Re: Dental phobia and fear of the dentist

[sushantpatel_doc]

Behavioral dentistry is an interdisciplinary science. The objective of the science is to develop in a dental practitioner an understanding of the interpersonal social force that influences a patient’s behavior. The foundation of practicing dentistry on children is the ability to guide them through their dental experiences. This ability is a prerequisite to provide their immediate dental needs. The concept of treating the patient and not just the tooth should be the operative with all patients, but is essential with a child patient.

One major aspect of child management in the dental chair is managing dental anxiety, a worldwide problem and universal barrier to oral health care. The dentist treating a child patient almost always assesses one aspect of behavior – cooperativeness. Cooperative behavior is the key to render treatment. According to Wright (1975), children can be generally classified in one of the three ways: cooperative, lacking cooperative ability or potentially cooperative. There are many behavior-rating scales available to assess and evaluate the behavior of a child on each dental visit. The child’s behavior on every dental visit depends on variables like age, parental behavior, parental anxiety, past medical / dental history, the awareness of their dental problem, type of dental procedure, the behavior management, and the procedural techniques followed by the dentist. [1]

According to Folayan and Idehen, behavior management strategies range from informal and common sense techniques to formal relaxation techniques. [2] Formal relaxations vary from pre-appointment preparations to modeling procedures during the dental visit. Tell-show-do (TSD) introduced by Addelston in 1959, remains the corner stone of behavior management techniques followed by dentists. Machen and Johnson showed that the time spent per child has diminished when compared with the period before the approach was introduced. [3] Distraction, physical contact in the form of patting and stroking also tend to be effective in reducing anxiety that may accompany dental care. [4] A technique found to be effective in preventing dental anxiety developing in a child, who has a potential to do so, is the use of positive reinforcement. Here, the child is praised and given gifts when he shows acts of cooperation. The desensitization technique is effective for children who have developed dental anxiety. It entails gradual exposure of the child to dental treatments for short periods of time starting from noninvasive procedures. Pinkham JR has shown that it is a time consuming technique, but very rewarding as the child eventually becomes comfortable with the dental procedures. [5] These established psychological strategies have been found to be more effective because the strategies enhance trust, feelings of control, and the development of coping skills in both the child and professionals. This retrospective study was planned with the following aims and objectives:

1.To assess the behavior pattern of children during their dental visits
2.To evaluate the behavior management techniques used in managing the children during their dental visits
3.Age-wise and sex-wise comparisons of data collected

Materials and Methods

Case records of 247 children (144 boys and 103 girls) who had had a minimum of three visits to the Department of Pedodontics, Meenakshi Ammal Dental College, Chennai, India, were used to carry out this retrospective study. All the children were examined and treated by the same pediatric dentist. Wright’s modification of Frankl’s behavior rating scale was used to assess the behavior of all the children in each of their visits to the dental office. Behavior was recorded in their case records in every visit by the same examiner. Case records were categorized into four groups based on the ages of the children [Table 1]: Group I (45) included 22 boys and 23 girls in the age range of 3-6 years; Group II (115) 66 boys and 49 girls, between 6 and 9 years of age; Group III (72) included 48 boys and 24 girls in the age range of 9-12 years; and Group IV (15) eight boys and seven girls, above 12 years of age. Behavior management techniques used by the dentist in managing the children during the three visits were also evaluated. They were categorized as Tell-show-do (TSD), Voice control (VC), Hand over mouth exercise (HOME), and others (presence of mother, reinforcements, retraining, modeling). The type of behavior management technique used on each visit was noted in the case records. Any improvement or deterioration of behavior during the same visit was also recorded. Comparison of the proportion of behavior and behavior management techniques between different age groups during the three visits, and comparison of the proportion of behavior and behavior management techniques between the males and females of each group during the three visits were done. The proportions were compared by either the Chi-Square test, Chi-Square test with Yates continuity correction or Fisher’s exact test (two-tailed), appropriately. In the present study, p < 0.05 was considered as the level of significance.

Results and Discussion

On the first dental visit, 10 children exhibited Frankl 1 (Wright’s –) behavior. Twenty-three children showed Frankl 2 (Wright’s -) behavior. Frankl 3 (Wright’s +) was exhibited by 161 children. Fifty-three children showed Frankl 4 (Wright’s ++) behavior [Figure 1]. Statistically significant differences in Frankl 1 (–) and Frankl 2 (-) categories, between different age groups, were seen (p-value 0.003 and 0.02, respectively). No statistically significant differences between the male and female groups were seen in any of the age groups.

On the second dental visit, five children exhibited Frankl 1 (–) behavior. Eighteen children showed Frankl 2 (-) behavior. Frankl 3 (+) behavior was exhibited by 159 children. Sixty-five children showed Frankl 4 (++) behavior. Statistically a significant difference in the Frankl 1 (–) category between the different age groups was seen (p-value 0.004). No statistically significant difference between the male and female groups was seen in any of the age groups.

On the third dental visit, four children exhibited Frankl 1 (–) behavior. Eleven children showed Frankl 2 (-) behavior. Frankl 3 (+) behavior was exhibited by 160 children. Seventy-two children showed Frankl 4 (++) behavior. Statistically significant differences in the Frankl 1 (–) and Frankl 4 (++) categories, between the different age groups, were seen (p-value 0.02). No statistically significant difference between the male and female groups was seen in any of the age groups.

The overall assessment of behavioral pattern during the three dental visits did not show any statistically significant difference. However, there had been a definite improvement in the behavior of children on their subsequent visits as shown in [Figure 2]. Frankl 3 (+) was the most common behavior observed in the children, in this study. Almost 65% of the total children population showed Frankl 3 behavior on all the three dental visits.

On the first dental visit, Tell-show-do was used in all the 247 children. Voice control, Hand over mouth exercise and other techniques were used on 20, 1, and 14 children, respectively [Figure 3]. Statistically significant differences in using voice control and other techniques category between age groups were seen (p-value 0.03 and 0.001, respectively). No statistically significant difference between the male and female groups was seen in any of the age groups.

On the second dental visit, Tell-show-do was used in all the 247 children. Voice control, Hand over mouth exercise and other techniques were used on 16, 0, and 11 children, respectively. Statistically significant differences in using other techniques between age groups were seen (p value 0.049). No statistically significant difference between the male and female groups was seen in any of the age groups.

On the third dental visit, Tell-show-do was again used in all the 247 children examined. Voice control, Hand over mouth exercise, and other techniques were used on 14, 1, and 9 children, respectively. Statistically significant differences in using voice control between age groups were seen (p-value 0.03). No statistically significant difference between the male and female groups was seen in any of the age groups.

Overall assessment of behavior management techniques during the three dental visits did not show statistically significant differences. However, [Figure 4] clearly proves that there is a gradual reduction in the use of more aversive techniques like Voice control and Hand over mouth exercise on the subsequent visits. Tell-show-do was observed to be the most common behavior management technique used, and this technique was used routinely in all the children visiting the department.

In this study children showed improvement in their behavior on subsequent visits. Howitt and Stricker, Venham and Quatrocelli, and Venham and Cipes, have shown that the behavior of children improves in subsequent dental visits, [6],[7],[8] and their results are in accordance with this study. Koenigsberg and Johnson have shown that behavior cannot be predicted from the preceding appointment. [9] Venham L has shown that the younger group of children became more apprehensive on their subsequent visits. [10] However, both the studies quoted above have considered the effect of treatment procedures on the behavior of children. Folayan and Ufomata have shown that there is no association between age and gender with behavior of the child, [11] which is again in accordance with the present study.

Allen and Stanley demonstrated that traditional behavior management techniques like Tell-show-do, restraints, Hand over mouth exercise, and sedation were better than the newer ones like modeling and contingency management. [12] Carr and Wilson showed that the Southeastern US dentists used less aversive techniques and there was a marked reduction in the use of the Hand over mouth exercise. [13] Peretz and Ram showed that the Israel dentists used Tell-show-do and material reinforcement more than any other behavior management strategies. [14] Adair et al , emphasized that the AAPD members used communicative skills more often, with the exception of the Hand over mouth exercise. [15] All the above-mentioned reports have been in favor of the results of this study and they emphasize the significance of Tell-show-do in the field of behavioral pediatric dentistry.

Summary and Conclusions

The findings and the results of this study can be summarized as follows

1.Better behavioral response was seen on subsequent visits
2.Frankl 3 (+) was the most common behavioral pattern seen
3.Tell-show-do was the most common management technique used
4.Reduction in the use of more aversive techniques on subsequent visits
5.There was no significant difference between boys and girls in their behavior pattern and the management techniques used

Behavior assessment helps us to plan appointments and provide quality oral health care to children. Proper use of management techniques improves behavior on subsequent visits, making things easy for the child patient and the pediatric dentist. Assessment and evaluation helps us to reinforce our beliefs in our own techniques.