|Year : 2022 | Volume
| Issue : 3 | Page : 260-264
Modifications of behavior management strategies pre- and post-covid-19 scenario: A survey among pediatric dentists
Mili Meghpara1, Nikhil Marwah1, Yashi Sharma1, Archana Paliwal2, Shubham Godhani3
1 Department of Pediatric and Preventive Dentistry, Mahatma Gandhi Dental College and Hospital, Jaipur, India
2 Department of Community Medicine, Mahatma Gandhi Medical College and Hospital, Jaipur, India
3 Department of Prosthodontics and Crown & Bridge and Implantology, Daswani Dental College and Research Centre, Kota, India
|Date of Submission||30-Apr-2022|
|Date of Decision||04-Jun-2022|
|Date of Acceptance||02-Jul-2022|
|Date of Web Publication||18-Oct-2022|
Department of Pediatric and Preventive Dentistry, Mahatma Gandhi Dental College and Hospital, Sitapura, Jaipur - 302 022, Rajasthan
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: COVID-19 presented a unique scenario among children, specifically all over the world. The children had decrease outdoors activities and learning times, increased use of electronic gadgets and changes in sleep patterns. These altered behavior patterns of children directly influenced their behavior in the dental operatory. This coupled with the stringent protocols of COVID-19, made the behavior management of children a tedious task. However, as they say that necessity is the mother of all inventions, the pediatric dentist took this time to evaluate newer methods of behavior management and modified old strategies with newer modifications. Aim: The main aim of this study was to observe the modifications in behavior management strategies among pediatric dentists in the post-COVID-19 era while managing the child in dental operatory. Materials and Methods: Four hundred pediatric dentists were mailed a questionnaire consisting of 24 open and closed-ended questions consisting of personal data, professional information, and questions regarding various behavior management techniques used by them in pre- and post-COVID-19 era. Data obtained were subjected to statistical analysis using SPSS version 26.0, IBM, and a comparison of frequencies of categories of variables with groups was made using Chi-Square test and McNemar test. Results: The results showed that there were statistically highly significant changes in behavior management strategies pre- and post-COVID-19 scenario with P < 0.01. Conclusion: Conventional techniques like Tell-Show-Do were popular in both pre- and post-COVID-19 times with minor modifications in approach, but conscious sedation and distraction techniques were evaluated to have gained more popularity in the post-COVID-19 times along with exploration of new novel techniques.
Keywords: Behavior management strategies, COVID-19 scenario, pediatric dentists, pre and post-COVID-19
|How to cite this article:|
Meghpara M, Marwah N, Sharma Y, Paliwal A, Godhani S. Modifications of behavior management strategies pre- and post-covid-19 scenario: A survey among pediatric dentists. J Indian Soc Pedod Prev Dent 2022;40:260-4
|How to cite this URL:|
Meghpara M, Marwah N, Sharma Y, Paliwal A, Godhani S. Modifications of behavior management strategies pre- and post-covid-19 scenario: A survey among pediatric dentists. J Indian Soc Pedod Prev Dent [serial online] 2022 [cited 2022 Dec 3];40:260-4. Available from: http://www.jisppd.com/text.asp?2022/40/3/260/358829
| Introduction|| |
Behavior management of the patient is an integral part of pediatric dental practice. A considerable number of children do not co-operate in the dental office, thereby causing a hindrance in delivering quality dental care. Certainly, it is not feasible to carry out any dental care that is needed for the child if his behavior cannot be effectively managed. Hence, behavior management is agreed to be a prime factor in performing dental care to children. Dental anxiety is a feeling of worry about the dental treatment which may not necessarily be related to an external stimulus. Anxieties are common among kids, including fear of the unknown and lack of control, both of which can happen during dental assessment and treatment.
Since the outbreak of COVID-19, all other healthcare providers, along with dental professionals around the world, have been facing challenges in providing care to patients. Pediatric dentistry faces additional challenges in the wake of this pandemic, as the COVID-19 management protocol leads to changes in the behavior of the children. One of the major difficulties for pediatric dentists during the COVID-19 pandemic is increased anxiety among patients due to donning of personal protection equipment (PPE) kits by dentists, simultaneously making communication and rapport development more effortful.
The above-mentioned challenges call for changes in behavior management techniques (BMT); hence, this survey among pediatric dentists aims to assess the behavior management strategies in the pre- and post-COVID-19 scenario, including the modifications thereof.
| Materials and Methods|| |
It is an observational type of study. The sample size was calculated using the Epi-Info 7.0, Jaipur, Rajasthan, India software program by using a 16% survey on behavior management techniques with a standard error of 4% or less and a 95% confidence interval level. It was estimated that a minimum sample size of 310 Pediatric dentists was required to achieve a level of precision for the study. The questionnaire pro forma was self-prepared. The preliminary questionnaire was tested, and validation (reliability and validity) of the questionnaire was done using a number of statistical methods with the help of statistician. It consists of 24 open and closed-ended questions, which were sent to 400 pediatric dentists all over India via e-mail or through Google Forms. A total of 360 pediatric dentists responded and participated in the study. After obtaining personal and professional information such as name, age, gender, workplace, and years of experience, questions were asked to enquire about what changes have been made in behavior management techniques by them in the post-COVID-19 era. Questions regarding pre-appointment counseling, challenges faced because of PPE kits, use of colorful PPE kits, and its impact on behavior management and the role of the play area in reducing fear and anxiety among children were asked. Furthermore, the survey participants were requested to give their suggestions about any novel strategies that they have adapted during the pandemic.
Data obtained was compiled on an MS Office Excel Sheet (version 2019, Microsoft Redmond Campus, Redmond, Washington, United States). Data were subjected to statistical analysis using the Statistical Package for the Social Sciences (SPSS Inc., version 17.0, Chicago). Comparison of frequencies of categories of variables with groups was made using Chi-square test and McNemar test. For all the statistical tests, P < 0.05 was considered statistically significant.
| Results|| |
The present study was conducted to observe the modifications of behavior management strategies of the child pre- and post-COVID-19 among the pediatric dentists. All the responses were compared on the basis of age, gender, place of practice, profession, and years of experience, as shown in [Table 1]. It depicts that out of 360 pediatric dentists, there were 65% of females and 35% of males, 61.7% in the age group of 25–35 years, 53.9% of pediatric dentists who practiced in colleges, with 80% having <5 years of experience.
[Table 2] depicts that 73% of pediatric dentists experienced difficulty in managing the child, due to post-COVID-19 protocols. Seventy-seven percentage of pediatric dentists made changes in the conventional BMT suiting their needs with a statistically highly significant difference seen for the frequencies (P < 0.01). [Table 2] also reveals that 80% pediatric dentists started focusing on preappointment behavior modifications through video calls in post-COVID-19 scenarios with statistically nonsignificant differences seen for the frequencies (P > 0.05).
[Graph 1] lists out the most common reason for difficulty in managing the child as per the pediatric dentists. It showed that 53% pediatric dentists experienced difficulty in managing the child in post-COVID-19 scenarios primarily due to the inability of the dentist to interact properly with the child due to PPE kits, which showed a statistically highly significant relation (P < 0.01).
[Graph 2] lists the presumable reasons which may induce a fear-provoking scenario for the children in the post-COVID-19 times. Fear due to PPE kits was the most quoted reason for an increase in fear among children (60.5%) and showed a statistically highly significant relation (P < 0.01).
[Table 3] depicts two entities; first, it describes various BMT used in pre-COVID-19 era as compared to post-COVID-19 protocols. The data in this table show that the Tell-Show-Do technique was the most popular technique in the pre-COVID-19 times (81.7%) and is still the most preferred technique (61.7%) among Pediatric dentists even in the post-COVID-19 scenario. The other techniques, such as distraction and conscious sedation, were in limited use previously, but their frequency had increased in post-COVID-19 times. This decrease in the frequency of Tell-Show-Do and increase in the frequency of distraction and conscious sedation in post-COVID-19 times were statistically highly significant relations (P < 0.01). There was not much change in the frequency of other techniques like modeling. The other parameters depicted in this table expressed the area most helpful in reducing fear and anxiety among children. Although the play area continued to be the most wanted area as per the children, waiting area and reception area also gained importance in post-COVID-19 scenario, which showed a statistically highly significant relation (P < 0.01).
[Table 4] depicts difficulty in managing the child due to COVID-19 protocols as per place of practice. The data present that the pediatric dentists practicing in college hospitals faced maximum issues relate to PPEs and communication as compared to private practice and these results showed a statistically highly significant relation (P < 0.01).
| Discussion|| |
COVID-19, a pandemic has now spread throughout the world like a wildfire. Behavior management undoubtedly lays the foundation of successful pediatric dental treatment, but after the COVID-19 outbreak, it has become, especially important in limiting infection. Unco-operative children are more likely to spread aerosols as compared to calm children, thereby enhancing the importance of skilful behavior management to minimize the transmission of SARS-CoV-2 infection.
As there was limited data regarding COVID-19 and changes in BMT, this study was conducted among 400 pediatric dentists in India to assess the changes in BMT in pre and post-COVID-19 scenarios. In this study, most of pediatric dentist believed that there is the change in BMT as well as difficulty to manage the children post COVID-19 with statistically highly significant results. The main reason for the difficulty to manage the post-COVID-19 was primarily due to the PPE kit and the inability of the dentist to interact properly with the child due to PPE kits which may lead to ineffective communication with the children during the procedure. Most of the pediatric dentists use colourful PPEs in order to minimize the fear and anxiety in children post COVID-19.
When the various BMT were compared among pre- and post-COVID-19 scenarios, Tell-Show-Do was evaluated to be the most preferred technique along with its various modifications while the use of other techniques such as distraction, conscious sedation had increased in post-COVID-19 times with a statistically highly evaluations. The decrease in use of Tell-Show-Do technique, although minimal could be attributed to difficulty in communication with barriers as previously discussed. The increased effectiveness of distraction technique may be attributed to the fact that the children had decrease outdoors activities and increased use of electronic gadgets post COVID-19 times; hence, they quickly familiarize and adapt to various distractions methods in the dental operatory. Conscious sedation has always been an important pillar in managing an anxious child, but its increased use and parental acceptance can solely be attributed to increased reading by parents on online sources. According to Simpson et al., who successfully used nonpharmacological techniques instead of inhalation sedation in one-third of his patients as sterilizing the reusable nasal hoods became challenging in COVID-19 times. However, the study by Sharath et al. concluded that Tell-show-do was the most common behavior management technique used and more aversive management techniques were rarely used in managing children in the dental office. Another study by Matava et al. reported that cases under sedation or general anesthesia in the operation theatre were avoided to reduce the burden on hospitals.
Majority of pediatric dentists also started focusing on preappointment behavior modifications through video calls in the post-COVID-19 scenario. Age-appropriate illustrative digital leaflets can be sent to the children and their parents along with the preappointment letter. This digital visual communication will make the child understand what to expect in the clinic. A study by Goswami et al. suggested that there is unacceptance of teledentistry and lack of face-to-face communication, leading to apprehension among patients due to inadequacy of proper communication with the dentists, so the need of teledentistry in coming modern times will be there.
According to our study, play area continued to be the most wanted area as per the children in reducing children's fear and anxiety, but the waiting area and reception area also gained importance in post-COVID-19 scenario, which showed a statistically highly significant relation. It might be due to the reasons that in the waiting area and reception area, there is drastically change in norms and protocol as per the COVID-19 times, the child feels more unique and wanted. Earlier, the child used to share the toys with their peer groups, but currently due to new protocol, sharing of the toys had been avoided and personalized playing items for the child in the play area helps to cope up the better behavior of the child in the dental operatory.
Another interesting reporting of our study was that pediatric dentist practicing in college hospitals faced maximum issues related to PPEs and communication as compared to private practice. The possible reason for this could be that in college hospitals, the type of PPEs are not as comfortable and colorful as compared to private practice for pediatric dentists. The environment of college, changing areas, proper air conditioning, and ventilation could also be associated with alternating factors for difficulty in managing the child. Hence, this barrier further may lead to more improper communication due to COVID-19 protocols for pediatric dentist.
This study also observed that various Pediatric Dentists had modified behavior management strategies post-COVID-19 times like Modifications of Tell-Show-Do, Modified Modeling, Aromatherapy, Binaural Beats, Colorful Attire, White Noise, Systematic Desensitization, and Thaumaturgy. Among these modifications, some of the “novel strategies” implemented by pediatric dentists as per the changing behavior patterns of children in this COVID-19 times are cartoon-modified face shields, masks with cartoon characters, colorful print on PPEs, making kids also wear PPEs and positive reinforcement in the form of colorful masks. Although there have been minor sparks of innovation all around the world, there is a wide range of scope for research among these modified or novel behavior management strategies in the future.
The present COVID-19 pandemic has changed the way we used to practice with our little child patients, but as pediatric dentists, we have to cross these barriers and give the best possible treatment to them and at the same time maintain and follow all the protocols. Significant changes within the dental clinics and their environment have become a “new normal” for all. Thus, pediatric dentists must adopt all the required behavior management skills to manage the fearful and anxious child.
| Conclusion|| |
The study concluded that the Tell-Show-Do technique was the behavior management technique of choice by the majority of pediatric dentists in both pre- and post-COVID-19 scenarios, whereas the Distraction technique and Conscious Sedation have greatly improved their presence and acceptability in post-COVID-19 times. In essence, most of the pediatric dentists either modified conventional BMT or implemented “novel strategies” to manage child's fear and anxiety in dental operatory due to the protocols in current times.
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]