175European Archives of Paediatric Dentistry // 11 (Issue 4). 2010

Key words: Behaviour management, behaviour-management techniques, parental attitude.

Postal address: Dr L. J. Bellet Dalmau. Dept. of Paediatric Dentistry, Faculty of Dentistry, International University of Catalonia, General Hospital in Catalonia, Josep Trueta, s/n. 08190, St. Cugat del Vallès (Barcelona), Spain

Email: ljbellet@csc.uic.es

J. Luis de León, F. Guinot Jimeno, L. J. Bellet Dalmau Dept. of Paediatric Dentistry, Faculty of Dentistry, International University of Catalonia, Sant Cugat del Vallès (Barcelona), Spain.

Acceptance by Spanish parents of behaviour-management techniques used in Paediatric Dentistry

AbstractAIM: This was to examine the attitude of a group of Spanish parents towards behaviour-management techniques used in paediatric dentistry. METHODS: A video with 8 different behaviour-management techniques used in paediatric den-tistry was shown to 50 parents whose children were being treated at the International University of Catalonia (Barce-lona, Spain). The techniques shown were: tell-show-do, nitrous-oxide sedation, passive restraint, voice control, hand-over-mouth (HOM), oral premedication, active restraint and general anaesthesia. Parents gave an acceptance rating of each of these techniques according to a scale of 0 to 10, with 0 being the lowest level of acceptance and 10 the high-est. RESULTS: The technique rated as most acceptable was the tell-show-do technique, while the least accepted was the HOM technique. An association was found between accept-ance of the different techniques and the socioeconomic status and gender of the parent, and the differences were

were found regarding the age or gender of the child treated, or the previous dental experiences of those interviewed or of their children, with acceptance of each of the techniques. CONCLUSIONS: The techniques were well accepted by all those surveyed with the exception of HOM technique and the use of the papoose board. On comparing this study to other studies previously carried out in other areas of the world, similar results were found.

IntroductionAnxiety and fear of dental treatment have been recog-nized 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 populations surveyed [Klingberg et al., 1994; Wogelius et al., 2003; Klingberg and Broberg, 2007; Lee et al., 2007]. The mean expected being around 9% as recently estimated by Klingberg [2008].

Behaviour management of child patients is essential in the practice of paediatric dentistry. Children’s behaviour can be managed using various techniques that have been widely described in the literature. It is necessary to understand which of the various techniques are acceptable to parents

a particular technique or disapproval. Bearing this in mind,

optimum communication between parents and dentists should be aimed at, so that paediatric patients are provided the best possible dental treatment.

Throughout the history of paediatric dentistry, attempts have been made to ensure the cooperation of child patients during

-ing children’s behaviour has been necessary. The different behaviour-management techniques have been aimed at maintaining communication with the patient while at the same time eliminating inappropriate behaviour [Wright, 1975].

There is a large body of literature showing that there have been changes in the behaviour-management techniques used in paediatric dentistry. Acceptance by parents, legal aspects, ethical issues, the viability and access of certain techniques, are the factors most frequently mentioned as being behind the changes in behaviour-management tech-niques in recent years [Wright, 1975; Davis, 1988; Houpt, 1993; Kuhn and Allen, 1994].

Various studies carried out over the last decades have shown how parents may accept one technique more than another, depending on the treatment that their child requires. Murphy

acceptance of behaviour-management techniques. In their study, they concluded that tell-show-do was the technique that was accepted by most parents. General anaesthesia (GA) and physical restraint by means of a papoose board were the least accepted. Since the reports of Murphy et al [1984] a number of further studies have been carried out over the years to identify those techniques that are most widely accepted and those that are not. One of these studies, by Lawrence et al. [1991] found that parents accepted the different techniques as long as they were given a detailed explanation of what they consisted of.

The socioeconomic status of the parents is another vari-

[Havelka, 1992]. According to Scott and García-Godoy [1998], the parents of Hispanic children accept the tell-show-do technique more than the use of hand-over-mouth (HOM) or a form of restraint such as the papoose board (PB). And yet, in a study carried out in the early 1990s, Frankel [1991] found a high level of acceptance among the mothers of chil-dren treated with the aid of PB.

176European Archives of Paediatric Dentistry // 11 (Issue 4). 2010

Acceptance of each of these behavioural management tech-niques has changed over time, differing also according to the culture of the geographical region in question [Long, 2004]. Carrying out studies to assess parental acceptance or rejec-tion is important as parental attitudes towards the application

that paediatric dentistry patients receive appropriate care. On many occasions, parents expect a paediatric dentist to have the ability to administer local analgesia to a child who may be

because he or she is a ‘children’s dentist’.

A recent parental survey by the American Board of Paediatric Dentistry Diplomates on the practical effects of behaviour-management techniques has indicated that children’s behaviour is said to have deteriorated over the past dec-ade [Casamassimo et al., 2002]. It concluded that children tend to cry more now than in the past, and the way parents approached childcare was blamed together with higher rates of divorce and other social factors. As a result, the use of effective behaviour management and pharmacological tech-niques by paediatric dentists has increased over the years. One of the most recent studies in this area was published by Eaton et al. [2005] in the USA. It was concluded that physical restraint and HOM were the least accepted techniques, while GA was third on the list of the most accepted techniques.

All of the behavioural management techniques, as described in the literature, are mostly in routine use by Spanish pae-diatric dentists. However, there has been no research on attitudes to these techniques by Spanish parents. Accord-ingly, the purpose of this study was to examine the attitude of Spanish parents towards behaviour-management techniques used in paediatric dentistry.

Materials and methodsStudy sample. The sample in this study was made up of fathers and mothers who brought their children aged 3 to 13 years for treatment by students in the Comprehensive Paedi-atric Dentistry Master’s Degree Program at the International University of Catalonia’s Dentistry Clinic (Barcelona Prov-ince, Spain). The following groups were excluded from the sample: children with mental or physical disabilities, children receiving pharmacological treatment for a chronic disorder, children under 3 years of age and children over 13 years of age. The sample consisted of 50 parents.

Questionnaire. Data was collected by means of an anony-mous questionnaire in which parents indicated their opinions regarding the different behaviour-management techniques used during dental treatment. The questionnaire also included information on the gender of the parent being sur-veyed, the number of children receiving dental treatment at the University Dental Clinic, the gender and age of the child, the parents’ previous experience of dental treatment, the child’s previous experience of dental treatment, and the socioeconomic status of the families.

Demonstration of behaviour management techniques. After each child’s medical history had been taken, the par-ents were invited either alone or in groups to a previously reserved classroom at the International University of Cata-lonia and shown a 12-minute video on a 2m x 2m screen using an EPSON EMP-81 projector. Following the showing of the video, which demonstrated and explained each of the behaviour-management techniques used in paediatric den-tistry, the parents were given a questionnaire in which they were asked to evaluate each of these techniques. The video shown to parents was the same as that used by Eaton et al. [2005], and approved by the AAPD. It was shown together with a video dialogue that had been translated into Span-ish and offered parents an explanation of what each of the behaviour-management techniques involved.

Rating. Parents personally evaluated each of the techniques shown in the video on a scale of 0 to 10, with 0 meaning that the parent was completely opposed to the technique and 10 meaning that the parent completely accepted the use of the technique. The behaviour-management techniques assessed were as follows (according to the order in which they appeared in the video): tell-show-do, nitrous-oxide sedation, passive restraint using a PB, voice control, HOM, oral premedication, active restraint by dental staff and GA. Parents had voluntarily signed an informed consent form beforehand acknowledging that they would be taking part in a study carried out by students in the Comprehensive Paediatric Dentistry Master’s Degree Program of the Interna-tional University of Catalonia, so that their opinions could be included in the sample and be valid for the study.

Parental background. Asking each parent to give his or her approximate annual family income assessed the socioeco-nomic status of each parent. An annual income of less than €9.000 was considered low, while €9.000 to €30.000 was

was considered high.

Statistical evaluation. All values were expressed as percent-ages. Replies were analyzed using the STATGRAPHICS® Plus Version 5.0 statistics software system, in order to obtain comparative diagrams and graphs using the ANOVA multi-factorial system.

ResultsAll of the 50 parents who agreed to take part in the study completed the questionnaires and signed the informed con-sent form they were given. There were 34 women and 16 men. With regard to the gender of the children treated at the University, 56% of the children were girls and 44% were boys. In the survey 54% had an average socioeconomic level, 32%

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Previous experience of dental treatment was positive for 86% of children and negative for the remaining 14%. As far as the

J. Luis de León, et al.

177European Archives of Paediatric Dentistry // 11 (Issue 4). 2010

Parental acceptance of Behaviour management

parents were concerned, previous dental experience was positive for 94% and negative for 6%.

Tell-show-do was the most accepted technique. This was followed in decreasing order of acceptance, percentage response, by voice control, active restraint, nitrous-oxide

-niques (Figure 1).

-economic level was associated with passive restraint PB (p = 0.0257), active restraint (p = 0.0063), oral premedication (p = 0.0015) and GA (p = 0.0014). While there was no difference in the acceptance of these techniques among those in the low and average socioeconomic groups, a different response was found among those belonging to the high socioeconomic group, who were less ready to accept them.

the gender of the person surveyed was associated with the technique of oral premedication, which fathers accepted

differences (p <0.05) were found when analyzing acceptance on the basis of previous experience of dental treatment by either patient or parents.

DiscussionVarious authors have studied the attitude of parents of paedi-atric patients regarding the different behaviour-management

the years with regard to the order of acceptance of these techniques [Lawrence et al., 1991; Frankel, 1991; Havelka et al., 1992; Scott and García-Godoy, 1998; Eaton et al., 2005].

Comparing our own study with three studies that have recently been carried out and which are the most similar to ours [Murphy et al., 1984; Lawrence et al., 1991; Eaton et al., 2005], we found a change in the ranking of the techniques

over time (Table 1). Tell-show-do has remained the most accepted technique for parents. The second most accepted technique in our study was voice control, unlike the other more recent studies that have a shown a gradual decrease in acceptance of this technique. In the Eaton et al. study [2005] it was in sixth position.

In our study, active restraint (PB) was ranked in third place. When this result was compared with those of earlier stud-ies [Murphy et al., 1984; Lawrence et al., 1991; Eaton et al., 2005], there was little difference as the technique was among those having the greatest acceptance in all the stud-ies reviewed.

Eaton et al. [2005] concluded, in their most recent study in the USA, that acceptance of the use of nitrous-oxide seda-tion had increased among parents in recent years. Foley [2005] suggests that the perception amongst dentists treating patients using nitrous-oxide sedation is generally less enthu-siastic than the patients themselves and their accompanying carer. However, in our study we found that it did not even appear among the top three techniques most accepted by Spanish parents.

The HOM technique was the least accepted, although its acceptance has varied over the years. Many specialists choose not to use this technique, as they consider it to be illegal and unprofessional, and they also feel it should not be used because parents will react negatively [Bowers, 1982]. However most recently a report by Oueis et al [2010], on paediatric dentists in the USA attitudes to HOM indicated that, although HOM was not included in any AAPD Guide-lines 50% of those dentists responding felt it was still an acceptable technique. The use of HOM continues to be most controversial.

If three of the latest studies completed in the USA are exam-ined [Murphy et al., 1984; Lawrence et al., 1991; Eaton et al.,

Figure 1. Levels of parental acceptance of different behav-iour-management techniques for the dental care of children as assessed by a group of Spanish parents.

Table 1: Results of recent studies in the USA showing ranking of acceptance of different behaviour-management techniques.

Murphy et al. [1984]

Lawrence et al. [1991]

Eaton et al. [2005]

1. Tell-show-do Tell-show-do Tell-show-do

2. Positive reinforcement

Nitrous oxide Nitrous oxide

3. Voice control Voice control General anaesthesia

4. Active restraint Active restraint Active restraint

5. Hand-over-mouth Hand-over-mouth Oral premedication

6. Sedation Passive restraint (papoose board)

Voice control

7. General anaesthesia

Oral premedication Passive restraint (papoose board)

8. Passive restraint (papoose board)

General anaesthesia

Hand-over-mouth

178European Archives of Paediatric Dentistry // 11 (Issue 4). 2010

2005], there seems to have been an increase in the accept-ance of sedation and oral premedication. In 1984 Murphy et al., found that sedation was among the least-accepted tech-niques. Sedation remained in that position in 1991 [Lawrence et al., 1991], but by 2005 [Eaton et al., 2005] acceptance had increased noticeably. In a study carried out in a city hospital it was found that more than 50% of the parents who took their children to an emergency unit asked for their children to be sedated before dental treatment [Quinby et al., 2004].

Acceptance of GA has also increased, but only in stud-ies carried out in the USA, where it was found that parents increasingly asked for their children to be given a GA for any dental procedure, because they said that the child had cried during the previous visit. They did not actually understand

sedation [Sheller, 2004]. The situation in Europe on seda-

extent there have been any changes in attitudes to sedation.

It was not possible to ascertain whether acceptance of GA has increased among parents in Spain as no previous stud-ies have been carried out. In our study, it was ranked in fourth position in the table of most accepted techniques. The data obtained in this study should be compared with the results of future studies so that any developments are known. The

from the high socioeconomic group accepted it least. Results were similar to those of previous studies [Murphy et al., 1984; Lawrence et al., 1991; Eaton et al., 2005], as this technique always appeared in the less accepted group.

Passive restraint using a PB, or ‘protective immobilization’ as it is sometimes called, has always been among the least accepted techniques. Murphy et al., [1984] reported it was the least accepted of all the techniques. By 1991 [Lawrence et al., 1991] it rose to sixth position, falling to seventh posi-tion in 2005 [Eaton et al., 2005], and in our study it came second last. As can be seen, this technique continues holding little attraction for parents over the years. However, Frankel [1991] found a high level of acceptance among mothers of non-cooperative children treated with this technique. This study was completed on the basis of a survey in which 90% of mothers said that they would agree to the use of the PB board again for subsequent visits, believing it would not have any negative effects on the child.

ConclusionBased on the results of this study, the technique that is most accepted, even with the passage of time, is tell-show-do. Parents still have a low opinion of the hand-over-mouth technique and levels of acceptance remain very low. The socioeconomic level of parents affects their acceptance of general anaesthesia, active restraint, papoose board and oral premedication techniques. The gender of the parent also affects the decision to give the child oral medication before dental treatment, with fathers showing greater acceptance of this technique.

AknowledgementsThe Ethics Committee of the International University of Catalonia approved the methods used in this study.

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