|Year : 2023 | Volume
| Issue : 1 | Page : 97-105
Behavior management techniques adopted by pediatric dentists in Cairo, Egypt: A cross-sectional study
Samah M Kanzel1, Kamal El Motayam2, Fatma Abdelgawad2
1 Pediatric Dentistry and Dental Public Health Department, Faculty of Dentistry, Aden University, Aden, Yemen
2 Pediatric Dentistry and Dental Public Health Department, Faculty of Dentistry, Cairo University, Cairo, Egypt
|Date of Submission||11-Jun-2022|
|Date of Decision||06-Dec-2022|
|Date of Acceptance||07-Dec-2022|
|Date of Web Publication||28-Feb-2023|
Dr. Samah M Kanzel
Pediatric Dentistry and Dental Public Health Department, Faculty of Dentistry, Aden University, Aden
Source of Support: None, Conflict of Interest: None
Introduction: The child patient is exposed to the dental environment that triggers natural fear response, so behavior management strategies are required to meet their needs. Objective: The objective of the study was to identify the most common behavior management techniques adopted by pediatric dentists in three Egyptian universities for each patient group. Materials and Methods: In this cross-sectional study, we applied convenient sample to the three major governmental universities located in Cairo. Ninety-two questionnaires were distributed to all pediatric dentistry specialists of the three universities. They were designed to record participants’ demographic and practice information and their current use of behavior management techniques for each patient age. Descriptive statistics, Chi-square (χ2) test, and Bonferroni corrections were used to analyze data. Results: Questionnaires were returned by 72 pediatric dentists (27.8% were males and 72.2% were females). Parental presence was practiced by all participants mainly for patients less than 2 years (93.1%). Tell-show-do is the most used technique (95.8%) for patients of 3–5 years. The use of advanced techniques by respondents was less than basic techniques, being least for sedation and highest for general anesthesia. Female respondent preferred basic behavior management techniques, whereas male participants chose advanced techniques more than females. Conclusions: Different behavior management techniques are being practiced for each patient group. The choice of the technique was influenced by the practitioner gender, years in practice, and position in the faculty.
Keywords: Behavior Guidance, Behavior Management Techniques, BMT, Dental Anxiety, Pediatric Dentistry
|How to cite this article:|
Kanzel SM, El Motayam K, Abdelgawad F. Behavior management techniques adopted by pediatric dentists in Cairo, Egypt: A cross-sectional study. J Int Oral Health 2023;15:97-105
|How to cite this URL:|
Kanzel SM, El Motayam K, Abdelgawad F. Behavior management techniques adopted by pediatric dentists in Cairo, Egypt: A cross-sectional study. J Int Oral Health [serial online] 2023 [cited 2023 Apr 2];15:97-105. Available from: https://www.jioh.org/text.asp?2023/15/1/97/370742
| Introduction|| |
Dental treatment exposes the child patient to an environment that triggers natural fear response, leading to difficulties in accepting certain types of treatment or even dental avoidance. Consequently, behavior management techniques (BMTs) are required to meet the needs and the developmental stage of each child patient.
As the etiology of dental anxiety is multifactorial, it is important to have a wide variety of BMTs tailored according to the need of the patient and the skills of the pediatric dentist. Moreover, the choice of BMT should reflect changes in parenting attitude and legal precautions.,,
BMTs are set of procedures employed by dental practitioners used to alleviate anxiety, establish communication, instill positive dental attitude, and enable performing quality oral health care safely and efficiently for children and persons with special healthcare needs.,,
The American Academy of Pediatric Dentistry (AAPD) has classified behavior guidance techniques (BGT) into basic and advanced techniques. Basic BGT included communication and communicative guidance, positive previsit imagery, direct observation, ask-tell-ask, voice control, nonverbal communication, tell-show-do (TSD), positive reinforcement and descriptive praise, memory restructuring, distraction, parental presence/absence, and nitrous oxide/oxygen analgesic. These techniques are considered the foundation for all the management activities provided by the dentist. However, some uncooperative children require more advanced techniques, e.g., protective stabilization, sedation, and general anesthesia (GA). Hand over mouth technique has lost its popularity being used less by pediatric dentistry practitioners, until it was eliminated from the clinical guidelines of AAPD.
The aim of this study is to identify the most common BMTs adopted by pediatric dentist in three governmental universities located in Cairo for each specific patient’s age in the management of uncooperative children.
| Materials and Methods|| |
Setting and design
A cross-sectional study was conducted in Cairo, Egypt, at Pediatric Dentistry Departments of Cairo, Ain-Shams, and Al-Azhar Governmental Universities for a period of 6 months, starting from January 11, 2017. Ninety-two questionnaires were distributed to pediatric dentists working or studying at those universities.
The power analysis has been applied to possess sufficient power to undertake the statistical test of null hypothesis such that there is no association linking the choice for BMTs and children’s age. By using a power of 80%, an alpha level of 0.05, a beta level of 0.2, in addition to effect size (ω) represented by 0.726, it was derived using the outcomes of an earlier study; a minimum required sample size was estimated to be 60 participants. G*Power version 184.108.40.206 was used to calculate sample size.
Convenient consecutive sample was applied; all pediatric dentist’s specialists in the mentioned universities were selected. Participants were either university staff members (master’s degree or PhD holders) or PhD students. The primary outcome was the BMTs adopted by them for each child age.
Inclusion criteria include qualified pediatric dentists (master’s and doctorate holders). The participants who were unwilling to participate or absent on all days of questionnaire distribution were excluded from the study; incomplete questionnaires were attempted to be returned to participant to finish all items; and if the attempt is unsuccessful, the questionnaire was excluded.
Ethical approval and informed consents
The ethical approval was obtained from the Research Ethics Committee, Faculty of Dentistry, Cairo University, with the identification No. 16-10-6. The Declaration of Helsinki’s guidelines were used to perform the study, with an existing ClinicalTrial.gov identification number: NCT03608124. Furthermore, approvals from Ain-Shams and Al-Azhar Universities to be included in the study were granted by signing an official letter from the Pediatric Dentistry and Dental Public Health Department, Faculty of Dentistry, Cairo University, for their participation in the study. All research methods were performed in accordance with Cairo University guidelines and regulations, which were in alignment with the other two universities. Participants were verbally informed about the study, and all details were written at the beginning of the questionnaire. Participants were asked at the beginning of the questionnaire that their participation is voluntarily, and by filling the questionnaire, their consent was granted.
Questionnaire was constructed based on AAPD Guidelines., It was in English language and designed to record the participant’s demographic and practice information and their current use of BMT. The questionnaire determines the most common techniques used for each child’s age and their relationship to practitioner gender, total year in practice, and position in the faculty.
A self-administered questionnaire was provided to pediatric dentists at their offices in the designated faculties, after department meetings or at the departments’ clinics. Each university was visited at least three times depending on the number of absent subjects. Participants were provided with enough time nearly 10–15 min to answer the questions.
Before starting of the questionnaire, we explained the nature of our study to the participating pediatric dentists and asked them to write exactly what they use for each child’s age group.
Categorical information was displayed in a form of percentage values and frequencies. Data were examined using the Chi-square test and then multiple pairwise comparisons with Bonferroni correction and multiple z-tests. At P < 0.05, the significance level has been established within all tests and based on a 95% confidence interval. Tables and figure were used to represent results. R statistical analysis software for Windows, version 4.1.3, was used to conduct the statistical analysis.
Questionnaires were written in English language and consist of 22 items in binary question format (yes/no) and multiple-choice questions; each item scores one to determine the most common BMTs for each patient’s age; and their relationship to practitioner gender, total year in practice, and position in the faculty as shown in Appendix (I).
| Results|| |
Personal and demographic information
Surveys were returned by 72 pediatric dentists (78.3% response rate); personal and demographic information of study participants is presented in [Table 1].
Association between behavioral management techniques’ preference and child’s age groups
Associations between BMTs’ preference and child’s age groups are presented in [Table 2]. For “parental presence,” the difference was statistically significant with higher percentage of participants choosing to use the technique with 0–2 years and 3–5 years with P value less than 0.001. For “TSD,” there was statistically significant difference (P < 0.001). Post hoc pairwise comparisons revealed the percentage of participants choosing to use the technique with 3–5 years and 6–8 years to be significantly higher than those choosing other age groups (P < 0.001). In addition, they showed percentage choosing 9–12 years to be significantly higher than those choosing 0–2 years (P < 0.001). For “GA,” there was a statistically significant difference (P > 0.001). Post hoc pairwise comparisons revealed the percentage of participants choosing to use the technique with 0–2 years and 3–5 years to be significantly higher than those choosing other age groups (P < 0.001). In addition, they showed percentage choosing 6–8 years to be significantly higher than those choosing >12 years (P < 0.001).
Association between behavioral management techniques’ preference and practitioner gender
Associations between BMTs’ preference and practitioner gender are presented in [Table 3]. For “TSD,” “nonverbal communication,” “voice control,” and “positive reinforcement,” significantly higher percentage chose to use the technique with females (P < 0.05). For “nitrous oxide sedation,” “oral sedation,” and “GA,” significantly higher percentage chose to use the technique with males with P value less than 0.05. For other techniques, there were no statistical significant differences (P > 0.05).
Association between behavioral management techniques’ preference and practitioner experience
Associations between BMTs’ preference and practitioner total years in practice are presented in [Table 4]. Significantly higher percentage of practitioners with more than 10 years of experience chose to use “TSD” in addition to “GA” with P value less than 0.05. Regarding other techniques, there were no statistical significant differences (P > 0.05).
|Table 4: Association between BMTs’ preference and practitioner years of experience|
Click here to view
Sedation or GA was the first alternative to hand over mouth exercise (HOME) after its elimination from AAPD clinical guidelines, as shown in [Figure 1].
|Figure 1: A bar chart showing pediatric dentist’s opinion regarding the first alternative to hand over mouth exercise|
Click here to view
Response rate was 78.3%, calculated by dividing number of participants who filled the survey to the number of participants who received them and multiplying by 100.
| Discussion|| |
As a result of the profound social changes and the modification in parenting styles, most of the parents prefer to become actively involved in their children’s oral health. The pediatric dentists recognized those changes and accommodated by allowing the presence of parents in the dental setting. In the study conducted in Saudi Arabia, parental presence was preferred by most parents; they reported that the main reason for their preference was safety and protection.
TSD technique was the most used technique for patients of 3–8 years, which was in accordance with previous studies.,, TSD is a simple, nonintrusive technique being accepted by pediatric dentists in addition to parents.,, In 2018, Rajasekhar et al. indicated that 43.1% of the participating pediatric dentists chose TSD to build a strong dentist–patients relationship. The justification is that children of 3–6 years have an imaginary way of thinking and tend to represent objects symbolically. They became considerably eager to learn about dental office. Therefore, describing the procedure and enabling them to explore dental instruments might affect the management process positively.
On the other hand, low proportion of pediatric dentists employed nitrous oxide analgesia/sedation for their patients, which reveal its unpopularity in Egypt. It was prohibited by the Egyptian Ministry of Health and Population in 2008, after some serious incidences due to the presence of impurities within nitrous oxide tank and its usage did not return up till now. On the contrary, nitrous oxide reported to be used by most pediatric dentists in many other countries. In another survey conducted in 2018 among members of the AAPD, they concluded that using nitrous oxide sedation for their child patients was increasing. According to AAPD guidelines on nitrous oxide sedation, it has an excellent safety when used by trained practitioner for carefully selected patients with suitable equipment and technique.
The least used technique was sedation (oral, intramuscular, and intravenous) compared with other BMTs, and this might reflect the more psychological trend in managing young patients and participant’s preference for GA more than sedation. Furthermore, anesthesiologists prefer GA over sedation in dental treatment as the risk of aspiration and/or inhalation is increased with sedation because of the absence of oral pack. Moreover, sedation usually needs several visits for treatment completion, whereas in general anesthesia (GA), the whole treatment can be accomplished in one session. Studies tracking sedation have shown a gradual decrease in popularity. In 1999, 70% of study participants reported employing conscious sedation. Then in 2004, Adair et al. indicated that 62% of pediatric dentists were utilizing conscious sedation. The percentage even decreased within the active AAPD members in 2018 to 15%. Surprisingly, in this study, sedation and general anaesthesia were selected by most participants to be the first alternative to HOME. The reason for eliminating and rejecting HOME was the possibility of inducing fear or psychological trauma to the child.,
Participants with more experience reported more frequent use of GA mainly for young children, because of the fact that they are more prepared to perform treatment under GA in their universities or private hospitals, in addition to societal increased demand for more comfortable treatment and parental acceptance of the advanced pharmacological BMTs instead of protective stabilization. GA can provide comprehensive management for young children with their infantile behavior and immature communication ability in a single visit and immediate relief of dental pain when other behavior measures fail.
According to this study, basic techniques were preferred by females, whereas males were more into advanced techniques. This finding was slightly different from Wells et al. study, where female pediatric dentists were substantially more likely to use passive restraint, nitrous oxide, TSD, and oral sedation.
To sum up, there is a wide diversity of BMT being used by the pediatric dentists for different children’s ages and situations; their appropriate use was proven to improve children behavior during dental treatment. The limitations of this study include those common to surveys, in which data quality is dependent on respondent conscientionsness in addition to the relatively small sample size. We recommend further studies on BGTs systematically in the dental setting in other governmental and private universities as well as in private hospitals or clinics.
| Conclusions|| |
Within the constraints of this research, we came to the conclusion that the utilization of BMTs has been changed, with a range of behavior management strategies practiced for managing uncooperative pediatric patients. Implementing each BMT was affected by age of children. Nitrous oxide and sedation were the least prevalent techniques among participants. The selection of different BMT was influenced by gender and degree of experience.
Many thanks to Dr. Philip Rowe, Visiting Research Fellow at Liverpool John University, United kingdom, for his contributions to the preliminary statistical analysis (permission to acknowledge has been taken from Dr. Rowe).
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
Guarantors of integrity of entire study, SMK, KM, FA; study concept, literature research, data acquisition, drafting for article, article preparation, SMK, FA; study design, data analysis/interpretation, discussion, SMK, FA; article revision/review, FA, KM; supervised and proofread article, SMK, FA, KM.
Ethical policy and institutional review board statement
Ethical approval was obtained from the Research Ethics Committee, Faculty of Dentistry, Cairo University on 24/10/2016 with the identification no. 16-10-6. All research methods were performed in accordance with Cairo University guidelines and regulations. Signed consent was waived in this study because it meets the Cairo University Research Ethics Committee requirements for waiving all consent.
Participant declaration of consent
Data availability statement
Materials, data, and associated protocols are available with the corresponding author upon request with no restrictions.
| Appendix (i)|| |
Faculty of Dentistry
Pediatric Dentistry Department
Questionnaire for pediatric dentistry practitioners regarding their uses of behavior management techniques for uncooperative children
This is a cross-sectional study entitled “behavior management techniques adopted by pediatric dentists in three Egyptian Universities” that will be conducted to identify the most common behavior management techniques adopted by pediatric dentist in three governmental universities located in Cairo for each specific patient’s age in the management of uncooperative children. This study targets pediatric dentists (master’s degree or PhD holders). This study was approved by the Research Ethics Committee, Faculty of Dentistry, Cairo University with approval number 16-10-6. Your responses on this questionnaire are confidential and your identity will be anonymous, and we will not ask you about your name. The information will be entered into the computer and analyzed along with all other responses. The questionnaire will take 10- 15 minutes of your time, and we want to thank you for agreeing to participate in this survey. Your responses are very important to us. Your participation is voluntary, and you are free to stop filling the questionnaire at any time. For further inquiries, please contact Samah Mohsen (01061494753) or Associate Prof. Fatma Abdelgawad (01006753265). This is a self-funded study.
Please answer with (√) in the appropriate place
- I. 1st alternative for HOME after its elimination from clinical guidelines of AAPD is: a- Voice control b- Sedation/G.A. c- HOME shouldn’t be eliminated
- II. Do you think audio-visual distraction aids is an effective method in anxiety management? No □ Yes □
- III. In your clinic, do you have rest area specially designed for children?
Yes □ No □
- IV. Further comments:
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]