|Year : 2019 | Volume
| Issue : 4 | Page : 350-359
Assessment of parental attitude toward different behavior management techniques used in pediatric dentistry
Sneha Pramod Desai, Preetam P Shah, Shweta S Jajoo, Patil S Smita
Department of Pediatric Dentistry, Bharati Vidyapeeth (Deemed to be University) Dental College and Hospital, Pune, Maharashtra, India
|Date of Web Publication||7-Nov-2019|
Dr. Sneha Pramod Desai
Department of Pediatric Dentistry, Bharati Vidyapeeth (Deemed to be University) Dental College and Hospital, Katraj Dhankawadi, Pune - 411 043, Maharashtra
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: The goal of any good dental treatment is to provide a quality dental care to the patient. This may not be possible if the patient is unwilling to cooperate or unable to do so due to their age or related factors. In such children, behavior management techniques are very helpful. With changing times, there have been changes in the law and the outlook of parents and society toward dental treatment. This influences the various behavior management methods used by pediatric dentists. Objectives: This study was conducted to assess the attitudes of parents of children of different pediatric age groups towards:
- Behavior management techniques used by pediatric dentists
- The effect of maternal anxiety on the child's behavior in clinic
- Pharmacological behavior management techniques
- The effect of parental presence in the operatory on the child's behavior.
Materials and Methods: Three hundred parents were evaluated and divided into three groups comprising 100 each on the basis of their children's age, Group A: 2–5 years, Group B: 6–9 years, and Group C: 10–13 years, which were further divided into two subgroups, on the basis of the child's gender, with each subgroup having parents of 50 male and 50 female children each. For example, Group A1: 50 parents of 2–5-year-old boys, Group A2: 50 parents of 2–5-year-old girls. Results: ANOVA test showed different hierarchies of acceptance for the techniques in all the groups. In all the three groups, tell show do, positive reinforcement, and live modeling were the most accepted techniques. However, statistically significant difference between the groups was not observed for the three techniques. The least accepted techniques for all the groups were hand over mouth technique and voice control technique. Conclusion: Parents were more receptive of those techniques which were visually more acceptable involving a communicative management, such as tell show do, positive reinforcement, and live modeling.
Keywords: Behavior management, management techniques, parental attitude
|How to cite this article:|
Desai SP, Shah PP, Jajoo SS, Smita PS. Assessment of parental attitude toward different behavior management techniques used in pediatric dentistry. J Indian Soc Pedod Prev Dent 2019;37:350-9
|How to cite this URL:|
Desai SP, Shah PP, Jajoo SS, Smita PS. Assessment of parental attitude toward different behavior management techniques used in pediatric dentistry. J Indian Soc Pedod Prev Dent [serial online] 2019 [cited 2021 May 12];37:350-9. Available from: https://www.jisppd.com/text.asp?2019/37/4/350/270475
| Introduction|| |
The institution of pediatric dentistry is based on the premise of being able to guide the children through the dental experience. No two children are alike; children of different ages differ in their behavior. Their behavior also depends on surrounding environment, parents, peers, siblings, their age and ability to understand.
The child is the center of attention for the parents. When it concerns the treatment for a child, it is not only the child but more importantly, the parents too, who form an important part of the relationship. Parents, thus, are more overprotective of their child and are likely to prevent any suffering their child might experience from a dental procedure.
Thus, the importance of good communication with the parent is necessary to set the stage for understanding prognostic possibilities and expectations of treatment.
Establishing a good communication with the pediatric patient is the main objective of the behavior management techniques (BMT).
BMT is very helpful in some children if they are unwilling to cooperate or are unable to do so due to their age or related factors. These techniques differ in their averseness, and more aversive techniques may be required for children who are stubborn, hyper motive. These techniques are alternatives or adjuncts to the dentist to deliver efficient dental treatment.
With changes in the law in recent years, the importance of society, it has become imperative to disclose in detail the procedure to the parent before its application. Hence, the following study was formulated to assess the parental attitude and acceptance of the BMT used by pediatric dentists.
| Materials and Methods|| |
Three hundred parents visiting the Department of Pediatric and Preventive Dentistry, Bharati Vidyapeeth Dental College and Hospital, Pune, for their children's first dental treatment were selected. The subjects included in the study were those parents visiting the department for their child's first dental visit. Parents of all socioeconomic status, age, education, and gender were included in this study.
The exclusion criteria were those parents who reported to the department for an emergency dental treatment; patients indicated for treatment under general anesthesia and parents of medically compromised children.
They were divided into three groups comprising 100 each on the basis of their children's age, Group A: 2–5 years, Group B: 6–9 years, Group C: 10–13 years, which were further divided into two subgroups on the basis of the child's gender.
A single video demonstrating the ten different BMT in the following order were presented: tell-show-do (TSD), positive reinforcement, live modeling, voice control (VC), hand-over-mouth exercise (HOME), passive restraints, active restraints, oral premedication, nitrous oxide sedation, and general anesthesia.
The video clip was recorded in Hindi language and was 11 min long, with each technique being about 40–60 s. The name of the technique was displayed before each video for 6 s. Different operators performed the techniques shown in the video. A scripted introduction was given by a single instructor along with a brief explanation of the technique after each procedure. At the end of the video, a picture displaying all the techniques in one frame was displayed. Then forms were distributed, and the instructor left the room. The video was recorded using a Sony DCR-DVD708 handy cam. Prism video converter and Pinnacle video software were used for editing the videos.
Consent for videotaping and using the techniques on the child was obtained from the parents. The age of the children shown in the videos ranged from 4 to 10 years of age.
The staff of the Department of Pediatric and Preventive Dentistry, Bharati Vidyapeeth Dental College and Hospital, Pune, viewed the tape, and changes were made in the videos until a desired video showing appropriate precision was obtained.
An informed consent was taken from the individuals prior to the study.
The questionnaire consisted of demographic variables such as name, age, occupation, and educational status. A visual analog scale for each of the techniques displayed in the video was shown. The visual analog scale is usually a horizontal line, 100 mm in length, anchored by word descriptors at each end, as such as “least acceptable” and “most acceptable” at the left and right end of the line [Figure 1]. The parents were asked to rate the visual analog scale according to what they felt was the most acceptable to the least acceptable.
Fourteen multiple-choice questions were also given in the questionnaire. The language used in the questionnaire was Hindi.
| Results|| |
The statistical analysis was done using Fisher's exact test, Chi-square test, and one-way ANOVA.
[Table 1] and [Graph 1] depict the comparative acceptability of all the BMT. One-way ANOVA test showed different hierarchies of acceptance for the techniques in all the age groups. In all the three groups, TSD, positive reinforcement, and live modeling were the most accepted techniques. However, statistically significant difference between the groups was not observed for the three techniques. The least accepted techniques in all the groups were HOME and VC technique. Statistically significant difference between the groups was observed for HOME.
|Table 1: Comparative evaluation of the acceptability of the behavior management techniques|
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Maternal anxiety plays an important role in the dental treatment of a child. 49% from Group A, 34% from Group B, and 33% from Group C were not aware of the negative effect of maternal anxiety [Table 2] and [Graph 2].
Parental dental history revealed that only 61% from Group A, 48% from Group B, and 62% from Group C had visited the dentist as adults [Table 3] and [Graph 3].
While 71% of parents from Group A had a good past dental experience, only 34% from Group B and 44% from Group C stated that they had a good past dental experience [Table 4] and [Graph 4].
About 16% from Group A, 14% from Group B, and 53% from Group C shared their negative dental experience with their child [Table 5] and [Graph 5].
Parental presence in the operatory may affect the dental treatment, 96% from Group A, 89% from Group B, and 86% from Group C said that they would prefer to stay with the child during treatment. The results were statistically significant (P < 0.05). Chi-square test was used [Table 6] and [Graph 6].
Parent's role during dental treatment can affect the patient's co-operation during treatment. About 57% from Group A, 38% from Group B, and 38% from Group C expected the dentists to explain each step of the dental procedure. 17% from Group A, 11% from Group B, and 26% from Group C would tell the dentist which tooth was required to be treated. 5% from Group A, 28% from Group B, and 7% from Group C would ask the dentist about their doubts after the dental treatment. 21% from Group A, 23% from Group B, and 29% from Group C stated that they would talk to the child during the dental treatment [Table 7] and [Graph 7].
About 100% from Group A, 91% from Group B, and 68% from Group C felt that their presence with their child would make him more cooperative [Table 8] and [Graph 8].
For the question about parent's consent for the use of the techniques on their child, 79% from Group A, 90% from Group B, and 100% from Group C consented to use of the techniques if required. Statistical analysis using Fisher's exact test showed significant results (P < 0.05) [Table 9] and [Graph 9].
Only 30% of parents from Group A, while 53% from Group B and 52% from Group C stated that they would give consent for the sedation and anesthesia procedures [Table 10] and [Graph 10].
|Table 10: Consent to use of pharmacological behavior management technique|
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Almost 48% from Group A, 3% from Group B, and 11% from Group C stated that fear of the procedure was the reason for their disapproval. 22% from Group A, 44% from Group B, and 37% from Group C stated that increase in the expense was the reason for their disapproval [Table 11] and [Graph 11].
|Table 11: Reason for no consent to use of pharmacological behavior management technique|
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Majority of the parents from all groups, i.e., 91% from Group A, 91% from Group B, and 88% from Group C stated that the dentist must inform them before the use of any technique on their child [Table 12] and [Graph 12].
43% from Group A, 58% from Group B and 66% from Group C stated that the videos were educational. 50% from Group A, 42% from Group B, and 23% from Group C stated that the videos increased their acceptability for the techniques [Table 13] and [Graph 13].
43% from Group A, 27% from Group B, and 82% from Group C felt that the attitude of the dental staff was important for an effective dental treatment [Table 14] and [Graph 14].
|Table 14: Parent's opinion on an effective dental treatment of their child|
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| Discussion|| |
There are various modes of presentation, namely, oral, written, and videos. Videos are more eye-catching and may have a lasting effect on the observer. Very few Indian studies have been done to assess the parent's attitude to BMT. Thus, this study was carried out using videos with an explanation of the procedure as a method to assess the parent's attitude. Studies done by Saleh M have used videos as a mode of presentation to the parents to assess their attitude.
Studies that were carried out earlier have used different methods of presentation of the techniques. One such study carried out, assessed the four methods of informing parents, by oral presentation, written presentation, videos without prior explanation, and videos with prior explanation of the techniques. Although the study showed that oral presentation was the preferred choice, there was not a significant difference between the methods.
Parents always accompany children through all dental appointments. They are involved in much of the decision-making and delivery of care. Parents play an important part in reducing a child's anxiety and allowing the dentist to form a treatment alliance.
Earlier, the level of communication with parents was very less and was actively discouraged by the dental staff. Subsequently, with changing attitudes in society, the parental involvement has increased. Drawing the parent into treatment decisions through informed consent procedures is now a standard of care.
The use and acceptance of a technique by the profession does not assure its legality as viewed by today's courts. With the emphasis on children's rights, the attitude of parents toward BMT constitutes another important factor which must be considered when selecting an approach for managing behavior.
Thus, the study carried out was carried out to assess the attitude of parents toward different BMT used by pediatric dentists in children of different age groups.
Comparative evaluation of different behavior management techniques
A comparative evaluation of different BMT showed different hierarchies of acceptance in all the groups. Mean visual analog scores were used to rank the BMT. Thus, the technique with the least score was ranked first. The results for Group A, Group B, and Group C are shown in [Table 1] and [Graph 1].
In all the three groups, TSD, positive reinforcement, and live modeling were the most accepted techniques. The probable reason why these techniques were most accepted could be because parents favored techniques where a more communicative and non-aggressive form of management was involved. However, statistically significant difference between the groups was not observed for the three techniques. These findings were consistent with previous studies done by Murphy et al., Lawrence et al., Eaton et al., and Havelka et al.
The least accepted technique among all groups was HOME. The reason for the least acceptance could be as the technique appears forceful. Studies demonstrating HOME have shown a sharp decline in its acceptance over the years. The decreasing acceptance of the technique over the years, make it seem doubtful whether this technique would be in use in the future. The finding was supported by a study done by Eaton et al. but were contradictory to the study done by Murphy et al. and Lawrence et al.
The active restraint was preferred over passive restraint in groups A and B. This finding is supported by studies done by Lawrence et al., and Eaton et al., Havelka et al., However, the findings were contradictory to the study done by Murphy et al.
Our results showed that individuals were unaware of the effect of maternal anxiety on the patient's behavior. This emphasizes the importance of educating the mothers. Furthermore, measures must be taken to reduce anxiety as it may pose a hindrance for seeking dental treatment [Table 2] and [Graph 2].
Mothers often accompany their children to their dental appointments; it is for this reason that the effect of maternal anxiety on children has received a considerable attention. Many investigations have indicated that there is a significant correlation between maternal anxiety and a child's cooperative behavior at the first dental visit. High anxiety on the part of the parents can affect the children's behavior negatively. Although scientific data state that children of all ages could be affected by their mother's anxieties, the effect is greatest with those under 4 years of age. This could be anticipated because the child–parent symbiosis begins at infancy and gradually diminishes.
Milgrom et al. stated that children who had a dentally anxious parent were twice as likely to be anxious when compared with children who had nonfearful parents.
Tuutti and Lahti  stated that parents bore the responsibility for their preschool children's oral health, and the presence of anxiety might influence parental attitudes and habits regarding the child's oral health care.
Parents' dental history, dental experience, and sharing the dental experience with their children
The results of our study showed that there may be a lack of knowledge about dental health amongst parents. This finding was supported by a study done by Zavras et al. and Suresh et al.
Children under the age of 5 years generally spend most of their time with parents and guardians, especially mothers, even when they attend preschools or nurseries. These early years involve “primary socialization” during which the earliest childhood routines and habits are acquired.
Studies have reported that poor attitude of parents towards oral health of infants and young children are associated with increased caries prevalence.
It has been found that the more positive the parents' attitudes toward dentistry, the better will be the dental health of their children.
The preventive cycle in good dental care strongly reflects on the parent's knowledge and positive attitude.
Zavras et al. have reported that well-educated mothers were more aware of their oral health and visited the dentists one or two times per year versus mothers with basic education.
Suresh et al. also reported that mothers with higher educational qualification and information gained through the dentist had a better knowledge about child's oral health [Table 3], [Table 4], [Table 5] and [Graph 3], [Graph 4], [Graph 5].
Parental presence in the operatory and role of parents during dental treatment
According to the results of our study, parents preferred to stay with the child during treatment [Table 6] and [Graph 6]. The reason for it may be because the younger the child, it is more likely that parents desire to be with them during their treatment. This finding was consistent with the study done by Kim et al.
According to our study, parents expected the dentists to explain each step of the dental procedure. This is essential to facilitate understanding and acceptance of treatment plans and behavioral techniques used by the dentist. This finding was consistent with the studies done by Murphy et al. and Lawrence et al., who stated that good communication with parents was also essential. Stephen and Wilson  stated that the parent must be coached on how to help the dentist, letting the clinician maintain primary communication with the child, and to avoid fear-provoking messages [Table 7] and [Graph 7].
Effect of parental presence on the child's cooperation
In our study, parents stated that their presence would have a positive effect on their child's cooperation.
Communication is an important tool. For most of the methods used, the way dentists approach and communicate with children is a model of respect and effectiveness. Simultaneous communication with child and parent also has advantages. The value of a parent hearing all the dental education messages given to the child sets them up to be re-enforcers of those messages at home.
Parents could give appropriate support, especially for very young children in new and challenging situations. The parental presence was important to the feelings of well-being of certain children, especially the very young patients  [Table 8] and [Graph 8].
Consent for the use of the techniques on their child
According to the results of our study, majority of the parents consented to use the BMT if required. The results were statistically significant [Table 9] and [Graph 9]. The reason for consent could be the detailed explanation during video demonstration.
Consent for techniques requiring pharmacological management and reason for disapproval
When parents were asked whether they would give consent for the techniques requiring pharmacological management, subjects from Group B and C showed greater acceptance [Table 10] and [Graph 10].
Parents who disapproved cited fear of the procedure and increase in the expenses as their reason for disapproval [Table 11] and [Graph 11].
Informed consent to use the behavior management techniques
From the results of our study, it was inferred that the dentist must inform the parent before the use of any technique on their child.
There are several factors which may influence a parent's willingness to consent to a BMT. The dentist should keep those factors in mind when obtaining informed consent. According to a study done by Fields et al., situational specific dental needs could modify parents attitudes toward the techniques. This was an important finding, and dentists should include an explanation of the urgency of the planned dental procedure when giving parents a rationale for the use of BMT [Table 12] and [Graph 12].
The effect of video on parent's outlook
According to our study, the results showed that the videos were educational and helped to increase the acceptability of the techniques.
The increased acceptance could be because the groups were not aware of the techniques that were shown in the videos, and the need for the use of the techniques during the dental treatment was explained through the video demonstration [Table 13] and [Graph 13].
Parent's view of an effective dental treatment
The results of our study showed that the attitude of the dental staff was an important factor for an effective dental treatment. The dentist's communication skills play an important role in behavior guidance. Along with the dentist, the soft skills of the dental staff are also important. The health professional may be inattentive to the communication style, but parents are very attentive to it. The communicative behavior of dentists is a major factor in patient satisfaction.
This finding was consistent with the study done by Milgrom and Weinstein  who stated that the entire team had an active role to play. Initial contact with the parents was through the receptionist, who could ease the parental concerns in a confident manner; the chair-side assistant may provide an invaluable role in assisting the dentist [Table 14] and [Graph 14].
| Conclusion|| |
Behavior management is a key factor in providing dental care for children. If a child's behavior in the dental office cannot be managed then it becomes difficult, if not impossible, to carry out any dental care that may be required. It is imperative that any approach to behavioral management for the child must be rooted in empathy and a concern for the well-being of each child.
The following conclusions were derived from our study:
Parents wanted to be actively involved during their child's dental treatment.
They were more receptive of those techniques which were visually more acceptable. Parents were more accepting of techniques involving a communicative management, such as tell show do, positive reinforcement, and live modeling.
Hand over mouth technique was the least accepted technique and was given the last priority in all the groups. The voice control technique was disliked by parents of all groups. This shows a declining acceptance for the techniques over the years.
Pharmacological BMT such as nitrous oxide sedation and oral sedation techniques were preferred over the aggressive management techniques.
Parents wanted to be informed before the use of any aversive behavior management technique on their child, which emphasizes the importance of informed consent.
Parents also stated that the videos helped to improve their understanding and broaden their outlook. This showed that parents were more receptive for the techniques once they were educated about the need for their use.
When parents are involved during the treatment of the child, they would be able to see the manner in which we help the child to cope with the treatment; it would ensure that the outcome of the treatment was smooth, as the child would be more cooperative during the treatment.
Children's mind and behavior is like clay, the manner in which it may be molded lie in the skill of the dentist, who with his/her finesse and can make even the most uncooperative child into a good dental patient.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11], [Table 12], [Table 13], [Table 14]