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1. © 2020 Journal of Indian Society of Pedodontics and Preventive Dentistry | Published by Wolters Kluwer - Medknow
274
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 (N2
O/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, N2
O/
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
Parental acceptance of behavior management
techniques for preschool children in dental practice:
Revisited
Kanchaporn Seangpadsa, Apiwan Smutkeeree, Pattarawadee Leelataweewud
Department of Pediatric Dentistry, Faculty of Dentistry, Mahidol University, Bangkok, Thailand
Introduction
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
Address for correspondence:
Dr. Pattarawadee Leelataweewud,
Department of Pediatric Dentistry, Faculty of Dentistry,
Mahidol University, No. 6, Yothi Road, Ratchathewi District,
Bangkok 10400, Thailand.
E‑mail: pattarawadee.lee@mahidol.ac.th
Access this article online
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DOI:
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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.
Submitted: 13-Aug-2020 Revised: 17-Aug-2020
Accepted: 03‑Sep‑2020 Published: 29-Sep-2020
This is an open access journal, and articles are distributed under the terms
of the Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0
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Original Article
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2. Seangpadsa, et al.: Parental acceptance of child management techniques
Journal of Indian Society of Pedodontics and Preventive Dentistry | Volume 38 | Issue 3 | July-September 2020 | 275
by parents. Previous studies during the past two
decades have shown variation in BMTs preferences
according to the level of acceptance among parents.[3‑14]
Although commonly used BMTs have not changed
much,dynamicsocietalfactorsinrecentyearsmighthave
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.[3‑14]
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
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 (N2
O/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
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3. Seangpadsa, et al.: Parental acceptance of child management techniques
Journal of Indian Society of Pedodontics and Preventive Dentistry | Volume 38 | Issue 3 | July-September 2020 |
276
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
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.
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.
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, N2
O/O2
, OS, and GA were not
different from each other but significantly higher than
PP/PA. However, those for the N2
O/O2
, OS, GA, and
PP/PA were not statistically different.
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).
Discussion
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, N2
O/O2
,
OS, and GA were not in the past.
Table 1: Parental demographic and relevant
information
Demographic (n=200) n (%)
Gender
Father 41 (20.5)
Mother 159 (79.5)
Age
22 to 38 years (Gen Y) 124 (62)
39 to 50 years (Gen X) 76 (38)
Education
Lower than bachelor’s degree 31 (15.5)
Bachelor’s degree 125 (62.5)
Higher than bachelor’s degree 44 (22)
Socioeconomic status by family income
Low (<USD 1000/month) 53 (26.5)
Moderate (USD 1000‑1500/month) 58 (29)
High (>USD 1500/month) 89 (44.5)
Parental dental anxiety (MDAS)
No 53 (26.5)
Low 93 (46.5)
Moderate 36 (18)
High/extreme 18 (9)
The main information influencing BMT acceptance
Safety and risk 111 (55.5)
Necessity and reason to use 53 (26.5)
Child acceptance 19 (9.5)
Effectiveness 17 (8.5)
MDAS=Modified Dental Anxiety Scale
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4. Seangpadsa, et al.: Parental acceptance of child management techniques
Journal of Indian Society of Pedodontics and Preventive Dentistry | Volume 38 | Issue 3 | July-September 2020 | 277
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 valuedthe 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
techniquewell.A recentstudyinIndiafoundthatalmost
all of the parents preferred being with their children
Table 2: Child’s demographic and relevant
information
Demographic (n=200) n (%)
Child age distribution (year)
2 44 (22)
3 42 (21)
4 48 (24)
5 66 (33)
Child dental caries status (dmft)
Caries free (0) 46 (23)
Mild (1‑4) 48 (24)
Moderate (5‑8) 47 (23.5)
Severe (9‑20) 49 (24.5)
Child dental anxiety (modified DAQ)
No dental anxiety 119 (59.5)
With dental anxiety 81 (40.5)
Child dental experiences
No 35 (17.5)
Yes 165 (82.5)
Child’s experience of BMTs
TSD 136 (68)
PP/PA 19 (9.5)
VC 32 (16)
AR 90 (45)
PR 53 (26.5)
OS 90 (45)
GA 5 (2.5)
BMT=Behavior management technique; TSD=Tell‑show‑do; VC=Voice
control; PR=Passive restraint; AR=Active restraint; PP/PA=Parental presence/
absence; OS=Oral sedation; GA=General anesthesia; DAQ=Dental anxiety
question; dmft=Decayed, missing, or filled primary teeth
Table 3: Mean Visual Analogue Scale score rated
for parental acceptance for each of behavior
management techniques
BMT Mean±SD
TSD 87.22±14.4
PR 74.53±23.8
VC 62.66±27.9
AR 61.39±31.1
Nitrous oxide 59.40±29.8
OS 57.40±30.6
GA 55.60±31.6
Parental presence/absence 51.08±32.8
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5. Seangpadsa, et al.: Parental acceptance of child management techniques
Journal of Indian Society of Pedodontics and Preventive Dentistry | Volume 38 | Issue 3 | July-September 2020 |
278
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’sexperiencewithBMTssignificantlyincreased
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 N2
O/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 (N2
O/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
Table 4:
The
factors
associated
with
parental
acceptance
of
behavior
management
techniques
BMTs
VC
AR
OS
GA
PP/PA
Factors
B (95%
CI)
P
B (95%
CI)
P
B (95%
CI)
P
B (95%
CI)
P
B (95%
CI)
P
Dental
anxiety
of
parents
Low (n=93)
−0.10 (−10.3‑10.1)
0.99
6.21 (−5.5‑18)
0.30
6.19 (−5‑17.4)
0.28
10.52 (−0.9‑21.9)
0.07
−2.16 (−13.8‑9.5)
0.71
Moderate (n=36)
−12.44 (−26‑1.1)
0.07
2.1 (−13.5‑17.7)
0.79
4.79 (−10‑19.6)
0.52
12.93 (−2.2‑28.1)
0.09
−11.49 (−26.9‑3.9)
0.14
High/extreme (n=18)
−0.09 (−18.1‑17.9)
0.99
11.55 (9.1‑32.2)
0.27
−3.66 (−23.3‑16)
0.71
−8.04 (−28.2‑12.1)
0.43
−31.35 (−51.8‑−10.9)
0.003*
BMT
experience
of
children
Experience
VC (n=32)
11.52 (0.4‑22.7)
0.04*
3.12 (−9.7‑15.9)
0.63
3.69 (−8.5‑15.9)
0.55
4.17 (−8.3‑16.6)
0.51
4.34 (−8.4‑17)
0.50
Experience
AR (n=90)
−3.33 (−12.9‑6.3)
0.50
12.6 (1.5‑23.7)
0.03*
2.06 (−8.5‑12.6)
0.70
6.85 (−3.9‑17.6)
0.21
−5.16 (−16.1‑5.8)
0.35
Experience
OS (n=90)
13.77 (−4.7‑32.3)
0.14
12.0 (−9.3‑33.3)
0.27
27.08 (6.8‑47.3)
0.01*
23.42 (2.7‑44.1)
0.03*
23.67 (2.6‑44.7)
0.03*
Experience
PP/PA (n=19)
0.22 (−13.6‑14)
0.98
−14.83 (−30.7‑1)
0.07
6.13 (8.9‑21.2)
0.42
−0.93 (−16.3‑14.5)
0.91
19.60 (3.9‑35.3)
0.02*
*Significant
association,
multiple
linear
regression,
*P<0.05.
BMT=Behavior
management
technique;
VC=Voice
control;
PR=Passive
restraint;
AR=Active
restraint;
PP/PA=Parental
presence/absence;
OS=Oral
sedation;
GA=General
anesthesia;
CI=Confidence
interval
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6. Seangpadsa, et al.: Parental acceptance of child management techniques
Journal of Indian Society of Pedodontics and Preventive Dentistry | Volume 38 | Issue 3 | July-September 2020 | 279
easilyacceptedbyparents.TSDisabasicforpractitioners
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
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
(N2
O/O2
),OS,andGA,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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