Prospective analysis of factors associated with dental behavior management problems, in children aged 7-11 years

Ramya Pai; Praveenkumar Mandroli; Deepa Benni; Pallavi Pujar

doi:10.4103/0970-4388.165684



ORIGINAL ARTICLE

Year : 2015 \| Volume : 33 \| Issue : 4 \| Page : 312-318

Prospective analysis of factors associated with dental behavior management problems, in children aged 7-11 years

Ramya Pai, Praveenkumar Mandroli, Deepa Benni, Pallavi Pujar
Post Graduate Student, Department of Pedodontics and Preventive Dentistry, Maratha Mandal's Nathajirao G. Halgekar Institute of Dental Sciences and Research Centre, Belgaum, Karnataka, India

Date of Web Publication

18-Sep-2015

Correspondence Address:
Dr. Ramya Pai
Department of Pedodontics and Preventive Dentistry, Maratha Mandal's Nathajirao G. Halgekar Institute of Dental Sciences and Research Centre, R.S No. 47 A/2, Bauxite Road, Near K.S.R.P Ground, Belgaum - 590 010, Karnataka
India

Source of Support: None, Conflict of Interest: None

Check

DOI: 10.4103/0970-4388.165684

Abstract

Aim: To determine the prevalence of child behavior management problems (BMP) and to analyze the influence and predictive power of nondental and dental background variables on BMP. Study Design: Prospective analytical study. Materials and Methods: The study group included 165 children aged 7-11 years who received comprehensive dental treatment, after obtaining written informed consent. Parents/guardians were interviewed using standardized questionnaire to obtain background information. Each child's treatment was carried out and was recorded with a fixed digital video (DV) recorder. The treatments were classified into three levels of invasiveness: Noninvasive (NI), moderately invasive (MI), and highly invasive (HI). The entire DV record of each treatment was observed, and child's dental behavior was rated independently by two precalibrated examiners using modified Venham's behavior rating scale. Then, the background factors obtained through the questionnaire data were analyzed for its association with child's dental behavior. Results: Statistical tests used were Chi-square test and multiple logistic regression analysis to determine the relationship of multiple variables with dental behavior. Comparison of child's behavior during different visits was done by Wilcoxan matched pairs test. The prevalence of BMP in children aged 7-11 years in the study sample was 0%, 4.2%, and 15.76% for NI, MI, and HI procedures, respectively. Three variables were significant predictors of behavior; order of birth that is, first born, history of hospitalization, and unpleasant past dental experience (P < 0.05). Conclusions: Direct conditioning pathway is the major factor in determining child's behavior. Dental experiences, duration of treatment, and complexity of treatment have greater impact on how the child behaves in a dental setup.

Keywords: Behavior management problems, children, co-operative behavior, prevalence

How to cite this article:
Pai R, Mandroli P, Benni D, Pujar P. Prospective analysis of factors associated with dental behavior management problems, in children aged 7-11 years. J Indian Soc Pedod Prev Dent 2015;33:312-8

How to cite this URL:
Pai R, Mandroli P, Benni D, Pujar P. Prospective analysis of factors associated with dental behavior management problems, in children aged 7-11 years. J Indian Soc Pedod Prev Dent [serial online] 2015 [cited 2021 Jan 26];33:312-8. Available from: https://www.jisppd.com/text.asp?2015/33/4/312/165684

Introduction

One of the most challenging problems faced by pediatric dentists is behavior management. Children's dental anxiety and/or dental behavior management problems (DBMP) are associated with many factors of both internal and external origins. Dental anxiety of external origin has been described as a simple conditioned phobia emerging from direct or indirect negative dental experiences. ^[1],[2] Dental anxiety of internal origin are characterized as a personality trait or endogenous anxiety. The dentist's behavior is another factor associated with children's dental behavior. ^[3] Mild fear and anxiety are expected and consistent with normal development, but they become a concern when the fear or anxiety is disproportionate to the actual threat. DBMP is a collective term for uncooperative and disruptive behaviors, which results in a delay of treatment or render treatment impossible, regardless of the type of behavior or its underlying mechanism. ^[4] Most of the existing literature on factors affecting dental fear and behavior focuses on the preschool age group as they most often present with behavior problems. However, school-aged child through adolescence can also present with behavior problems where communication cannot be established by the clinician. ^[5]

Failure to manage a disruptive child can place the child, dentist, and staff at risk, and may compromise the quality and efficiency of dental care. It is necessary to effectively predict children's dental behavior, identify children at the risk of BMP before such problems arise, and develop an appropriate management strategy during the first dental visit. The purpose of this study was to determine the prevalence of child BMP and to analyze the influence of nondental and dental background variables on BMP.

Materials and Methods

The study included 165 child aged 7-11 years (mean age: 8.64 years) visiting the Department of Pedodontics and Preventive Dentistry, Maratha Mandal's Nathajirao G. Halgekar Institute of Dental Science and Research Centre, Belgaum, India, for routine dental treatment needs. There were no gender-based, racial, ethnic, or socioeconomic restrictions on participation.

The study was approved by institutional review board. Written informed consent in local languages was obtained from all the parents/guardians who were willing to participate in the study.

Inclusion criteria

Child aged 7-11 years.
Child requiring comprehensive dental treatment(s), including filling, tooth extraction, pulp therapy, pit and ﬁhild sealant, and/or topical fluoride application.
Accompanying parent/guardian is one of the child's primary caretakers.
Investigator has no previous connection with the child or guardian, (i.e., this was the child's first visit to the examining dentist).
Accompanying guardian is able to understand and reply our questions.

Exclusion criteria

Children with dental emergencies such as trauma, acute pulpitis, acute apical periodontitis, and acute dentoalveolar abscess.
The child with easily discernable mental limitations or communicative disorders.

Methodology

Interview

Upon arrival at the clinic, an investigator blind to procedure interviewed each child's accompanying parent/guardian using a standardized written questionnaire. ^[6] The questions covered the child's personality factors, previous dental and medical treatment experience, environmental conditions within and outside the family, and the parent/guardian's experience with dental treatment [Figure 1].

Figure 1: Flowchart depicting the methodology of the study

Click here to view

Clinical treatment

The treatment was carried out using conventional behavior management techniques (except sedation and general anesthesia) according to the child's circumstances. These techniques included communicative management, nonverbal communication, positive reinforcement, and tell-show-do. The parent/guardian was present or absent during the treatments unless his/her presence obviously disturbed the child's behavior. Each child's dental treatment was recorded with a fixed digital video (DV) recorder focused on the child and dentist [Figure 2], [Figure 3], [Figure 4].

Figure 2: The clinical set up for treatment

Click here to view

Figure 3: The set up for video recording; front view

Click here to view

Figure 4: The set for video recording; rear view

Click here to view

The treatments were classified into three levels of invasiveness: ^[7]

Noninvasive (NI) (e.g., oral prophylaxis, topical fluoride application).
Moderately invasive (MI) (e.g., pit and ﬁssure sealant, preventive resin restoration, and glass ionomer restorations not requiring local anesthesia).
Highly invasive, including any treatment requiring local anesthesia (e.g., deep caries restoration, indirect pulp treatment, pulpotomy, pulpectomy, or tooth extraction).

Assessment of children's behavior

The entire DV record of each treatment was observed independently by two precalibrated pedodontists who were blind to questionnaire data, and the child's behavior was rated on modified Venham's clinical behavior rating scale ^[7] as follows:

0: Relaxed
1: Uneasy
2: Tense
3: Reluctant
4: Interfering
5: Out of contact

The ratings of 0-2 indicated acceptable behavior that did not disturb the continuity of treatment and ratings of 3-5 indicated BMP that interrupt the continuity of treatment.

Analysis of factors affecting the child's dental behavior

The following factors were considered from the questionnaire data for their association with child's dental behavior: Type of family (Nuclear/Joint), order of birth, history of hospitalization, parents' dental anxiety, past dental experience, parents' expectation of child's dental behavior, interaction with siblings, interaction with other children, conduct toward parents, and school performance.

Statistical analysis

Data were analyzed using Statistical Package for Social Services (SPSS, IBM, India) software version 20.0. Association of child's dental behavior with various factors considered was determined using Chi-square test. Multiple logistic regression analysis was done to determine the relationship of various independent variables with dental behavior during HI procedure. Furthermore, comparison of child's behavior during NI, MI, and HI procedure was done by Wilcoxon matched pairs test. The confidence level of study was set at 95% (i.e., α = 0.05).

Results

The prevalence of BMP was 0%, 4.24%, 15.76 % during NI, MI, and HI procedures, respectively [[Table 1] and Graph 1].

Table 1: Distribution of children with their behavior during noninvasive, moderately invasive, and highly invasive procedures

Click here to view

Behavior during noninvasive procedure

All the children showed acceptable behavior during NI procedure. No BMP was observed.

Behavior during moderately invasive procedure

There was statistically significant association between the following factors and behavior of children during MI procedure; nuclear family (P = 0.0404), first born (P = 0.0123), parents' dental anxiety (P = 0.0003), parent's expectation of negative dental behavior (P = 0.00001), interaction with the siblings (P = 0.0035), interaction with other children (P = 0.0035), conduct toward parents (P = 0.0226), and school performance (P = 0.0373).

Behavior during highly invasive procedure

The following factors significantly predicted the child's dental behavior during HI procedure; nuclear family (P = 0.0005), first born (P = 0.0001), history of hospitalization (P = 0.00001), parents dental anxiety (P = 0.00001), unpleasant past dental experience (P = 0.0005), parent's expectation of negative dental behavior (P = 0.00001), interaction with the siblings (P = 0.00001), interaction with other children (P = 0.00001), conduct toward parents (P = 0.00001), and school performance (P = 0.0004) [Table 2].

Table 2: Association between different factors with behavior of children during highly invasive procedure

Click here to view

Multivariate logistic regression analysis was done for children's behavior during HI procedure to evaluate the cumulative effect of all factors considered. Order of birth, that is, first born, history of hospitalization, past dental experience were the significant predictors of behavior (P < 0.05) with odds ratio of 0.03, 0.12, and 17.93, respectively. Based on the results of multivariate regression analysis, a regression equation was drawn: Logit P = + 0.4220 (Efv) − 0.2050(Hh) − 0.1280(Fb) + 0.6250 (Efv: Experience at first visit; Hh: History of hospitalization; Fb: First born) [Table 3].

Table 3: Step wise logistic regression analysis behavior of children during highly invasive procedure

Click here to view

The children's behavior during NI, MI, and HI procedure was compared by Wilcoxon matched pairs test by ranks. The difference in behavior among the three procedures was significant with P = 0.018, 0.0001, and 0.0003, respectively.

Discussion

Considering clinical relevance, the purpose of this study was to determine the prevalence of child BMP and to analyze the influence of nondental and dental background variables on BMP in children aged 7-11 years. Children's or adolescents' uncooperative behaviors toward dental treatment are known as DBMP. DBMP is a collective term for behaviors resulting in the delay or cancellation of treatment, as determined by the treating dentist or dental staff. ^[8] DBMP has been discussed in a multi-factorial context where personal, environmental, and situational factors interact. Children and adolescents vary in age, competence, temperament, personality, intellectual capacity, and maturity. They also differ greatly in life experience, family situation, and cultural background. It is necessary for a clinical pediatric dentist to effectively predict children's dental behavior (especially in a busy clinic), identify children at risk of DBMP before such problems arise. The various factors analyzed in this study were gender, type of the family, order of birth, history of hospitalization, past dental experience, presence of dental anxiety in parents, parent's expectation of child's dental behavior, and child's personal factors such as interaction of child with siblings, other children, parents, and school performance.

The prevalence of DBMP in children included in the study was 0%, 4.2%, and 15.76% during NI, MI, and HI procedures, respectively. The multiple logistic regression analysis revealed the factors, which significantly predicted negative behaviors such as unpleasant past dental experience, first born child, and history of hospitalization.

Age is a well established factor which determines the co-operative level of the child during the dental procedures. ^{[9],[10],[11]} Younger children show more disruptive behavior. So, to eliminate age as variability, the children belonging from only single stage of psychological development were included in this study, that is, 7-11 years old. This age group corresponds with the concrete operational stage of cognitive development theory by Jean Piaget and stage of industry versus inferiority, that is, mastery of skills of Emotional development by Erik Erikso. ^[12] By this stage, children show an improved ability to reason; the ability to see another point of view develops while animism declines. Children in this period are much more like adults in the way they view the world, but they are still cognitively different from the adults.

The results of this study showed that unpleasant past medical experience is a significant predictor of child's dental behavior (P = 0.00001). Children who had past medical problems, had been hospitalized, will be afraid of visiting a physician. Children who are often ill also have greater problems in coping with stress situation. ^[9]

Regarding the previous dental experience, children of those parents who perceived their child's previous appointments to be unpleasant showed negative behavior (P = 0.0030). This perception of the parent can arise due to pain experienced by the child and negative behavior during previous appointments. Also, parent's perception of dental appointments being unpleasant may be passed onto the child creating more negative behavior. ^[13],[14]

Results of this study showed that first born children were significantly associated with developing BMP compared to latter borns (P = 0.0090). Among the family characteristics, the order of birth have significant effect on the behavior. ^[15] Review of the birth order literature suggests a relationship between cognitive ability, especially verbal ones and facets of emotion and knowledge. Research has shown that there are birth order differences in intelligence and in the personality dimensions. ^[16] The association between first born and BMP can be by the fact that the first-borns are the center of attention and the sole object of care yet the experience of dethronement is thought to make first-borns vulnerable to the effects of stress and uncertain in difficult situations. With only adults for role models, first-borns take on adult characteristic such as seriousness, to be in control, adhere to norms and rules, and likes order and structure. ^[17] Other characteristics of the family type of family, that is, joint or nuclear was associated with behavior problems when considered as an individual factor but not when multiple factors considered. Children in joint family or with siblings are likely to learn lessons of patience, tolerance, and cooperation. In a nuclear family, parents play an important role in shaping the personality characteristics of the child. However, this difference did not have an effect on behavior, indicating that child-rearing practices may not be related to dental behavior. ^[6],[18] Gender, presence of dental anxiety in parents, parent's expectation of child's negative behavior, ^[8],[19] and child's personal factors such as interaction with siblings, interaction with other children, ^[7] conducts toward parents and school performance were not the significant predictors of behavior when effect of multiple factors was considered. Child's dental behavior is also affected by other factors such as dentist's factors ^[20] and treatment plan, that is, level of invasiveness and duration of the treatment. ^[21] Appropriate pediatric behavior management should include thoughtful scheduling of appointments according to a treatment plan formulated with consideration of the effects of age and appointment length. The treatment plan for each child in the present study was divided into three phases according to the levels of invasiveness, that is, NI, MI, and HI. This helped in desensitizing the child to desensitize the dental environment and guided the child to show more acceptable behavior. This finding is in accordance with "latent inhibition theory", ^[22] whereby children tend to become less afraid if they have had more neutral visits (e.g., check-up, cleaning) before exposure to invasive dental treatments (e.g., restorations, extractions).

Several limitations of this investigation must be noted. First, this study used a convenience sample from a single Pediatric dental health care set up, so the prevalence of children's dental behaviors we found are not necessarily representative. Second, a binary variable derived from the Venham's scale was used in this study because it could be easily applied by a pediatric dentist during daily clinic work. Children's dental behavior, however, varies in association with many factors, and the regression equation only provides a reference to predict a child's dental behavior. Pediatric dentists should therefore adjust their behavior management strategy to meet the needs of individual child patients. Third, this study focused only upon children's background variables. Future research that examines the effects of dentist factors is needed. Fourth, the accuracy of parent/guardian provided questionnaire response was doubtful, especially the guardian's subjective rating of the child's behavior. It is often difficult to elicit a precise history from the parent/guardian, who is effectively the third party and who is probably trying to project the child's positive traits.

To summarize, multiple pathways underline a child's behavior pattern in a dental setup. It appears that the direct conditioning pathway is the major factor in determining child's behavior. Dental experiences of actual amount of experienced procedures, duration of treatment, and complexity of treatment have greater impact on how the child behaves in a dental setup.

Conclusion

On the basis of clinical observations, results and statistical analysis, and within the limitation of the present study, following conclusion can be drawn.

The prevalence of BMP in children aged 7-11 years in the study sample was 0%, 4.2%, and 15.76% for NI, MI, and HI procedures, respectively.
Order of birth, that is, first born, history of hospitalization, and unpleasant past dental experience predicted the child's ability to cope with a dental situation in this study sample.
Multiple pathways underline a child's behavior pattern in a dental setup. Dental experiences of the actual amount of experienced procedures, duration of treatment, and complexity of treatment have greater impact on how the child behaves in a dental setup.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Locker D, Shapiro D, Liddell A. Negative dental experiences and their relationship to dental anxiety. Community Dent Health 1996;13:86-92.
2.	Locker D, Liddell A, Dempster L, Shapiro D. Age of onset of dental anxiety. J Dent Res 1999;78:790-6.
3.	Weinstein P, Getz T, Ratener P, Domoto P. The effect of dentists′ behaviors on fear-related behaviors in children. J Am Dent Assoc 1982;104:32-8. [PUBMED]
4.	Klingberg G, Broberg AG. Dental fear/anxiety and dental behaviour management problems in children and adolescents: A review of prevalence and concomitant psychological factors. Int J Paediatr Dent 2007;17:391-406.
5.	Pinkham JR. Behavior management of children in the dental office. Dent Clin North Am 2000;44:471-86.
6.	Suprabha BS, Rao A, Choudhary S, Shenoy R. Child dental fear and behavior: The role of environmental factors in a hospital cohort. J Indian Soc Pedod Prev Dent 2011;29:95-101. [PUBMED]
7.	Xia B, Wang CL, Ge LH. Factors associated with dental behaviour management problems in children aged 2-8 years in Beijing, China. Int J Paediatr Dent 2011;21:200-9.
8.	Klingberg G, Broberg AG. Dental fear/anxiety and dental behaviour management problems in children and adolescents: A review of prevalence and concomitant psychological factors. Int J Paediatr Dent 2007;17:391-406.
9.	Holst A, Schröder U, Ek L, Hallonsten AL, Crossner CG. Prediction of behavior management problems in children. Scand J Dent Res 1988;96:457-65.
10.	Allen KD, Hutfless S, Larzelere R. Evaluation of two predictors of child disruptive behavior during restorative dental treatment. J Dent Child (Chic) 2003;70:221-5.
11.	Gustafsson A, Broberg A, Bodin L, Berggren U, Arnrup K. Dental behaviour management problems: The role of child personal characteristics. Int J Paediatr Dent 2010;20:242-53.
12.	Proffit WR. Contemporary Orthodontics. 2 ^nd ed. St. Louis: Mosby Year Book Inc.; 1993. p. 197-204.
13.	Versloot J, Veerkamp J, Hoogstraten J. Dental anxiety and psychological functioning in children: Its relationship with behaviour during treatment. Eur Arch Paediatr Dent 2008;9 Suppl 1:36-40.
14.	Paryab M, Hosseinbor M. Dental anxiety and behavioral problems: A study of prevalence and related factors among a group of Iranian children aged 6-12. J Indian Soc Pedod Prev Dent 2013;31:82-6. [PUBMED]
15.	Lee CY, Chang YY, Huang ST. The clinically related predictors of dental fear in Taiwanese children. Int J Paediatr Dent 2008;18:415-22.
16.	Paulhus DL, Trapnell PD, Chen D. Birth-order effects on personality and achievement within families. Psychol Sci 1999;10:482-8.
17.	Aminabadi NA, Sohrabi A, Erfanparast LK, Oskouei SG, Ajami BA. Can birth order affect temperament, anxiety and behavior in 5 to 7-year-old children in the dental setting? J Contemp Dent Pract 2011;12:225-31.
18.	Dash JK, Sahoo PK, Baliarsing RR, Dash SN. A study of behaviour patterns of normal children in a dental situation and its relationship with socioeconomic status, family type and sibling position. J Indian Soc Pedod Prev Dent 2002;20:23-9. [PUBMED]
19.	Holst A, Hallonsten AL, Schröder U, Ek L, Edlund K. Prediction of behavior-management problems in 3-year-old children. Scand J Dent Res 1993;101:110-4.
20.	Zhou Y, Cameron E, Forbes G, Humphris G. Systematic review of the effect of dental staff behaviour on child dental patient anxiety and behaviour. Patient Educ Couns 2011;85:4-13.
21.	Aminabadi NA, Farahani RM, Sohrabi A, Pouralibaba F. Lingual eruption of mandibular permanent incisors: A space correlated phenomenon? J Contemp Dent Pract 2009;10:25-32.
22.	Davey GC. Dental phobias and anxieties: Evidence for conditioning processes in the acquisition and modulation of a learned fear. Behav Res Ther 1989;27:51-8. [PUBMED]