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ORIGINAL ARTICLE
Year : 2020  |  Volume : 38  |  Issue : 3  |  Page : 274-279
 

Parental acceptance of behavior management techniques for preschool children in dental practice: Revisited


Department of Pediatric Dentistry, Faculty of Dentistry, Mahidol University, Bangkok, Thailand

Date of Submission13-Aug-2020
Date of Decision17-Aug-2020
Date of Acceptance03-Sep-2020
Date of Web Publication29-Sep-2020

Correspondence Address:
Dr. Pattarawadee Leelataweewud
Department of Pediatric Dentistry, Faculty of Dentistry, Mahidol University, No. 6, Yothi Road, Ratchathewi District, Bangkok 10400
Thailand
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JISPPD.JISPPD_349_20

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   Abstract 


Background: Parental acceptance of behavior management techniques (BMTs) in dental practice is important and subjected to change with the dynamics of the society. Aims: The aim of this study was to evaluate the parental acceptance of eight selected BMTs: tell–show–do (TSD), voice control (VC), passive restraint (PR), active restraint (AR), parental presence/absence (PP/PA), oral sedation (OS), inhalation sedation nitrous oxide/oxygen (N2O/O2), and general anesthesia (GA) and its associated factors in a group of Thai parents. Design: The cross-sectional study was conducted among 200 parents of preschool children in Bangkok metropolitan. Materials and Methods: Parents were asked to rate the BMTs demonstrated in video with a Visual Analog Scale (VAS). Possible relevant factors were collected via questionnaires. Descriptive statistics were used to describe the samples. BMTs were ranked by mean VAS using the general linear model repeated measure. The association between the mean VASs and parental and child's factors was analyzed using the one-way ANOVA and independent t-test. Significant factors were further analyzed by multiple linear regression. The level of confidence was set at 95%. Results: All BMTs were acceptable. TSD was rated the highest, followed by PR, VC, AR, N2O/O2, OS, GA, and PP/PA, respectively. Parental dental anxiety was associated with less acceptance of PP/PA. Child's experience of VC, AR, OS, and PP/PA was related to better acceptance of the techniques. Conclusions: The BMTs were better accepted with similar pattern compared to past studies. PP/PA was the least accepted related to high parental anxiety. Child's experience with BMTs increased the acceptance.


Keywords: Behavior management technique, parental acceptance, preschoolers


How to cite this article:
Seangpadsa K, Smutkeeree A, Leelataweewud P. Parental acceptance of behavior management techniques for preschool children in dental practice: Revisited. J Indian Soc Pedod Prev Dent 2020;38:274-9

How to cite this URL:
Seangpadsa K, Smutkeeree A, Leelataweewud P. Parental acceptance of behavior management techniques for preschool children in dental practice: Revisited. J Indian Soc Pedod Prev Dent [serial online] 2020 [cited 2020 Oct 30];38:274-9. Available from: https://www.jisppd.com/text.asp?2020/38/3/274/296639





   Introduction Top


Child behavior management techniques (BMTs) contribute to the success of dental care in preschool children. The techniques rely on art of communication, psychological approaches, physical stabilization, or pharmacological approaches.[1] Preschool children are the group for whom BMTs are used most often in dental practice compared with other age groups.[2] Parental acceptance of BMTs dictates how children will be managed and the techniques are not equally approved by parents. Previous studies during the past two decades have shown variation in BMTs preferences according to the level of acceptance among parents.[3],[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14]

Although commonly used BMTs have not changed much, dynamic societal factors in recent years might have directly or indirectly affected the parental acceptance of BMTs. Current parenting styles, children with less self-control and adaptive skills as well as decreasing parental expectations for their child's behavior during dental procedures[15] may influence BMT selection and success. The worldwide Internet and social media might have changed people's perspective on health care. Gender of parents could also be a factor as a survey by the Pew Research Center of American parents found that more than half of the mothers admitted being more overprotective than fathers.[16] It was quite clear that the communicative technique tell–show–do (TSD) had been viewed favorably and highly accepted across cultures. Aversive techniques as voice control (VC), physical restraint, and pharmacological management had been seen differently across countries and over time.[3],[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14] Disagreement on the selection of BMTs between dentists and parents can increase the parental anxiety and may cause some delays or neglect of the child's dental treatment.

This study aimed to examine the parental acceptance of eight selected BMTs used in preschool children in dental practice and its associated factors in a group of Thai parents. The results would provide dental practitioners with an up-to-date parental perspective on BMTs and related factors. This would assist dentists to properly prepare for options, explanation, and discussion on BMTs with parents for the best benefit of the child.


   Materials and Methods Top


This cross-sectional study was approved by the Institution Review Board (IRB), Faculty of Dentistry/Faculty of Pharmacy, Mahidol University (COA. No. MU–DT/PY–IRB 2019/003.0801), and Thai Clinical Trial Registry (TCTR20191127003).

The sample size was calculated using Wayne D's formula with a 95% confidence level based on a study of parental attitudes toward BMTs in Thailand in 1998[3] with general anesthesia (GA), which was the least accepted by the mean Visual Analog Scale (VAS) score of 40.3 mm (standard error of 3.1). The required sample size in this study was 200 in total.

The study was conducted among a group of Thai parents who had sought dental care for their healthy children from the Pediatric Dental Clinic, Faculty of Dentistry, Mahidol University, Bangkok, Thailand, from March to June 2019. Two hundred and thirty parents who were primary caregivers of preschoolers and able to read and understand Thai were fully informed and asked to participate in the study. Participation and withdrawal of which would not affect their children's dental care.

Each participating parent was asked to watch eight BMTs' video clips on a 13” screen laptop computer in random order. Parents were asked to rate their agreement with each BMT at the end of each clip using the 100-mm VAS by drawing a horizontal line reflecting completely disagree (0 mm) to totally agree (100 mm). Then, they were asked to complete a questionnaire on parental and family backgrounds, as well as children's information. The status of each child's dental caries was recorded as decayed, missing, or filled primary teeth (dmft) and was collected from the most recent oral examination record of the clinic. If any parts of the study process were not complete, the data would be excluded from the study.

The BMT videos with Thai subtitles demonstrated the selected BMTs that dentists were currently practicing on preschool children during dental treatment including TSD, VC, parental presence/absence (PP/PA), nitrous oxide/oxygen inhalation (N2O/O2), passive restraint (PR) with Papoose Board, active restraint (AR) by parents, oral sedation (OS), and GA. The roles were played by a dentist, a 4-year-old girl and her mother. Each displayed technique was reviewed by three pediatric dentists and the ethical committees to ensure its appropriate contents for 40–60 s in length.

The questionnaire was designed to collect the parent's and child's factors possibly associated with parental acceptance of BMTs. Parental factors included the demography, dental anxiety using the Modified Dental Anxiety Scale (MDAS),[17] self-assessed parenting styles,[18] and attitudes toward BMTs. The children's factors including age, temperament assessed by parents according to Thomas et al.'s classification,[19] experiences with BMTs in dental setting, and child dental anxiety using the modified dental anxiety question[20] were collected. The validity of the questionnaire's contents was tested by three pediatric dentists and three pediatricians using item-objective congruence. The IOC score per question was higher than 0.5. The test–retest reliability was conducted in 10 parents at 1 month after the initial completion. Intraclass correlation coefficient values ranged between 0.809 and 0.952 (P <0.001).

Statistical analysis

Data were analyzed by the SPSS version 21 (IBM, Chicago, IL, USA). Descriptive statistics were used to describe the samples and their children. Parents' ages were converted into generations X (born between 1965 and 1980) and Y (born between 1981 and 1999)[16] for analysis. Child dental caries status represented by dmft score was classified into 4 levels of severity: caries free (0), mild (1–4), moderate (5–8), and severe (9–20) according to the level reported to impact on the quality of life of children.[21] BMTs were ranked by mean VAS and analyzed using the general linear model (GLM) repeated measure. The association between the mean VASs and family income, parental dental anxiety, child's age, temperament, and dental caries status was analyzed using the one-way ANOVA. The parental generation, child dental anxiety, and experience with BMTs associated with VASs were analyzed using the independent t-test. Selected factors revealed that some associations were further analyzed by multiple linear regression (MLG). The level of confidence was set at 95% in all analyses.


   Results Top


A total of 210 enrolled, but ten (5%) could not complete the study procedure and were excluded. A total of 200 parents with a mean age of 36.4 years (range, 22–50 years) had completed all parts. Most parents were mothers, married couples (93%), had a bachelor's degree or higher (84.5%), and used authoritative parenting style (91.5%) from wide range of family incomes. The MDAS demonstrated that 73.5% of parents had some levels of dental anxiety. Majority of them (93%) believed that BMTs could improve child cooperation during dental treatment. Parental demographic data and relevant information are displayed in [Table 1]. Parents also reported that the dentists (52%) and their spouses (43%) were influential in BMT choices the most and their acceptances were based on safety, risk, and the necessity for using the techniques.
Table 1: Parental demographic and relevant information

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Children whose parents were enrolled in the study were 2–5 years old with a mean age of 4.1 years and average dmft of 5.0. Children's temperament as reported by parents was 49% easy, 7% difficult, 12% slow to warm up, and 32% mixed. Most children had dental experience, and 79.5% of those also experienced at least one BMT. The children's demographic data and relevant information are displayed in [Table 2].
Table 2: Child's demographic and relevant information

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The mean VAS for all BMTs was higher than 50 (range, 51.08–87.22) displayed from the highest to the lowest in [Table 3]. The mean VAS for the TSD was the highest and significantly higher than that of all the other BMTs. The GLM repeated measure indicated that mean VASs for VC, AR, N2O/O2, OS, and GA were not different from each other but significantly higher than PP/PA. However, those for the N2O/O2, OS, GA, and PP/PA were not statistically different.
Table 3: Mean Visual Analogue Scale score rated for parental acceptance for each of behavior management techniques

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There was no association between the mean VASs for eight BMTs and the parent's generation, family incomes, the child's age, temperament, dental caries status, and dental anxiety. Parents' dental anxiety was found to be associated with the mean VAS for PP/PA as the parents with high and extreme dental anxiety rated the technique lower than 40, as shown in [Table 4] (P = 0.003). An association between previous BMT experience of the child and mean VASs for those particular techniques was seen in some BMTs, as demonstrated in [Table 4]. The mean VASs for the VC, AR, OS, and PP/PA were significantly higher in the group of parents whose children had been exposed to those particular BMTs before (P = 0.04, 0.03, 0.01, and 0.02, respectively). Moreover, parents whose children experienced OS also rated significantly higher for GA (P = 0.03) and PP/PA (P = 0.03).
Table 4: The factors associated with parental acceptance of behavior management techniques

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   Discussion Top


This cross-sectional study was carried out in a group of Thai parents in Bangkok confined to only who had sought dental care for their preschool children with mixed severity of early childhood caries. The contemporary BMTs focused in this study are currently practiced in several parts of the world. Hand-over-mouth technique was not included in this study because it was no longer taught in the dental curriculum in Thailand. The study was conducted in generation X and Y parents two decades after a previous study in Baby boomer and generation X parents in 1998.[3] Some changes in parental acceptance were expected. All eight BMTs were acceptable in this study, whereas several of them including AR, N2O/O2, OS, and GA were not in the past.

TSD was on the top among all, which is consistent with other studies. It is viewed favorably as a common instructional, simple, and noninvasive technique. TSD and positive reinforcement have been the most accepted techniques across cultures regardless of the region or development of the countries. [3,5-11,14] Only in one recent study comparing among parents with different racial and ethnic backgrounds in the United States[13] that TSD was slightly less accepted than VC by Hispanic parents. This is may be because the parents recruited in that study could be the parents of children older than preschool age at the time of the study.

Two forms of physical restraint, AR and PR, have been view differently in most studies. AR was reported moderately acceptable while PR with a device designed for medical purposes (Papoose Board) was ranked very low in most studies, especially in Western[10],[12],[13] and Middle East countries.[5],[9],[11] In Thailand, PR was barely accepted two decades ago (mean VAS: 58).[3] It gained much more acceptance in this study, even higher than AR. It was viewed as a safe, protective, and effective technique by studied parents. AR, on the other hand, was much lower accepted and viewed as aggressive techniques that might be harmful to the children either psychologically or physically. Common use in medical diagnosis and urgent medical care may contribute to an increase in PR acceptability. Practitioners could find PR useful for a young child undergoing through some short dental procedures where pharmacological approaches are limited or not available. Moreover, a parent can be allowed to be with the child and gently places him or her on the restraining board. Acceptance of AR and VC was comparable to that of pharmacological approaches.

Interestingly, pharmacological techniques were viewed with more favor but much less than the PR. Acceptance of inhalation sedation with nitrous oxide and oxygen, OS, and GA was comparable statistically. Although most parents in this study valued the primary teeth and sought dental care for their children, dental treatment is usually considered elective and more so for primary teeth. It may be difficult for the parents to see the benefits of dental care which outweigh the risks posed by the pharmacological techniques in young children. Pharmacological techniques also require both special equipment, facilities, and trained personnel. They are mostly offered only at universities, some dental centers, and some privacy settings. In the past decade, acceptance of a pharmacological approach had increased in both developing and developed countries owing to the increasing number of outpatient surgical centers and outpatient surgeries.[11],[13],[14] Improvement of access and familiarity may help increase the acceptance in the future. Conditions such as urgent needs, pain, and extensive dental needs in one visit were reported to increase the acceptance of both PR and pharmacological approaches.[12]

PP/PA was the lowest in the rank and almost unacceptable and in this study. This may be one finding that reflects change in parental acceptance. This was consistent with findings in many previous studies.[3],[6],[10],[12] Another study in the southern part of Thailand 20 years ago[4] had reported that 60% of parents agreed to parental separation as compared to 54% in this study making the lowest acceptance score. It is not surprising that parents with high and extreme dental anxiety would be likely to reject PP/PA. Only those who had experienced with PP/PA or OS (which usually excludes the parent) accepted this technique well. A recent study in India found that almost all of the parents preferred being with their children during treatment and believed that their presence would enhance their preschoolers' cooperation.[22] In addition, a study revealed no advantage of PP/PA over other basic, nonpharmacological BMTs.[23] PP/PA should be reserved for only when necessary and keep the parents well informed of the benefit before use. This should also concern a dentist when using BMTs that indirectly require parental exclusion.

High parental dental anxiety was found associated with less acceptance for PP/PA but not the other BMTs in this study. An Israeli study[8] showed that high dental anxiety was related to less acceptance of VC but greater acceptance of sedation. However, other studies[10],[12] in developed countries found no association between parental dental anxiety and acceptance of BMTs. The children's experience with BMTs significantly increased the parental acceptance of those specific BMTs. Although a study by Alammouri in Jordan[24] did not find this type of association, our finding is consistent with a study in the United States[14] on advanced BMTs including pharmacological approaches and restraints. The safe and successful practice of the BMTs would be very important and build a positive attitude of parents toward those BMTs.

Child's factors showed a very minimal influence on parental acceptance of BMTs. It was noted in this study that parents whose children were very young (2–3 years old) or had no dental experience would rely more on the pharmacological techniques including N2O/O2, OS, and GA. Parents of the older children would rely more on the child's coping skills shaped by nonpharmacological approaches.

This study failed to show the influence of a parent's generation, X and Y, on BMT acceptance. Generation Y parents are expected to be more receptive and open for more novel options beyond a certain old way.[25] Recent studies[9],[12] also suggested that parents had changed to be more overprotective and less likely to set limits on their children's behavior. Our finding did suggest that the younger generation accepts spectrum of pharmacological approaches (N2O/O2, OS, and GA) significantly more, however, parent's generation was not a significant factor in multiple linear regression model.

It was previously reported that a decent prior explanation and video presentation increased parental acceptance.[5],[22],[26] This study tried to control the explanation by including only a brief description of each technique in a certain pattern in both video and VAS score sheets. Our result added that safety and risk issues of each BMTs and necessity of use are essential content in prior explanation by the practitioner.

Parental acceptance of BMTs determines the success of pediatric dental care and warrants the best benefit of the child. Nonaversive communicative approaches are easily accepted by parents. TSD is a basic for practitioners to start with and ready to use for all children. Passive physical immobilization in a Papoose Board is highly accepted factors including parental dental anxiety and the child's experience with BMT and its success should be assessed before offering BMT options.


   Conclusions Top


Parental acceptance of eight BMTs in a group of Thai parents was ranked (1) TSD, (2) PR (with a Papoose Board), (3) VC and AR, (4) inhalation sedation (N2O/O2), OS, and GA, and (5) PP/PA. Pharmacological approaches have become more acceptable. High parental dental anxiety was associated with less acceptance of PP/PA; child's experience with BMTs increased parental acceptance of those BMTs including pharmacological techniques and PP/PA.

Acknowledgment

We would like to thank Dr. Yos Chantho and Assoc. Prof. Dr. Araya Phonghanyudh for their original video clips, Asst. Prof. Dr. Varangkanar Jiraratanasopa for her insightful statistical advice, and all staff of Pediatric Dental Clinic, Faculty of Dentistry, Mahidol University, for valuable support throughout the study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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