|Year : 2016 | Volume
| Issue : 2 | Page : 159-164
Assessment of child behavior in dental operatory in relation to sociodemographic factors, general anxiety, body mass index and role of multi media distraction
Gyanendra Mishra1, Seema Thakur1, Parul Singhal1, Shiv Nath Ghosh2, Deepak Chauhan1, Cheranjeevi Jayam1
1 Department of Pedodontics and Preventive Dentistry, Himachal Pradesh Government Dental College, Shimla, Himachal Pradesh, India
2 Department of Psychology, Himachal Pradesh University, Shimla, Himachal Pradesh, India
|Date of Web Publication||14-Apr-2016|
Dr. Gyanendra Mishra
Department of Pedodontics and Preventive Dentistry, Himachal Pradesh Government Dental College, Shimla, Himachal Pradesh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background and Objectives: Children and adolescents comprise a group of individuals representing a large variation in size, competence, maturity, personality, temperament and emotions experience, oral health, family background, culture, etc. Furthermore, a growing child is in a constant state of flux as he grows up and actively interacts with the environment. Many factors contribute to the dental behavior of the child. The aim of this study was to evaluate the effect of sociodemographic factors, general anxiety, body mass index (BMI), and role of multimedia on the child behavior (CB) in the dental operatory. Materials and Methods: Three hundred and one children aged 3-14 years and their parents participated in the study. In the first visit, the questionnaire was filled by the parent and general examination was done. During the second visit, the required dental procedure was rendered, and the behavior was recorded by a single examiner. Results: Among sociodemographic factors, increasing age is directly related to child's positive behavior, whereas other factors such as gender and socioeconomic status (SES) are not significantly related. General anxiety significantly affects the child's behavior. BMI of the child is not related to child's behavior in dental operatory. Multimedia was not found to be significantly affecting the behavior of the child in dental operatory. Interpretations and Conclusion: The principle conclusion of this study is that there is a significant association of age and treatment procedure rendered with the CB in the dental operatory whereas gender, SES, general anxiety, BMI, and multimedia do not show any significant association with the CB in the dental operatory.
Keywords: Anxiety, body mass index, child behavior, multimedia, socioeconomic status
|How to cite this article:|
Mishra G, Thakur S, Singhal P, Ghosh SN, Chauhan D, Jayam C. Assessment of child behavior in dental operatory in relation to sociodemographic factors, general anxiety, body mass index and role of multi media distraction. J Indian Soc Pedod Prev Dent 2016;34:159-64
|How to cite this URL:|
Mishra G, Thakur S, Singhal P, Ghosh SN, Chauhan D, Jayam C. Assessment of child behavior in dental operatory in relation to sociodemographic factors, general anxiety, body mass index and role of multi media distraction. J Indian Soc Pedod Prev Dent [serial online] 2016 [cited 2021 Apr 18];34:159-64. Available from: https://www.jisppd.com/text.asp?2016/34/2/159/180446
| Introduction|| |
A child cannot be treated as a single entity since his behavior depends a great deal on his/her parents and the surrounding environment.  Sociodemographic factors include age, gender, and the socioeconomic status (SES) of the person. Every child presents with different behavior and various factors such as age, gender, personality, and SES might affect child behavior (CB). , Anxiety is described as a vague, unpleasant feeling accompanied by the intuition that something undesirable is going to happen. Nowadays, children are getting actively involved with the electronic gadgets and the internet.  These factors might contribute to the behavior of the child.
Till date, there is no published study in the literature that has evaluated the effect of body mass index (BMI) and the role of multimedia on the behavior of the child in the dental operatory.
Aims and objectives
The purpose of this study was to evaluate the effect of sociodemographic factors, general anxiety, BMI, and role of multimedia affecting the CB in the dental operatory.
| Materials and Methods|| |
The present questionnaire-based study was conducted in the Department of Pedodontics and Preventive Dentistry at Himachal Pradesh Government Dental College and Hospital, Shimla, Himachal Pradesh - 171 001, India. The sample for the study was comprised all patients attending the regular outpatient department for the 1 st time, belonging to the age group of 3-14 years, accompanied by their parents and meeting the other framed inclusion and exclusion criteria's during 1½ year. Prior consent was obtained from the accompanying parents.
Subjects chosen for the survey satisfied the following inclusion and exclusion criteria.
- All subjects having their first dental visit.
- Patients with age between 3 and 14 years.
- Children accompanied by parents only.
- Parents from all sociodemographic status.
- Patients who had previous dental treatment done.
- Guardians instead of parents accompanying children.
- Patients with special care needs.
- Patients with congenital anomalies.
In this study, 301 parents visiting for the dental treatment of their child for the 1 st time in the Department of Pedodontics, Himachal Pradesh Government Dental College, Shimla, were provided with a formulated questionnaire to be filled.
In the questionnaire "Spence children anxiety scale" (parent report) and (preschool version) form were used to assess the general anxiety of the child.  The SES was recorded using "A New Instrument (scale) for Measuring the Socioeconomic Status of a Family;"  which was later evaluated for correlation with specific strata of the society.
Child's height and weight was recorded by the examiner using:
- Height chart (interval of 1 cm. each).
- Weight (interval of 0.5 kg each).
The BMI  was assessed using the formula:
"BMI = Weight (kg)/height (in m)." 
During the first visit thorough oral examination was done and if required the radiographs were taken.
In the second visit, the child was exposed to the required dental procedure. The operator/working dentist was same for all the patients. For all dental procedures, proper aseptic protocol was followed. If the tooth was indicated for restorative or endodontic procedure proper isolation was done by rubber dam or cotton rolls depending on the cooperation of the patient. During the procedure, the child's behavior was assessed by single examiner other than operator who was trained in the use of Frankel's scale. 
| Results|| |
Data were analyzed using SPSS software (SPSS Inc., Chicago, III, USA) for windows release. Association of behavior with sociodemographic variable, general anxiety, BMI, and multimedia was determined using Chi-square test. The level of significance was set at 5% (i.e., P < 0.05). Three hundred and one children and their parents participated in the study.
Among sociodemographic factors, increasing age is directly related to child's positive behavior, whereas other factors such as gender and SES are not significantly related. General anxiety significantly affects the child's behavior. BMI of the child is not related to child's behavior in dental operatory. Multimedia was not found to be significantly affecting the behavior of the child in dental operatory [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6].
|Table 3: The relationship between social status score and Frankel behavior |
Click here to view
| Discussion|| |
Behavior management is widely agreed to be a key factor in providing dental care for children. Indeed, if a child's behavior in the dental surgery/office cannot be managed then it is difficult if not impossible to carry out any dental care that is needed. In today's changing world behavior of children may be affected by interplay of multiple factors such as BMI and multimedia, sociodemographic factors, and general anxiety. Hence, it is necessary for us to understand their role in the child's behavior. With this understanding, this study was taken up to evaluate the effect of these variables on CB in the dental operatory, which are discussed as following.
Effect of age
Initial part of questionnaire contained questions to assess age (general information part of questionnaire); since this variable is shown to have a significant role in understanding the CB in dental operatory. In our study, age was significantly associated with child's behavior (P = 0.000). Several studies are reported to correlate age with CB such as Klingberg et al., (1994)  Kyritsi et al.,  and Brill,  which reported that the age of the child is a factor which almost always shows significant relationship with CB in the dental surgery. Our study noted that older the child, the more positive behavior was exhibited. This is in agreement with the studies done by Kamran et al.,  Xia et al.,  Kyritsi et al.,  Brill,  Klingberg,  and Klingberg et al. 
This study also observed that those children belonging to the 7-10 year age group displayed less negative (28.9%) and definitely negative behavior (1.8%) than their 3-6 year age counterparts (48.5% and 20.4%, respectively). This finding does not correspond with the study done by Kamran (2011)  which showed that children belonging to 7-10 year age group displayed more negative and definitely negative behavior than their 3-6 year age counterparts. According to Suprabha et al.  also it was concluded that the effect of treatment variables and subjective experiences on child dental fear seems to diminish with advancing age.
Effect of gender
This variable was added to assess the relation of gender on CB; and whether it is significant. Our study did not show any statistically significant relationship between gender and CB (P = 0.262). However, slightly more female children (7.8%) showed definitely negative behavior than male children (7.6%). Prior studies have shown mixed results as Suprabha et al.  quoted in their study that the gender of the child was unrelated to the behavior. Kyritsi et al. (2009)  while studying the Greek population also found that the dental behavior was unrelated to gender but was related to the age of the child patient. These findings were in accordance to the results of our study.
Effect of socioeconomic status
The SES is an important determinant of health, nutritional status, mortality, and morbidity of an individual. SES also influences the accessibility, affordability, acceptability, and actual utilization of available health facilities.  There are many different scales to measure the SES of a family such as those proposed by Prosad (1970)  and Pareek classification.  The Modified Kuppuswamy scale, which is commonly used to measure SES in urban communities, was used in this study. This scale includes education, occupation of head of the family, and income per month from all sources. 
Young children and those belonging to families of low SES have been documented in the literature to present with negative behavior. Children in joint family or with siblings are likely to learn lessons of patience, tolerance, and cooperation. In a nuclear family, which is a growing trend now-a-days, the parents play an important role in shaping the personality characteristics of the child. This difference does not seem to have effect on behavior, indicating that child-rearing practices may not be related to the dental behavior. 
Our study did not show any statistically significant relationship between SES and CB (P = 0.453). However, it was found that children belonging to upper high SES families had the highest incidence of negative (42.9%) and lowest incidence of definitely negative behavior (0.0%) as compared to children belonging to high SES (23.3% and 11%, respectively). The upper middle count SES showed 32.9% and 5.3%, lower middle SES count showed 30.3 and 10.6%, and low SES families showed 33.3% and 0.0%, of negative and definitely negative behavior respectively.
The results of our study were in accordance with those of Dash et al.,  and Kamran et al.,  whereas Brill  and Wright and Alpern  have reported a statistically significant relationship between CB and SES of the parents.
Role of anxiety
Anxiety and fear of dental treatment have been recognized as a source of serious health problems in children.  Research among child populations has indicated previously a prevalence of dental fear/anxiety varying from 5.7% to 21% depending on methods and population surveyed. , A child's response to dental experience can be influenced by many variables such as previous negative medical and dental experiences, social influences, and personality factors.  In dentistry, there have been several reports showing dental anxiety (DA) is an important limiting factor that interferes or rather prevents the effective utilizations of the services available. , For many patients, fear and anxiety are a real problem that can become a barrier to treatment in the long run.  There are some patients who avoid dentists altogether because of their extreme fears, even in cases of emergency such as toothache.  The most common origins of DA happen to be an earlier painful or negative experience during visit to a dentist or pediatrician. Patient's anxiety also poses major management problems for the dental team as more treatment time will be required for an anxious patient and is very likely to miss treatment. 
Nigam et al. quoted that association of anxiety has been often seen with short- and long-term impairment in social, academic, familial, and psychological functioning. It has been seen that the children of parents with anxiety disorders are more likely to develop anxiety disorders themselves because of genetic factors and the atmosphere in which they are raised. Most children experience anxiety purely on the basis of psychological, social, and environmental influences and parents face special challenges because children with anxiety tend to be nervous, avoidant, annoying, or exhausting. 
According to Humphris et al.  high anxiety level among the children visiting the dental operatory might result from lack of dental health education which in turn might end with poor compliance and attitude, or it might be linked to personality characteristics, fear of pain, past traumatic dental experiences in childhood, and dentally anxious family members or peers. High anxiety level would make it more difficult to manipulate patients and yield difficult patients and thus increase the levels of dental profession-related stress.
Our study did not show any statistically significant relationship between anxiety and CB (P = 0.054). In our study, 71 (23.59%) children had low anxiety, 176 (58.47%) had medium anxiety levels, whereas 54 (17.94%) children exhibited high anxiety levels. Among the low anxiety level group, 1 (1.4%) depicted definitely negative, 15 (21.1%) depicted negative, 36 (50.7%) depicted positive, and 19 (26.8%) depicted definitely positive behavior. In the medium anxiety group, 17 (9.7%) depicted definitely negative behavior, 61 (34.7%) depicted negative behavior, 60 (34.1%) depicted positive behavior, and 38 (21.6%) depicted definitely positive behavior. In the high anxiety group, 5 (9.3%) depicted definitely negative behavior, 15 (27.8%) depicted negative behavior, 23 (42.6%) depicted positive, and 11 (20.4%) depicted definitely positive behavior.
Overall prevalence of DA in this study was medium (58.47%), but high (17.9%) anxiety (phobia) was low. This was consistent with the results of other studies conducted by Halonen et al.,  Locker et al.,  which found a considerably greater percentage of participants with DA.
Role of body mass index on child's behavior
Our study did not find any significant association between BMI and child's behavior (P = 0.910). Till date, there is no published study in the literature that has assessed the relationship of BMI with the CB.
In this study, BMI count in underweight category was 196 (65.11%), ideal category 88 (29.23), overweight category 13 (4.3%), and obese category 4 (1.3%). This depicts that the children have more underweight BMI. This may be attributed to the hilly terrain of the state and the associated hardships. In the underweight category group, 15 (65.2%) depicted definitely negative behavior, 64 (70.3%) depicted negative behavior, 74 (62.2%) depicted positive, and 43 (63.2%) depicted definitely positive behavior. In the ideal BMI category group, 6 (26.1%) depicted definitely negative behavior, 24 (26.4%) depicted negative behavior, 38 (31.9%) depicted positive, and 20 (29.4%) depicted definitely positive behavior. In the overweight BMI group, 2 (8.7%) depicted definitely negative behavior, 2 (2.2%) depicted negative behavior, 5 (4.2%) depicted positive, and 4 (5.9%) depicted definitely positive behavior. In the obese group, 0 (0.0%) depicted definitely negative behavior, 1 (1.1%) depicted negative behavior, 2 (1.7%) depicted positive, and 1 (1.5%) depicted definitely positive behavior.
Role of multimedia
Till date, there is no published study in the literature that has assessed the relationship of multimedia with the child's dental behavior. Our study did not find any significant association between multimedia and child's behavior. Total media use was not significantly associated with CB (P = 0.912). In this section, the answer was categorized as low, medium, high, and very high. In low category, 9 (8.7%) depicted definitely negative behavior, 27 (26.0%) depicted negative behavior, 44 (42.3%) depicted positive, and 24 (23.1%) depicted definitely positive behavior. In medium use category, 7 (6.2%) depicted definitely negative behavior, 39 (34.8%) depicted negative behavior, 41 (36.6%) depicted positive, and 25 (22.3%) depicted definitely positive behavior. In high category, 3 (7.1%) depicted definitely negative behavior, 15 (35.7%) depicted negative behavior, 15 (35.7%) depicted positive, and 9 (21.4%) depicted definitely positive behavior. In very high category, 4 (9.3%) depicted definitely negative behavior, 10 (23.3%) depicted negative behavior, 19 (44.2%) depicted positive, and 10 (23.3%) depicted definitely positive behavior.
Our study showed that the type of treatment rendered was affecting the behavior significantly (P = 0.000). The local anesthesia was administered according to the need felt. It showed that noninvasive treatments such as restorations (glass ionomer cement (GIC) [27.8%, 27.8%], composite [0.0%, 100%], indirect pulp capping (IPC) [60.0%, 33.3%]), and oral prophylaxis (0.0%, 100%) showed positive and definitely positive behavior; similarly, among the invasive treatments rendered such as extraction and root canal treatment (RCT) (52.8%, 37.7%) showed the same pattern as of that shown by the noninvasive procedures that is more of positive and definitely positive behavior, whereas other invasive procedures such as pulpotomy (54.5%, 4.5%), pulpectomy (39.3%, 15.5%) showed more of negative and definitely negative behavior. This suggests the relation between dental fear and curative treatment in children to be complex; a difference in the experienced invasiveness between extractions and fillings may exist for the children.
This study was done in a dental hospital cohort in children who reported for their dental treatment for the 1 st time ever. The treatment was rendered according to the felt need of the patient by a single dentist. It should however be noted that behavior modification employed by the dentist could have influenced the behavior outcome, which was unavoidable. Further studies are required to be done to interpret the result to a larger population size in future.
A limitation of this study may relate to the fact that this was not a random sample of patients scored by independent observers, rather all the patients reporting for their first dental operatory visit who were treated by a single dentist who also rated the patient's behavior. This may have introduced some observer bias although every effort was made to be consistent with the patient's ratings.
| Conclusion|| |
Under the conditions of this study, the inference may be drawn that among sociodemographic factors, increasing age is directly related to child's positive behavior, whereas other factors such as gender and SES are not significantly related. General anxiety of child significantly affects child's behavior in the dental operatory. BMI of the child is not related to child's behavior in dental operatory. Multimedia was not found to be significantly affecting the behavior of the child in dental operatory.
I owe this article to my Guru Late Dr. Kapil Rajiv Sharma, Professor and Head, Department of Pedodontics, H.P. Govt. Dental College and Hospital, Shimla. Who allowed me to go ahead with this thesis topic despite not understanding the same. I wish to thank Dr. Neha Sikka (M.D.S.) who rendered her selfless support by doing the statistical analysis on time.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Klinberg G. Dental anxiety and behaviour management problems in paediatric dentistry - A review of background factors and diagnostics. Eur Arch Paediatr Dent 2008;9 Suppl 1:11-5.
Kyritsi MA, Dimou G, Lygidakis NA. Parental attitudes and perceptions affecting children′s dental behaviour in Greek population. A clinical study. Eur Arch Paediatr Dent 2009;10:29-32.
Brill WA. Child behavior in a private pediatric dental practice associated with types of visits, age and socio-economic factors. J Clin Pediatr Dent 2000;25:1-7.
Huesmann LR. The impact of electronic media violence: Scientific theory and research. J Adolesc Health 2007;41 6 Suppl 1:S6-13.
Mahajan BK, Gupta MC. Textbook of Preventive and Social Medicine. 3 rd
ed. Delhi: Jaypee Brothers; 1995. p. 134-5.
Fiscella K, Williams DR. Health disparities based on socioeconomic inequities: Implications for urban health care. Acad Med 2004;79:1139-47.
Drewnowski A, Specter SE. Poverty and obesity: The role of energy density and energy costs. Am J Clin Nutr 2004;79:6-16.
Adler NE, Boyce T, Chesney MA, Cohen S, Folkman S, Kahn RL, et al.
Socioeconomic status and health. The challenge of the gradient. Am Psychol 1994;49:15-24.
Kamran M, Qiam F, Khan H. Evaluation of age, gender, and parental factors affecting CB in dental surgery. JKCD 2011;1:82-6.
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.
Klingberg G, Berggren U, Carlsson SG, Noren JG. Child dental fear: Cause-related factors and clinical effects. Eur J Oral Sci 1995;103:405-12.
Klingberg G, Berggren U, Norén JG. Dental fear in an urban Swedish child population: Prevalence and concomitant factors. Community Dent Health 1994;11:208-14.
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.
Aggarwal OP, Bhasin SK, Sharma AK, Chhabra P, Aggarwal K, Rajoura OP. A new instrument (Scale) for measuring the SES of a family: Preliminary study. Indian J Community Med 2005;30:111-4.
Prosad BG. Changes proposed in the social classification of Indian families. J Indian Med Assoc 1970;55:198-9.
Pareekh U. In: Manual of SES (rural). Delhi: Mansayam; 1981.
Ramesh Masthi NR, Gangaboraiah, Kulkarni P. An exploratory study on socio economic status scales in a rural and urban setting. J Family Med Prim Care 2013;2:69-73.
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.
Wright GZ, Alpern GD. Variables influencing children′s cooperative behavior at the first dental visit. ASDC J Dent Child 1971;38:124-8.
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.
Okoro CA, Strine TW, Eke PI, Dhingra SS, Balluz LS. The association between depression and anxiety and use of oral health services and tooth loss. Community Dent Oral Epidemiol 2012;40:134-44.
Woodmansey KF. The prevalence of dental anxiety in patients of a university dental clinic. J Am Coll Health 2005;54:59-61.
Hawamdeh S, Awad M. DA: Prevalance and associated factors. Eur J Gen Dent 2013;2:270-3.
Milgrom P, Weinstein P, Getz T. Treating Fearful Dental Patients: A Patient Management Handbook. 2 nd
ed. Seattle, Washington: University of Washington, Continuing Dental Education; doi: 10.1111/j. 1600-0528.1996.tb00893.
Nigam AG, Marwah N, Goenka P, Chaudhry A. Correlation of general anxiety and dental anxiety in children aged 3 to 5 years: A clinical survey. J Int Oral Health 2013;5:18-24.
Humphris GM, Morrison T, Lindsay SJ. The modified dental anxiety scale: Validation and United Kingdom norms. Community Dent Health 1995;12:143-50.
Halonen H, Salo T, Hakko H, Räsänen P. Association of dental anxiety to personality traits in a general population sample of Finnish University students. Acta Odontol Scand 2012;70:96-100.
Locker D, Liddell A, Burman D. Dental fear and anxiety in an older adult population. Community Dent Oral Epidemiol 1991;19:120-4.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]