | 54 | Film of management techniques | Most acceptable technique – Tell-Show-Do Least acceptable techniques – HOM and passive restraint |
Limitation
In present study the sample size was small. Survey can be conducted to include large population to understand the parental participation during child’s oral care and acceptance of behavior management technique.
Contemporary parents accepted more positive behavior management technique in the present study. This paper aids in the choice of behavior management techniques to be employed to treat young children in the study population and help to build the trust of the parents and child.
Conclusion
The anxiety level increases during the condition related to dentistry as confirmed by CFSS-DS scale. The increased anxiety can be overcome by developing positive approach towards dentistry and by the various behavior management techniques. Parents preferred more positive approaches and management techniques even in the emergency dental condition. A generalized low parental tolerance level for firm management techniques in the present study population was seen.
- Mann Whitney test used as the test of significance- Most – most preferred technique by the parents- Least – least preferred technique by the parents
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