RESEARCH ARTICLE

Acceptance of Parents for Behavior Management Technique

with Reference to Previous Dental Expertise and
Dental Anxiety
Harshita Shukla1, Sadanand Kulkarni2, Milind B Wasnik3, Nilesh Rojekar4, Durga Bhattad5, Pratima Kolekar6

A b s t r ac t
Introduction: Behavior management of pediatric patients may be done by behavioral and pharmacological techniques. Parents play a vital
role when making a decision for treatment for the kid.
Aim: To evaluate parental acceptance towards behavior management techniques (BMT) at the side of its reference to previous dental expertise
and dental anxiety.
Materials and methods: A descriptive cross-sectional survey was conducted among forty parents of children between three to twelve
years before dental treatment. The statistical analysis was done using the Chi-square test, Student’s paired and unpaired t-test. p < 0.05 was
considered statistically significant. Data analysis was performed using software package of statistical analysis (SPSS 22.0 version and GraphPad
Prism 6.0 version).
Results: The most accepted technique was audiovisual technique followed by tell-show-do and anesthesia. The least accepted technique was
oral sedation. Parents whose children were treated at the Postgraduate Clinic of Department of Pediatric Dentistry had lower incomes than
those from the private practice. 24% preferred general anesthesia compared to active restraint.
Conclusion: Audiovisual technique is the most accepted behavior management technique by parents and is an efficient distraction technique
for behavior management for anxious pediatric patients. Postgraduate clinic parents had lower incomes than those at the private practice.
Parental dental experience and dental anxiety didn’t have an effect on the acceptance of any specific behavior management technique.
Keywords: Audiovisual technique, Behavior management (BMT), Parental dental anxiety.
International Journal of Clinical Pediatric Dentistry (2021): 10.5005/jp-journals-10005-2115

Introduction 1–6
Department of Pedodontics and Preventive Dentistry, Swargiya
McElory (1895) has fantastically expressed that “Although operative Dadasaheb Kalmegh Smruti Dental College and Hospital, Nagpur,
dentistry could be perfect, the appointment may be a failure if Maharashtra, India
a child departs in tears.” Stress is usually related to infants initial Corresponding Author: Harshita Shukla, Department of Pedodontics
dental visit and has a poor impact on infant’s psychology creating and Preventive Dentistry, Swargiya Dadasaheb Kalmegh Smruti
the dental appointment ugly one.1 Dental College and Hospital, Nagpur, Maharashtra, India, Phone:
Anxiety is one of the vital reasons for not seeking dental +91 915 8438020, e-mail: [email protected]
treatment by youngsters. Malamed, claims that anxiety, associate How to cite this article: Shukla H, Kulkarni S, Wasnik MB, et al.
degreed pain are related to the dentistry since past though he Acceptance of Parents for Behavior Management Technique with
acclaims that dentist shouldn’t be considered as an instrument Reference to Previous Dental Expertise and Dental Anxiety. Int J Clin
of pain. Pediatr Dent 2021;14(S-2):S193–S198.
Alvesalo (1993) expressed that among 6–12-year-old youngsters Source of support: Nil
showed that 20–43% exhibited high dental fear. Anesthetic Conflict of interest: None
needles verified to be the foremost fear-eliciting stimuli. Negative
dental experiences due to dental pain end up in the development
of fear and anxiety, which may result in the turning away of further A substantial proportion of youngsters don’t cooperate within
dental treatment. Thus, the concern of painful dental treatments the dental chair, therefore forestalling the delivery of high-quality
and dental anxiety square measure unsupportive issues with that attention. To attain cooperation throughout dental treatment, it
dentists should cope up.4 Since youngsters exhibit a broad variety became necessary to switch or influence the children’s behavior.6
of physical, intellectual, emotional, and social development and Behavior management technique (BMT) is extremely useful in
a diversity of attitudes and temperament, it’s vital that dentists some children if they are unwilling or unable to cooperate. These
have a large variety of Behavior guidance techniques to fulfill the techniques dissent in their averseness, and additional aversive
wants of the individual child and be tolerant and versatile in their techniques could also be needed for kids. These techniques
implementation.5 square measure alternatives or adjuncts to the dentist to deliver
Behavior management of the child patient is an associate efficient dental treatment.7 Different studies suggested that all
degree integral element of the pediatric practice to attain the BMT were not equally acceptable to parents and some techniques
cooperation of the child throughout the dental treatment. were generally unacceptable.6

© The Author(s). 2021 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons.
org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and non-commercial reproduction in any medium, provided you give appropriate credit to
the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain
Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
 Parental Acceptance of Behavior Management Technique

Tell-show-do is the most accepted technique in most previous period participated in the study. Parents of children with mental or
studies (Murphy et al., 1984; Lawrence et al., 1991; Abushal and physical disabilities were excluded from the sample (Fig. 1).
Adenubi, 2003; Eaton et al., 2005; Alammouri6; Luis de Leo’n et al.,
2010; Muhammad et al., 2011). General anesthesia, conscious Video
sedation, physical restraint, and hand-over-mouth are always Video with an introduction to each behavior management
reported, although in differing order, as the least accepted technique, explaining the techniques one by one, was made for use
techniques (Murphy et al., 1984; Lawrence et al., 1991; Abushal and in this study. Three children (one girl seven years old, and two boys
Adenubi, 2003; Eaton et al., 2005; Alammouri6; Luis de Leo’n et al., eight years old) acted in the video with the prior written informed
2010; Muhammad et al., 2011).8 consent of their parents. The children were instructed to react as
Parents have a really vital factor for the productive dental if they were actually receiving the dental treatment. The video,
treatment of a toddler, since he/she is answerable for the kid, brings which lasted 10 minutes, was recorded in the postgraduate clinic.
the kid to the dentist, and makes the final selections concerning The BMT included in the video were: (1) Tell-show-do, (2) Voice
treatment for the kid (Themessl-Huber et al., 2010; Roberts et al., control, (3) Modelling, (4) HOME (hand-over-mouth exercise), (5)
2010; AAPD Clinical pointers, 2011). Parental dental anxiety could Active restraint, (6) Parental presence/absence (PPA), (7) Audiovisual,
also be related to the child’s dental behavior (Roberts et al., 2010; (8) Oral sedation and (9) General anesthesia. The techniques were
AAPD Clinical pointers 2011). Parental dental anxiety and their presented in the same order.16
turning away from dental treatment were found to be related
to missing dental appointments and better risk of decay for his Rating
or her youngsters (Wigen et al., 2009).8 Another integral side of While watching the video alone, before the dental treatment of
kid attention is to produce folks with previous data of behavior the child, parents were given 10 seconds between each successive
management techniques (BMTs). This delivery of knowledge presentation of a technique to rate the technique just viewed on
provides a mechanism by which parents will participate in a scale of 0–10, as a measure of their acceptance. Rating 0 meant
treatment selections with full understanding of things associated that the parent completely opposed the technique and 10 meant
with their child’s projected attention and helps in reducing that the parent completely accepted its use for their child
situational parental anxiety. Thus, insights into factors that influence (Eaton et al., 2005; Luis de Leo’n et al., 2010).
parental perceptions square measure necessary.9
Havelka et al. three had examined the hypothesis that parental
Questionnaire
rank influences preference toward behavior management After watching the video, the parents were asked to fill questionnaire
techniques used throughout dental treatment of youngsters. which was given to them in vernacular language, similar in form
Peretz and Zadik complete that the majority folks most well-liked to those used by Eaton et al. (2005) and Luis de Leo’n et al. (2010).
an evidence before behavior management was thought-about The questionnaire included information concerning gender, age,
for his or her youngsters, so an in depth clarification would and previous dental experience (positive, negative, never been to
increase the parent’s acceptance to firm techniques.6 Ayral (2002) the dentist before) of the parents and also concerning the family
expressed that the utilization of video data for getting consent income of the parents. An annual family income for parents of
before associate degree invasive procedure in medical specialty less than `50,000 was considered low, `50,000–`1,00,000 was
complete that video data decreases operative anxiety all told classified as average and that of over `1,00,000 was considered
collaborating patients.10 high. The questionnaire included the Greek version of modified
The hypotheses of the present study were: (1) There corah dental anxiety scale (MDAS) for measuring parental dental
is a possible association between parents’ dental anxiety anxiety (Coolidge et al., 2008). At the end of the questionnaire,
and/or dental experience and their acceptance of different the parent was asked to answer the following question: ‘‘In the
behavior management techniques applied to their children; situation where your child was not cooperative enough to complete
(2) There is a difference in parental acceptance between children
treated in the Institutional Postgraduate clinic or in private
practice. The aim of the present study was to examine parents’
acceptance of nine behavior management techniques used in
everyday clinical practice of pediatric dentistry and the association
of this acceptance with several possible confounding factors,
including parental dental anxiety and experience.

M at e r ia l s and Methods
Ethical approval
The study was approved by the Institutional Ethical Committee.
Informed consent was taken from parents.

Study Sample
The study was conducted in two locations; the postgraduate clinic
of the Department of Pediatric Dentistry at Swargiya Dadasaheb
Kalmegh Smruti Dental College and Hospital, Nagpur and the
private pediatric dental practice. The parents of all 3 to 12-year-old Fig. 1: Distribution of study participants according to sociodemographic
children who visited these two clinical settings over a 2-months details

S194 International Journal of Clinical Pediatric Dentistry, Volume 14 Special Issue 2 (Behavior Management)
 Parental Acceptance of Behavior Management Technique

Fig. 2: Audiovisual technique

Fig. 3: Tell-show-do

Fig. 4: Parents' previous dental experience

the dental treatment, and the pediatric dentist recommended Out of all proposed behavioral management techniques,
the use of either (1) general anesthesia or (2) one of active audiovisual aid (24%) was rated higher than any other by all parents
restraint, voice control or hand-over-mouth techniques, which (Fig. 2). Tell-show-do (16%) was the second most accepted technique
would you prefer?’’ The parent was asked to write the number 1 or followed by general anesthesia (12%) (Fig. 3). The least accepted
2 to indicate the answer. techniques were oral sedation (4%) Parental previous dental
experience (50% positive, 30% negative, 20% never been to
Statistical Analysis the dentist before) was not associated with their acceptance of
Statistical analysis was done by using descriptive and inferential individual Behavior management techniques (Fig. 4).
statistics using Chi-square test, Student’s paired and unpaired Parents from the Postgraduate clinic rated active restraint
t-test, and software used in the analysis was SPSS 22.0 version and (14.29%), HOME (14.29%) higher than those at the private practice,
GraphPad Prism 6.0 version and p < 0.05 is considered as the level where the respective values were 4.55% for both. No statistically
of significance. significant correlations were found between the acceptance of the
different techniques (Fig. 5).
R e s u lts Parental dental anxiety (mean MDAS = 10.09 ± 4.87, range = 5–25)
was not associated with their acceptance of Behavior management
A total of 50 parents (28 from the Postgraduate clinic and 22 from
techniques. The mean MDAS score for the parents from the
the private practice) agreed to participate in this study. Parents
private practice was 10.1 ± 4.41 and that for the parents from the
from the Postgraduate clinic statistically significant lower incomes
Postgraduate clinic 10.08 ± 5.38, being not statistically significantly
(p < 0.05) than those from the private practice. Acceptance of each
different. However, 24% of the parents of both study locations
BMT was not related to parental age, gender, or family income.
selected General Anesthesia when answering the last question
Out of 50 children, 14 were from 3–6 age-group, 19 from 6–9
described above (Fig. 6).
age-group, 17 from 9–12 age-group. No statistically significant
correlation was found between the parental rating of each
technique and the child’s age, (50% positive, 30% negative, 20% Discussion
never been to the dentist before), either for children treated in the The management of children’s behavior is integral element of
Postgraduate clinic or those treated in private practice. pediatric practice. Behavior modification techniques measure used

International Journal of Clinical Pediatric Dentistry, Volume 14 Special Issue 2 (Behavior Management) S195
 Parental Acceptance of Behavior Management Technique

Fig. 5: Parental acceptance of behavior management technique

Table 1: The most and least accepted techniques in previous studies

Author Most accepted technique Least accepted technique
Boka et al.8 Tell-show-do Passive restraint general
Parental presence/ anesthesia
absence nitrous oxide
inhalation sedation
Muhammad Positive reinforcement General anesthesia
et al. (2011) Effective communication Hand-over-mouth
Luis de Leo’n Tell-show-do Hand-over-mouth
et al. (2010) Voice control
Alammouri6 Tell-show-do Hand-over-mouth
Positive reinforcement Nitrous oxide sedation
Distraction
Fig. 6: Parental acceptance of BMT in case of uncooperative patient
Eaton et al. Tell-show-do Hand-over-mouth
(2005) N2O
by dental practitioners to ascertain communication, alleviate worry Abushal and Tell-show-do Parent separation
and anxiety, facilitate delivery of quality dental care, build a trusting Adenubi Positive reinforcement Physical restraint
relationship between medical practitioner, child, and parent, and (2003)
Distraction
promote the child’s positive angle towards oral healthcare, so
serving to them to cope and show disposition to undertake dental
treatment procedures.11 alliance. Earlier, the extent of communication with Parents was
Dental anxiety has been the first reason for not seeking dental terribly less and actively discouraged by the dental workers. With
care for kids. These fears and anxieties ought to be addressed or ever-changing attitudes in society, parental involvement has
it will have an effect on patients’ oral health and will end in costly accumulated. Drawing the parent into treatment choices through
dental treatments that might be avoided through preventive consent procedures is currently a regular of care.7
care. So, there’s a necessity for correct assessment of dental The use and acceptance of a method by the profession doesn’t
anxiety followed by a treatment session during a pleasant or less assure its lawfulness as viewed by today’s courts. With the stress
nerve-racking dental setting to alleviate worry and anxiety. The on children’s rights, the angle of parents toward BMT constitutes
people of the patients selected within the present study belonged necessary issue that should be thought of once choosing an
to 3-12 years as kids show tumultuous or negative behavior during approach for managing behavior. Thus, the study was allotted
this people and have measure tough to manage.12 to assess the attitude of parents toward different BMT utilized by
There measure varied modes of presentation, namely, oral, pediatric dentists in children of various age teams.7
written, and videos. Videos square measure additional and will In the present study majority of parents accepted audiovisual
have an enduring impact on the observer. Only a few Indian studies technique as BMT for his or her kid, that may be a novelty factor
square measure done to assess the parent’s angle to BMT. Thus, as the majority of the previous study explicit tell-show-do to be
this study was carried out using videos with an explanation of the the most accepted BMT by parents (Table 1). Within the past,
procedure as a method to assess the parent’s angle.7 major focus around patient pain and anxiety management was
Parents perpetually accompany kids through all dental focused on pharmacological treatments, whereas the literature
appointments. they’re concerned about a lot of the decision-making printed throughout the last decade has progressively centered
and delivery of care. Parents play a crucial half in reducing a child’s on non pharmacological techniques. One cognitive behavioral
anxiety and permitting the pedodontist to create a treatment strategy is named distraction—a method supported the notion of

S196 International Journal of Clinical Pediatric Dentistry, Volume 14 Special Issue 2 (Behavior Management)
 Parental Acceptance of Behavior Management Technique

a human’s restricted capability for attention. Distraction techniques where the cost of dental treatment is high, whereas the lower
vary from passive to active interventions, with the assumption socioeconomic find government hospitals more convenient than
that the additional interactive the distraction technique, involving private where cost may be low but waiting period for treatment
visual, sense modality and tactile stimuli, the bigger the potential and number of visits may be much more.15
for distraction from pain. In recent years, video game has become Previous dental experience of the parent or the child was
well-liked in clinical analysis studies as innovative distraction not statistically significantly associated with the acceptance of
technique.4 specific individual behavior management techniques, and this is
Fernandez et al. concluded that the employment of the in agreement with the results of other studies (Peretz and Zadik,
audiovisual material used as a way of distraction improves the 1999; Luis de Leo´n et al., 2010).
world behavior of youngsters aged 6–8 years however doesn’t Parents were asked to choose if they would prefer general
cut back their parent’s perception of the patients’ anxiety, or the anesthesia or one invasive technique in the case where their child
patient’s self-reported anxiety, pain or pulse rate in line with the was not cooperative enough to complete dental treatment. 24%
measure scales used.13 stated a preference for general anesthesia. A possible explanation
Tell-show-do was the second most typically accepted BMT is that, these parents based on their previous negative dental
during this study. The terribly high rating found for tell-show-do experience, expect general anesthesia to be less stressful to their
was expected because it is among the safest and least invasive children or they believe that the implementation of those invasive
Behavior management techniques and its satisfactoriness seems techniques would be a negative experience for them. In a study
comparatively stable over time (Eaton et al., 2005; Roberts et al., by Eaton et al., the third most acceptable technique by parents
2010; AAPD Clinical pointers, 2011).8 was general anesthesia. Modern parents are willing to abdicate
General anesthesia (12%) being the third most typically disciplinary actions and opt for pharmacological techniques.2,3
accepted BMT that was the foremost stunning part. Parental Sheller (2004) found that parents demanded that general
acceptance towards sedation was rated not up to alternative BMT anesthesia be given to their children for any dental procedure to
as reportable in studies by alternative investigators (Fields et al., a greater extent because they believed their children would not
1984; Potato et al., 1984). Oldsters overtime square measure actually cooperate during dental treatment.8
tending to be more well-off with the concept of getting their kid On the overall acceptance of every technique, there were no
treated underneath general anesthesia or sedation as reportable statistically significant correlations between them.
by Eaton et al. (2005).14
Acceptance of general anesthesia was more in private practice C o n c lu s i o n
(22.73%) than in Postgraduate clinics (3.57%) this could be
attributable to distinction within the socio-economic standing at Behavior management is a key factor in providing dental care
each place. Parents of high education viewed dental sedation for for children. Audiovisual technique is the most accepted BMT
kids as a secure approach.14 During this study, we have a tendency by parents and is a novel method that can be an effective and
to failed to address the extent of education; it’s potential to assume alternative distraction technique for the behavior management for
that prime socioeconomic standing is similar to high education as anxious pediatric patients. Postgraduate clinic parents had lower
a result of it’s typically measured as a mix of education, financial income than those at the private practice. General anesthesia was
gain, and occupation. accepted by the majority of the parents as BMT which is a rare
In the present study, it had been discovered that patients finding. Prior explanation of BMT to parents would increase the
visiting Postgraduate clinics were from poor socioeconomic acceptance by reducing the dental anxiety amongst the parents.
standing and people visiting private practice majority were from
good socio-economic standing that was found to be statistically References
significant (p < 0.05) (Fig. 7). Winnier et al. stated that the patients
1. Shah HA, Swamy N, Kulkarni S, et al. Evaluation of dental anxiety and
from higher socioeconomic class may be going to private dentists hemodynamic changes (Sympatho-Adrenal Response) during various
dental procedures using smartphone applications v/s traditional
Behavior management techniques in pediatricpatients. Int J
Appl Res 2017;3(5):429–433.
2. Bhandari R, Thakur S, Singhal P, et al. Parental awareness,
knowledge, and attitude toward conscious sedation in North
Indian children population: a questionnaire – based atudy. Indian J
Dent Res 2018;29:693–697.
3. Vishwakarma AP, Bondarde PA, Patil SB, et al. Effectiveness of two
different behavioral modification techniques among 5–7-year-old
children: a randomized controlled trial. J Indian Soc Pedod
Prev Dent 2017;35:143–149.
4. Shetty V, Dentistry P, Suresh LR, et al. Effect of virtual reality
distraction on pain and anxiety during dental treatment in 5 to 8 year
old children. J Clin Pediatr Dent 2019;43(2):1–6.
5. Kawia HM, Mbawalla HS, Kahabuka FK. Application of behavior
management techniques for pediatric dental patients by
Tanzanian dental practitioners. Open Dent J 2015;9:455–461.
DOI: 10.2174/1874210601509010455
6. Alammouri M. The At titude of parents toward behavior
management techniques in pediatric dentistry. J Clin Pediatr
Fig. 7: Socioeconomic status Dent 2006;30(4):310–313.

International Journal of Clinical Pediatric Dentistry, Volume 14 Special Issue 2 (Behavior Management) S197
 Parental Acceptance of Behavior Management Technique

7. Desai SP, Shah PP, Jajoo SS, et al. Assessment of parental attitude 11. Radhakrishna S, Srinivasan I, Setty JV, et al. Comparison of three
toward different behavior management techniques used in behavior modification techniques for management of anxious
pediatric dentistry. J Indian Soc Pedod Prev Dent 2019;37:350–359. children aged 4-8 years. J Dent Anesth Pain Med 2019;19(1):29–36.
DOI: 10.4103/jisppd.jisppd_138_18 DOI: 10.17245/jdapm.2019.19.1.29
8. Boka V, Arapostathis K, Vretos N, et al. Parental acceptance of Behavior 12. Khandelwal M, Shetty RM, et al. Effectiveness of distraction
management techniques used in pediatric dentistry and its relation techniques in managing pediatric dental patients. Int J Clin Pediatr
to parental dental anxiety and experience. Eur Arch Paediatr Dent Dent 2019;12(1):18–24. DOI:10.5005/jp-journals-10005-1582
2014;15(5):333–339. DOI: 10.1007/s40368-014-0119-y 13. Fernandez CC, Rodríguez AIL, Perez JL, et al. Effect of audiovisual
9. Elango I, Baweja DK, Shivaprakash PK. Parental acceptance of distraction on children’s Behavior, anxiety and pain in the dental
pediatric behavior management techniques: a comparative study. setting. Eur J Paediatr Dent 2014;297–302.
J Indian Soc Pedod Prev Dent 2012;30:195–200. DOI: 10.4103/0970- 14. Almarwan MS, Dhar V, Leventer M, et al. Parental perception toward
4388.105010 dental sedation in pediatric patients. IJSR 2019;8(7):711–720.
10. Kupietzky A. Effects of video information on parental preoperative DOI:10.21275/ART20199529
anxiety level and their perception of conscious sedation vs. 15. Winnier JJ, Parmar A. Pediatric dental procedures: a survey of
general anesthesia for the dental treatment of their young child. knowledge and pediatric dental procedures : a survey of knowledge
J Clin Pediatr Dent 2006;31(2):90–92. DOI: 10.17796/jcpd.31.2. and attitudes of parents. Int J Dent Health Sci 2015;2(5):1171–1182.
773784g75vq15w45 http://youtu.be/dY6dxeZ1YxM.

S198 International Journal of Clinical Pediatric Dentistry, Volume 14 Special Issue 2 (Behavior Management)