|Year : 2018 | Volume
| Issue : 2 | Page : 167-172
Assessment of the effect of parental presence in dental operatory on the behavior of children aged 4–7 years
Shilpa Ahuja, Kapil Gandhi, Ritika Malhotra, Rishabh Kapoor, Shraddha Maywad, Geetika Datta
Department of Pedodontics and Preventive Dentistry, Inderprastha Dental College and Hospital, Ghaziabad, Uttar Pradesh, India
|Date of Web Publication||2-Jul-2018|
Department of Pedodontics and Preventive Dentistry, Inderprastha Dental College and Hospital, Ghaziabad, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Child presents a unique challenge to accept a dental treatment, and such a challenge gets modified by the presence or the absence of a parent in the operatory. Many dentists have reportedly and controversially used parental separation anxiety as a tool to control behavior of an uncooperative child and also to deliver quality dental treatment in young children. But is the parental separation beneficial for dentist to gain child cooperation? Aims and Objectives: The objective is to evaluate the influence of parental presence or absence in the operating room on child's behavior during dental procedure on children of 4 years and above. Materials and Methods: The study was carried out on 30 children of 4–7 years of age group, 16 (4–6 years) preschoolers, and 14 (6–7 years) early schoolers. Two consecutive restorative procedures were carried out. On a first visit, parents were present and on a second visit, separation of parents was done. Behavior rating was done by commonly used Frankel's Behavior Rating Scale. Results: Chi-square test was performed for the statistical analysis. There was no significant difference found in the child's behavior by the presence or absence of parents in the perception of dental treatment in the dental operatory. In contrast to that there was a significant increase in cooperative behavior of some children due to other factors influencing the behavior of the child with a Chi-square value = 35.296, P < 0.001. Conclusion: Parents can be excluded from the dental operatory to eliminate many behavior-related problems during the course of treatment.
Keywords: Anxiety, behavior management, early schoolers, parental separation, preschoolers
|How to cite this article:|
Ahuja S, Gandhi K, Malhotra R, Kapoor R, Maywad S, Datta G. Assessment of the effect of parental presence in dental operatory on the behavior of children aged 4–7 years. J Indian Soc Pedod Prev Dent 2018;36:167-72
|How to cite this URL:|
Ahuja S, Gandhi K, Malhotra R, Kapoor R, Maywad S, Datta G. Assessment of the effect of parental presence in dental operatory on the behavior of children aged 4–7 years. J Indian Soc Pedod Prev Dent [serial online] 2018 [cited 2019 Aug 18];36:167-72. Available from: http://www.jisppd.com/text.asp?2018/36/2/167/235685
| Introduction|| |
Parental factors such as child–parent relationship, parental anxiety, parent's perceptions for child's behavior in the dental operatory, parent's past dental experiences, and parental presence or absence in the operatory during dental treatment have a major role in the behavior of the child in the dental operatory during treatment.
In pediatric dentistry, the long-term success of any treatment provided by a pediatric dentist highly depends on the cooperation level of a child. Being a pedodontist, to gain a level of cooperation by applying various behavior management approaches forms the base of operative dentistry. Among all, one of the important behavior management approaches is parental presence or absence in a dental operatory during dental treatment. In our daily practice, we observe that the majority of the parents do not want to get separated from their children during a dental procedure, and the same is with children too. However, the role of parental presence in the child's behavior in a dental operatory is still controversial. Is it beneficial or their presence acts as mere hindrance in developing child's rapport with the dentist? Whether parent's presence in the dental operatory during treatment helps the dentist to carry out dental treatment and instills positive behavior in the child. A wide diversity exists in practitioner philosophy and parental attitude regarding parents' presence or absence during pediatric dental treatment.
The pediatric dentist must understand the ways by which the parents influence behavior of the child which will aid in the use of proper behavior guidance technique. According to Kamp, separation of the child from the parent eliminated many behavior-related problems and excluding the parent from the dental operatory allows the dentist to develop a rapport with the child without any interference. Starkey , strongly advocated separation of the parent and child. While According to Olsen, one should avoid separation of the child from parents during their initial visits as their presence may help in the prediction of future child's behavior. Most dental practitioners probably are more comfortable when the parents are not in the operatory. At the same time, the parents also want to be present in the dental operatory during their child's treatment and end up trusting the dentist. Such parents are simply uncomfortable if they do not visually verify their child's safety. Pediatric dentists should welcome this added involvement of parents and accustomed to the concerns of parents for their children.
Dentists who don't allow parents in the dental operatory during treatment make exceptions also, for example, dental treatment of a disabled child, in which parents play a major role in support and communication with the child. Another examples are very young children <4 years of age who have not yet achieved cognitive maturity to understand full verbal communication are mostly benefited by the parent's presence. Separation anxiety also plays a major role in very young children.
| Materials and Methods|| |
The study was carried out in the Department of Pedodontics and Preventive Dentistry, Inderprastha Dental College and Hospital, Ghaziabad. The study was conducted on a sample size of 30 children of 4–7 years age group, in which 16 was preschool children of age group 4–6 years and 14 was early school children of 6–7 years age group. The children with no previous dental experience were included in the study, which required at least two simple restorative procedures and who are mentally and physically healthy. The children presenting to the emergency department and children requiring aggressive behavior management were excluded from the study. Two consecutive visits have been made. In both visits, simple restorative procedures were performed. On a first visit, at the start of visit, prediction of the parents about their child's behavior during the treatment in their presence or absence was taken. At the first visit, parents were made to present in the dental operatory during treatment. Restorative procedure was carried out by applying required behavior management technique. Basic behavior guidance technique were used, that is, Tell–Show-Do, voice control, modeling, euphemism, and contingency management. Video recording of the procedure was made while working with the handpiece and behavior rating was done using Frankel's Behavior Rating Scale at the end of the visit by an independent rater. Patient was recalled after 1 week for the next visit. Deliberate separation of parents with the patient was made in the next visit. Restorative procedure was performed. Video recording of the procedure was made while working with the handpiece and again behavior rating was done using Frankel's Behavior Rating Scale at the end of the visit by an independent rater. All restorations were performed by the single operator. An independent rater was trained and calibrated for the rating of patients. Frankel Behavior Rating Scale was used by an independent rater to rate the behavior of the child.
The variables were compared using Frankel Behavior Rating Scale to rate the behavior of child between first and second visit. Comparison of change in behavior between first and second visit was done in relation to gender and age also. Statistical analysis was done using Chi-square test.
| Results|| |
Comparison of behavior on the first and second visit was done using Frankel's Behavior Rating Scale by an independent rater [Table 1] and [Graph 1]. It was found that, on the first visit, 20% of the children showing negative behavior were changed into definitely negative on the second visit. About 80% of children showing negative behavior on the first visit were transformed into positive score on the second visit, showed significant difference in the behavior between first and second visit. Nearly 95.8% of children showing positive score on the first visit remained unchanged on the second visit. About 4.2% of the children showing positive score on the first visit were changed with a definitely positive score on the second visit [Table 1] and [Graph 1].
In a comparison of behavior between early and preschoolers based on age group on the first and second visit, it was found that the on the first visit, preschoolers showed slightly more negative score (29%) as compared to early schoolers (0.0%), whereas on the second visit not any significant difference was found [Table 2], [Table 3] and [Graph 2], [Graph 3].
|Table 2: Comparison of behavior between early and preschoolers on the first visit|
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|Table 3: Comparison of behavior between early and preschoolers on the second visit|
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In a comparison of behavior between male and female on the first and second visit, no significant difference related to gender was found [Table 4], [Table 5] and [Graph 4], [Graph 5].
|Table 4: Comparison of behavior between male and female on the first visit|
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|Table 5: Comparison of behavior between male and female on the second visit|
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| Discussion|| |
The triad formed by the dental team, child, and parents influences the pediatric dental care, so each part of triad interrelates and their relationships are very dynamic. A good communication with the parents and child is considered to be the first and foremost step in the development of positive attitudes in the child and parents about dentistry. According to the current study, most of the parents wanted to be present in the operatory and be involved more actively. The parent's prediction about their child's behavior in their absence was taken in the very first visit, and it was found that mostly parents felt their presence would make the children more comfortable. The results are similar to the survey of Kamp in 1982, who found 66% of parents wanted to be present in the operatory and 92% of these parents felt that their presence would make the child more comfortable. These results are similar to several studies on parental presence in the dental operatory while doing dental procedures. Frankel  found that 92% of mothers wanted to be present in the operatory while treatment and 37% of them felt that their child feels secured with their presence. In accordance to survey of Bauchner et al. found that 78% of parents expressed a preference of their presence in a hospital emergency room during medical procedures and that 91% of them believed that the child would feel comfortable in their presence. In a study of Boj and Azanza, parents were asked about their child's behavior in their presence, and 60% of the parents predicted that their children would behave better when they are present in the operatory; however, 90% responded, they would not mind waiting outside.
In the current study, the age of 4–7 were chosen, as separation anxiety plays a major role in very young children below 4 years of age, which is a normal stage of development and it should fade as child gets older. It is a necessary and healthy adaptation made by a child to develop psychologically and emotionally. Another reason is that children <4 years of age, who are not mature enough to understand full verbal communication are mostly benefited by the parent's presence. At the age of 4–7 years, psychological and emotional development occurs and after the age of 7 years, there is a development of trust and autonomy, so the parental presence or absence does not play a significant role. Considering above-stated factors, the age group of 4–7 years was found to be more appropriate for the current study. Frankel et al. reported that children of age group 41–49 months showed more negative behavior in the absence of their parents in operatory during dental treatment than their unseparated counterparts, while children more than 4 years of age presented no significant differences in behavior in the absence or presence of parents. Guthrie  supported the parental presence during dental treatment of children 3 years or younger due to the normal developmental factor termed as “separation anxiety,” Marcum et al. surveyed 90 pediatric dentists. About 90% of them allowed parents for dental examination of children <4 years and 40% did not allow parents for restorative procedures with children <4 years. This increased trend of parental presence in the operatory might be due to increased awareness of separation anxiety.
In the current study, basic behavior guidance techniques like verbal and nonverbal communication, Tell-Show-Do, voice control, and contingency management were used because they are most commonly used and they form the foundation for all of the management activities provided by the dentist. Children, however, occasionally present with behavior considerations that require more advance techniques. At the start of the appointment, making interactions with child can help in establishing trust and rapport with the dentist. Communication is a subjective process that is an extended personality of the dentist. It is always associated with other management techniques, that is, Tell-Show-Do, voice control, nonverbal communication, contingency management, and distraction.
In the current study, parental presence or absence did not influence the child behavior, which is similar to the result of many studies by different authors. Lewis and Law  found no difference in children's behavioral response between mother-present or mother-absent groups in the dental operatory during treatment. Venham , gave choice to parents and children regarding separation. Parents and children did not choose to separate initially, but over many appointments, separations occurred. There were no differences in the behavior of children between parental presence or absence. Pfefferle et al. examined the behavior of 48 children 36–60 months old and found no significant differences between children of separated parents and nonseparated parents for any behavioral changes. The recent survey of Vasiliki et al. also found the similar results as above. In contrast to the above, in a recent study of Nathan et al., parent's presence played an important role for children 30 months of age or older. Parent's presence was found to be significant for examinations and treatment visits. Increasing trends to permit parents in the operatory during examination and treatment appear to emerge.
In contrast to that there was a significant increase in cooperative behavior of some children. This difference in the outcome is due to other factors influencing the behavior of the child such as child's coping ability, desensitization, personality characteristics, mother's anxiety, and behavior management approach of the dentist. In a Cox's study on 90 children, it was concluded that according to the dentist, the child's behavior was better in the absence of parents in the operatory during treatment.
In the present study, children were divided into two age groups, that is, 4–6 and 6–7 years for statistical evaluation. No significant differences were found in behavior related to age. On a first visit, preschoolers showed slightly more negative score when compared to early schoolers, whereas on the second visit, not any significant difference was found. This difference in the behavior of the child in the first and second visit may also be due to other factors as stated above such as child's coping ability, personality characteristics, desensitization, mother's anxiety, and behavior management approach of the dentist. Pfefferle et al. divided children for statistical analysis into two groups of 36–47-month-old and 48–59-month-old and he found no statistically significant difference between two age groups.
The present study also divided children according to sex to see if there is any significant difference of behavior between male and female. There were no significant differences in behavior between males and females. The findings of the current study was supported by the many authors Wright and Alpern, Venham, Frankel et al., and Pfefferle et al. These results are in contrast to the result of Shirley and Poyntz's study, who found that girls showed more matured behavior than the boys.
| Conclusion|| |
This study demonstrates the significance of parental separation as behavior management approach. Within the scope of the study and the variables, it can be recommended to exclude parents from the dental operatory to eliminate many behavior-related problems during the course of treatment. Basic behavior guidance techniques such as verbal and nonverbal communication, Tell-Show-Do, voice control, and contingency management form the foundation for all of the management activities provided by the dentist.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Suprabha BS, Rao A. Role of parent in behavior guidance of children in dental operatory: Current trends. Int J Adv Res 2015;3:466-70.
American Academy of Pediatric Dentistry. Guideline on behavior guidance for the pediatric dental patient. Pediatr Dent 2015;37:180-93.
Kamp AA. Parent child separation during dental care: A survey of parent's preference. Pediatr Dent 1992;14:231-5.
Starkey PE. Training office personnel to manage children. In: Wright GZ, editor. Behavior Management in Dentistry for Children. Ch. 12. Philadelphia, USA: WB Saunders; 1975. p. 225-7.
Pfefferle JC, Machen JB, Fields HW, Posnik WR. Child behavior in the dental setting relative to parental presence. Pediatr Dent 1982;4:311-6.
Olsen NH. The first appointment – A mutual evaluation session. J Dent Child 1965;32:208-11.
Wright GZ, Stigers JL. Nonpharmacologic management of children's behaviors. In: McDonalds RE, Avery DR, Dean JA, editors. Dentistry for the Child and Adolescent. 9th
ed. St. Louis: CV Mosby; 2011. p. 27-40.
Wright GZ, Starkey PE, Gardner DE. Parent-Child Separation: Managing Children's Behavior in the Dental Office. St. Louis, Mo: CV Mosby Co.; 1983. p. 57-74.
McTigue DJ. Behavior management of children. Dent Clin North Am 1984;28:81-93.
Frankel RI. The papoose board and mothers' attitudes following its use. Pediatr Dent 1991;13:284-8.
Bauchner H, Vinci R, Waring C. Pediatric procedures: Do parents want to watch? Pediatrics 1989;84:907-9.
Boj JR, Azanza N. The Presence of Parents in the Dental Operatory. Research Abstract Presentations Section III, 44th
Annual Session. American Academy of Pediatric Dentistry; 1991. p. 13.
Robillard D. Separation anxiety in infants. AARN News Lett 1994;50:16-7.
Frankel SN, Shiere FR, Fogels HR. Should the parent remain in the operatory? ASDC J Dent Child 1962;29:150-62.
Guthrie A. Separation anxiety: An overview. Pediatr Dent 1997;19:486-90.
Marcum BK, Turner C, Courts FJ. Pediatric dentist's attitudes regarding parental presence during children's dental procedures. Pediatr Dent 1995;17:432-6.
Nash DA. Engaging children's cooperation in the dental environment through effective communication. Pediatr Dent 2006;28:455-9.
Lewis TM, Law DB. An investigation of certain anatomic responses of children to a specific dental stress. J Am Dent Assoc 1958;57:769-77.
Venham LL, Bengston D, Cipes M. Parent's presence and the child's response to dental stress. ASDC J Dent Child. 1978;45:213-7.
Venham L. The effect of mother's presence on a child's response to dental treatment. J Dent Child 1979;46:51-7.
Vasiliki B, Konstantinos A, Vassilis K, Nikolaos K, van Loveren C, Jaap V, et al.
The effect of parental presence on the child's perception and co-operation during dental treatment. Eur Arch Paediatr Dent 2016;17:381-6.
Nathan JE, Rayman MS, Golden BE, Vargas KG. Discretionary parental presence in the dental operatory: A survey of pediatric dentists and parents. Pediatr Neonatal Nurs Open J 2015;2:50-61.
Cox IC, Krikken JB, Veerkamp JS. Influence of parental presence on the child's perception of, and behaviour, during dental treatment. Eur Arch Paediatr Dent 2011;12:200-4.
Wright GZ, Alpern GD. Variables influencing children's cooperative behavior at the first dental visit. ASDC J Dent Child 1971;38:124-8.
Shirley M, Poyntz L. Children's emotional responses to health examinations. Child Dev 1945;16:89-95.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]