Types of Behavior Management Techniques used for Pediatric. Dental Patients

Transcription

1 Types of Behavior Management Techniques used for Pediatric Dental Patients BY MARY REGINA PHAM B.S., Auburn University, Auburn, 2003 D.D.S., University of Southern California, Los Angeles, 2009 THESIS Submitted as partial fulfillment of the requirements for the degree of Master of Science in Oral Sciences in the Graduate College of the University of Illinois at Chicago, 2011 Chicago, Illinois Defense Committee: Indru Punwani, Chair and Advisor Shahrbanoo Fadavi Anne Koerber Adriana Semprum- Clavier

2 ACKNOWLEDGEMENTS I would like to convey my most sincere thanks and appreciation for the members of my thesis committee, Dr. Adriana Semprum-Clavier, Dr. Indru Punwani for his direction and guidance, Dr. Shahrbanoo Fadavi for her willingness to answer questions and her encouragement. Lastly, to Dr. Anne Koerber, for her guidance, patience, and unlimited amount of time spent to help and support my efforts in research. Thank you to my friends Jacqueline Pham, Clair Pong, and Leah Bentley for your friendship, time, and assistance with preparing the surveys for distribution. I would also like to thank my family, especially my parents Joe and Elizabeth for always being supportive and understanding through all my years of educational endeavors. Finally, I would like to thank my fiancé Hideki for his unlimited love and support throughout our journey together. MRP ii

3 TABLE OF CONTENTS CHAPTER PAGE 1. INTRODUCTION 1.1 Background Purpose of Study Hypotheses REVIEW OF LITERATURE 2.1 Use of Behavior Guidance Techniques in Children Changes in AAPD Guidelines Basic Behavior Guidance Advanced Behavior Guidance Parental Attitudes Towards Behavior Guidance Techniques METHODOLOGY 3.1 Sample Selection Survey Tool Data Collection RESULTS 4.1 Total Respondents and Response Rate Demographic Data of Respondents Patient Age and Current Usage of Basic Behavior Guidance Patient Age and Current Usage of Advanced Behavior Guidance History of Changes of Basic Behavior Guidance History of Changes of Advanced Behavior Guidance Anticipated Changes in Basic Behavior Guidance Anticipated Changes in Advanced Behavior Guidance DISCUSSION 5.1 Summary of Methods and Findings Differences in Usage Across Practitioner Type Limitation to Study Strengths Future Research CONCLUSION CITED LITERATURE. 39 iii

4 TABLE OF CONTENTS (continued) CHAPTER PAGE APPENDICES APPENDIX A.. 41 APPENDIX B.. 43 APPENDIX C.. 44 APPENDIX D.. 48 VITA. 49 iv

5 LIST OF TABLES TABLE PAGE I. DEMOGRAPHIC CHARACTERISTICS: GENERAL DENTISTS AND PEDIATRIC DENTISTS. 21 II. GENERAL AND PEDIATRIC DENTISTS CURRENT USE OF BASIC BEHAVIOR GUIDANCE ACROSS PATIENT AGE GROUPS.. 22 III. GENERAL AND PEDIATRIC DENTISTS CURRENT USE OF PARENTS IN THE OPERATORY ACROSS PATIENT AGE GROUPS 23 IV. GENERAL AND PEDIATRIC DENTISTS CURRENT USE OF ADVANCED BEHAVIOR GUIDANCE ACROSS PATIENT AGE GROUPS.. V. GENERAL AND PEDIATRIC DENTISTS CHANGES IN USE OF BASIC BEHAVIOR GUIDANCE.. VI. GENERAL AND PEDIATRIC DENTISTS CHANGES IN USE OF ADVANCED BEHAVIOR GUIDANCE VII. VIII. GENERAL AND PEDIATRIC DENTISTS ANTICIPATED CHANGES IN USE OF BASIC BEHAVIOR GUIDANCE GENERAL AND PEDIATRIC DENTISTS ANTICIPATED CHANGES IN USE OF ADVANCED BEHAVIOR GUIDANCE v

6 LIST OF ABBREVIATIONS AAPD BGT HOME IRB ISDS American Academy of Pediatric Dentistry Behavior Guidance Techniques Hand Over Mouth Exercise Institutional Review Board Illinois State Dental Society vi

7 SUMMARY A survey was conducted among pediatric dentists and general dentists in the state of Illinois. This research was completed in order to report the current, past, and anticipated change in usage of basic and advanced behavior guidance techniques used for pediatric dental patients. The data was obtained through a voluntary mailed survey. A total of 173 general dentists and 98 pediatric dentists took part in the research. Data analysis revealed that the majority of pediatric dentists reported using the basic and advanced behavior guidance techniques for pediatric patients of all ages, with the exception of moderate sedation. The majority of general dentists reported not using advanced behavior guidance techniques and nitrous oxide/oxygen inhalation for pediatric dental patients; however, they did report using all of the nonpharmacological basic behavior guidance techniques for pediatric dental patients across all age groups. The majority of both groups reported no change in usage of basic and advanced techniques compared to 5 years prior and did not anticipate changes in use over the next 2-3 years. The majority of general and pediatric dentists also reported allowing parents in the operatory. Nearly all of the respondents denied using the Hand over mouth exercise (HOME). The demographic characteristics that separated the general dentists and pediatric dentists were gender, years in practice, and the percentage of patients that were self-pay. There were differences noted between general dentists and pediatric dentists in the current, past, and anticipated change in Behavior vii

8 guidance technique (BGT) usage for child dental patients across most children s age groups, with the most significant differences noted in the usage of advanced behavior guidance techniques. viii

9 1. INTRODUCTION 1.1 Background Behavior guidance in pediatric dental patients is important because it allows the dentist to establish communication, alleviate fear and anxiety, deliver quality dental care, build a trusting relationship with the child, and promote the child s positive attitude toward oral health care (AAPD ). Basic behavior guidance techniques (BGT) learned during dental school training largely shape what will be practiced by the dentist (Adair et al., 2004). Most general dentists are taught the basic methods of pediatric patient behavior guidance in dental school such as: tell-show-do, positive reinforcement, and distraction (Adair et al., 2004). Pediatric dentists, on the other hand, receive additional training and experience in advanced behavior guidance techniques which include protective stabilization, moderate sedation, and general anesthesia (Adair et al., 2004). Although pediatric dentists use of behavior guidance techniques have been documented, few studies have documented general dentists usage of basic or advanced behavior guidance techniques for pediatric dental patients. This is important considering there will be a greater need in the future for general dentists to treat more pediatric patients (Davis, 2000). Previous studies surveying pediatric dentists have noted changes over time in the usage and acceptance of BGTs for pediatric dental patients. Pediatric dentists use of BGTs has changed over time from more external ways to manage the child to more psychological ways to guide the child s behavior. Factors such 1

10 2 as sedation guidelines, parental attitudes, ethical/legal concerns, and cost may influence the current and future usage of certain BGTs by general dentists and pediatric dentists. 1.2 Purpose of Study The purpose of this study was to report the current basic and advanced BGTs used among pediatric dentists and general dentists in the state of Illinois for various age groups of pediatric dental patients. Comparisons were made between the two groups to determine if current usage of certain behavior guidance techniques were more prevalent, if usage changed over the last five years, and if there were any anticipated changes in BGTs in the next few years. 1.3 Hypotheses Hypothesis 1: There was no change over time in the usage of basic behavior guidance techniques between general dentists and pediatric dentists. Hypothesis 2: There was change over time in the usage of advanced behavior guidance techniques between general dentists and pediatric dentists. Hypothesis 3: There was a decrease over time in usage of moderate sedation among pediatric dentists and general dentists. Hypothesis 4: There was an increase over time in use of general anesthesia among pediatric dentists and general dentists.

11 2. REVIEW OF LITERATURE 2.1 Use of Behavior Guidance Techniques in Children Few studies have been conducted concerning general dentists usage of various behavior guidance techniques for pediatric dental patients; most studies have focused on pediatric dentists usage of BGTs. Additionally, changes over time in usage of various BGTs for pediatric dental patients have been documented in the literature dating as early as In the early 1970s, aversive behavior management techniques were more frequently used than non-aversive methods. The first study published reporting dentists usage of various behavior guidance techniques for children was completed by the Association of Pedodontic Diplomates who conducted a survey of its members in The most used BGTs were drugs (84%) and physical restraint (84%), followed by parents in the operatory (81%), physical contact of face and airway (80%), general anesthesia (80%), nitrous oxide inhalation (28%), and hypnosis (13%) was the least used. The BGTs used by pediatric dentists at this time focused more on restraint or pharmacological methods to manage the child s behavior, although the respondents were in strong support of psychological principles of achieving cooperation of the child (AAPD, 1972). In the late 1970s, there was a shift towards more psychological methods of BGTs and more emphasis was placed on researching the principles of lessaversive behavior guidance methods. Levy et al. in 1979 conducted a survey of Washington State Academy of Pediatric Dentists which reported techniques 3

12 4 creating a more positive interaction with the child. The methods evaluated included: Tell-show-do, parents in the operatory, behavior modeling, distraction, and positive reinforcement. The limitation with this survey was that it was only a sample of 34 Washington Academy of Pediatric Dentists members. Although more psychological and communicative techniques were reportedly being used, the Hand over mouth exercise (HOME) was still used by the majority (88%) of pediatric dentists at this time (Levy, Domoto, 1979). In 1981, the American Academy of Pediatric Dentistry surveyed its members to compare differences in usage compared to the 1972 survey of the AAPD Diplomates. Comparisons were also made between the AAPD members and Pedodontic Diplomates with regard to reported usage of both basic BGTs and advanced BGTs. No significant differences in attitudes were noted; therefore, this study was used for justification of surveying AAPD Diplomates for future BGT studies since the sample was a good representation of all the members of the AAPD. The results showed similar usage of BGTs by Pedodontic Diplomates as reported by the 1972 survey except that HOME (with airway restriction) had surprisingly increased from 36% in 1972 to 54% in Nitrous oxide/oxygen inhalation usage by AAPD Diplomates increased dramatically from 35% in 1972 to 65% in 1981 (AAPD 1981). In 1990, Allen et al., were the first to survey AAPD Diplomates on both traditional and newer BGTs. In order of most to least frequently used, the techniques were: tell-show-do (96%), non-contingent prize (93%), restraint (83%), verbal reprimand (76%), sedation (74%), HOME (73%), live modeling

13 5 (66%), parents in operatory (64%), stop treatment (55%), relaxation (46%), noncontingent distraction (26%), contingent rewards (14%), and hypnosis (12%). This study showed that non-aversive techniques were being used more often. However, restraint (83%) and HOME (73%) were still being widely used (Allen et al., 1990). Before 1993, there were limited studies of BGTs usage among general dentists for pediatric patients. McKnight et al. in 1993 assessed BGTs across practitioner type, age, and region in a national survey. Although general and pediatric dentists were consistent in the use of some techniques, they inconsistently applied other techniques. The large majority (>88%) of both general dentists and pediatric dentists used tell-show-do and voice control for pediatric patients. There were greater differences noted between the two groups with advanced BGT usage. For example, the usage of HOME and physical restraint varied significantly between general dentists and pediatric dentists. HOME was reported by 53% of pediatric dentists and 21% of general dentists. Seventy-one percent of pediatric dentists reported physical restraint, compared to 3% of general dentists. At this time, the reported reasons for changes in the utilization patterns for most techniques were sedation guidelines, informed consent requirements and professional liability insurance (McKnight et al.,1993). By 1999, most pediatric dentists (57%) had either stopped using or dramatically decreased usage of the HOME (Carr et al., 1999). The majority of Southeastern pediatric dentists utilized more non-aversive BGTs, such as

14 6 parents in the operatory and nitrous oxide/oxygen inhalation compared to five years prior. The majority of pediatric dentists reported that changes in utilization patterns were due to parent influences and legal and ethical concerns (Carr et al., 1999). The latest published study reporting utilization of basic and advanced BGTs in children dental patients was in 2004 by Adair et al. He surveyed members of AAPD regarding their current, past, and anticipated change in usage of various BGTs. The most widely used BGTs among AAPD members were tellshow-do (99%), positive reinforcement (99%), distraction (96%), voice control (92%), nonverbal communication (91%), and nitrous oxide/oxygen inhalation (86%). Restraints were also used by the majority of respondents (73%). Half of the respondents indicated using less HOME than five years ago and 24% planned on using it less over the next few years. Parental presence in the operatory was still commonly being used (66%), and most respondents (85%) believed parenting styles had changed in ways that adversely impacted children s behavior in the dental setting (Adair et al., 2004). This review indicates that pediatric dentists change in usage and acceptance of behavior guidance techniques for child dental patients have been well documented from the early 1970s up to 2004 (AAPD 1972, Levy et al. 1979, AAPD 1981, Allen et al. 1990, McKnight et al. 1993, Carr et al. 1999, Adair et al. 2004). On the other hand, there are limited studies describing the current use of various BGTs by general dentists for pediatric dental patients.

15 7 2.2 Changes in AAPD Guidelines The American Academy of Pediatric Dentistry Guideline on Behavior Guidance for pediatric dental patient was first adopted in 1990 and last modified in The purpose of the Guideline is to educate healthcare providers, parents, and other interested parties about the behavior guidance techniques used currently in pediatric dentistry (AAPD ). Historically, there have been changes since the Guideline s inception in The majority of the changes involve terminology, with only limited changes in technique. For example, in 1990 the Guideline was termed Behavior Management, which was revised to Behavior Guidance in 2006 (AAPD, 1990, 2006). With regard to protective stabilization, the term has evolved from its first description of Physical Restraints. It was modified to Medical Immobilization, before eventually being referred to as Protective Stabilization. Furthermore, parental presence/absence in the operatory was officially added as a basic BGT in 2000 and HOME was eventually removed from the guidelines in These changes may be due to the shift towards less aversive terminology, research on changes in BGT usage, or changes in societal or parental acceptance of certain BGTs. 2.3 Basic Behavior Guidance Basic behavior guidance techniques are communicative techniques designed to help develop a positive attitude toward oral health in the child by

16 8 establishing a positive relationship and allowing for successful completion of dental procedures (AAPD ). When usage of these techniques is employed by the dentist, it is important to keep in mind the cognitive development of the child (AAPD ). According to the AAPD Guidelines, the current basic behavior guidance techniques include: Tell-showdo, voice control, nonverbal communication, positive reinforcement, distraction, parental presence/absence, and nitrous oxide/oxygen inhalation. It is important, therefore, to include a review of these basic behavior guidance techniques in the review of the literature. Tell-show-do is a technique of behavior shaping that involves verbal explanations of procedures in phrases appropriate to the developmental level of the patient (tell). Demonstrations for the patient are completed which allow the child to see, hear, smell, and touch various aspects of the proposed procedure in a non-threatening way (show). Completion of the procedure then follows without deviating from the demonstration (do) (AAPD ). The objectives are to teach the patient important features of the dental visit, familiarize the patient with the dental setting thus reducing the fear of the unknown, and shaping the patient s response to procedures through desensitization (AAPD ). Voice control is a technique that involves a controlled alteration of voice volume, tone, or pace to influence and direct the patient s behavior (AAPD ). It may be used with any patient; however, it is important to explain the usage to parents prior in order to prevent any misunderstanding. The objectives

17 9 of voice control are to gain the patient s attention and compliance, prevent negative behavior, and establish appropriate adult-child roles (AAPD ). Nonverbal communication involves the reinforcement of behavior through appropriate contact, posture, facial expression, and body language (AAPD ). This technique may be used for any patient. The objectives are to enhance the effectiveness of other BGTs and to maintain and gain the patient s attention and compliance (AAPD ). Levy et al., found that 83% of pediatric dentists in Washington State used nonverbal communication in the form of touching and stroking a child s hand or arm (Levy et al., 1979). Positive reinforcement is the technique of encouraging appropriate patient behavior by giving appropriate feedback. When effectively used, positive reinforcement will reward the desired behaviors and promote the recurrence of those behaviors (AAPD ). Positive reinforcement may be used for all patients, and includes social and nonsocial reinforcers (AAPD ). Social reinforcers include positive voice tone, facial expressions, verbal praise, and appropriate physical demonstrations of affection by all members of the dental team; nonsocial reinforcers include tokens and toys (AAPD ). Distraction technique is a method of basic behavior guidance that diverts the patient s attention away from what may be perceived as an unpleasant procedure (AAPD ). Distraction has been shown to be very acceptable by parents and widely used by pediatric dentists (Adair et al., 2004). Distraction may be used with any patient and is designed to decrease the perception of unpleasantness and prevent negative behavior (AAPD ).

18 10 Parental presence or absence is a technique that may be used to gain the patient s cooperation for treatment (AAPD ). A wide range of practitioner philosophies exist regarding parents presence or absence during pediatric dental treatment. It is beneficial that the dentist s preference be presented and discussed with the parent and child at the initial visit. Traditionally, parents had been excluded from the dental operatory (Wright, 1983). Adair et al. in 2004 reported that 87% of pediatric dentists preferred to have parents in the operatory for children under age 3 years. Parental presence or absence is contraindicated in patients whose parents are unwilling or unable to effectively support the dentist when asked (AAPD ). The objective of this BGT is to gain the patient s attention and improve compliance, discourage negative behaviors, establish appropriate dentist-child roles, minimize anxiety, achieve a positive dental experience, and enhance communication among the dentist, child, and parent (AAPD ). Nitrous oxide/oxygen inhalation is a safe and effective technique used to reduce anxiety and enhance effective communication (AAPD ). It is used in combination with communicative behavior guidance techniques to relax the patient and increase cooperation during dental treatment. Nitrous oxide/oxygen inhalation also facilitates analgesia, amnesia, and gag reflex reduction (AAPD ). It is contraindicated in patients with chronic obstructive pulmonary disorders, severe emotional disturbances or drug-related dependencies, in first trimester of pregnancy, under treatment with bleomycin sulfate, or those with methylenetetrahydrofolate reductase deficiency (AAPD

19 ). Consultations are recommended before nitrous oxide/oxygen inhalation for patients with underlying medical conditions (AAPD ). The use of nitrous oxide/oxygen inhalation was reportedly used by the minority (35%) of 1972 survey respondents (AAPD 1972). In 2004, Adair et al. reported that 86% of pediatric dentists currently used nitrous oxide/oxygen inhalation in patients ages 3 to >12 years (Adair et al., 2004). Most healthy, non-disabled children can be effectively managed using the basic behavior guidance techniques described. These basic techniques should form the foundation for all dentists in the dental treatment of children. 2.3 Advanced Behavior Guidance The occasional difficult pediatric dental patient will present with behavioral considerations that require more advanced behavior guidance techniques. These children often will not cooperate due to lack of psychological or emotional maturity and/or mental, physical or medical disability. The advanced behavior guidance techniques commonly taught in advanced pediatric dentistry training programs include protective stabilization, sedation, and general anesthesia (AAPD ). Protective stabilization is defined by the AAPD as the restriction of the patient s freedom of movement, with or without the patient s permission, to decrease risk of injury while allowing safe completion of treatment; the restriction may involve another person, a patient stabilization device, or a combination of both (AAPD ). Informed consent must be obtained and documented in

20 12 the patient s record prior to the use of protective stabilization. In the 1972 AAPD Diplomate survey, the use of immobilization of selected patients was 84%. According to Adair s 2004 study, the usage by pediatric dentists decreased to about 70% for nonsedated children. The objectives of protective stabilization are to reduce or eliminate untoward movement, protect patient, staff, dentist, or parent from injury, and to facilitate delivery of quality dental treatment (AAPD ). Moderate sedation is defined as a drug-induced depression of consciousness during which patients respond purposefully to verbal commands (AAPD ). With moderate sedation, no intervention is required to maintain patient airway, cardiovascular function is usually maintained, and spontaneous ventilation is adequate (AAPD ). According to Adair et al., 27% of pediatric dentists indicated they had decreased their use of moderate sedation over the past five years (Adair et al., 2004). Some reasons for the decrease in moderate sedation usage over time include difficulty in complying with AAPD Guidelines on moderate sedation, lack of third party reimbursement, and increased use of general anesthesia (Carr et al., 1999). Deep sedation is defined as a drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully after repeated verbal or painful stimulation (AAPD ). The ability to independently maintain ventilator function may be impaired, cardiovascular function is usually maintained, patients may require assistance in maintaining patient airway, and spontaneous ventilation may be inadequate (AAPD 2010-

21 ). A state of deep sedation may be accompanied by partial or complete loss of protective airway reflexes (AAPD ). Carr et al reported that a small percentage of pediatric dentists increased the usage of deep sedation due to the use of an anesthesiologist in the dental office for intravenous administration of conscious sedation medications. The decision to use sedation must take into consideration the alternative behavioral guidance modalities, dental needs of patient, effect on quality of dental care, patient s emotional development, and patient s physical considerations (AAPD ). The goals of sedation are to guard the patient s safety and welfare, minimize physical discomfort and pain, control anxiety, minimize psychological trauma, maximize potential for amnesia, control behavior and movement, and return the patient to a state in which safe discharge from medical supervision is possible (AAPD ). anesthesia is a controlled state of unconsciousness accompanied by loss of protective reflexes, including the ability to maintain an airway independently and respond purposefully to physical stimulation or verbal command (AAPD ). This can be done in the hospital or ambulatory setting depending on the patient. According to the current AAPD guidelines, office-based deep sedation or general anesthesia techniques require at least 3 individuals: the anesthesia care provider, the operating dentist, and other staff. anesthesia is always effective in managing an uncooperative child s behavior. Risks of morbidity or mortality as well as potential considerable expense should be discussed with the parents. The goal of general anesthesia

22 14 is to provide safe, efficient, and effective dental care, eliminate anxiety, reduce untoward movement and reaction to dental treatment, aid in treatment of the mentally, physically, or medically compromised patient, and eliminate the patient s pain response (AAPD ). Hand over mouth exercise (HOME) is a BGT that was removed from the AAPD Guideline in May 2006 and has been the most scrutinized behavior modification technique. HOME is a method used to gain a disruptive child s attention but has been associated with professional controversy and poor parental acceptance (Lawrence et al., 1991). This technique is used for intercepting and managing hysterical or uncooperative behavior that cannot be modified by basic behavior guidance techniques (AAPD ). The technique involves gently placing a hand over the child s mouth and behavioral expectations are calmly explained. This may inadvertently lead to total airway obstruction, therefore maintenance of a patent airway is mandatory. Upon the child s demonstration of self-control and more suitable behavior, the hand is removed and the child is given positive reinforcement. Written informed consent from a legal guardian must be obtained and documented in the patient record prior to the use of HOME (AAPD ). Historically, HOME had been an accepted behavior guidance technique in pediatric dentistry and was well documented in dental literature for over 35 years (AAPD ). In 1981, 90% of pediatric dentists who responded to a national survey indicated they used HOME with an open airway, while 54% stated they used hand over mouth with airway restriction in selected cases (AAPD 1981). In Adair s 2004 study, he

23 15 reported that 79% of pediatric dentists responded that they no longer used HOME Parental Attitudes Towards Behavior Guidance Techniques Research on parental attitudes and factors which influence parent s beliefs regarding the use of the behavior guidance methods is important (Eaton, 2005). Parental attitudes toward behavior guidance techniques are subject to change over time, as society changes. As society changes and parental attitudes towards behavior guidance techniques changes, general dentists and pediatric dentists must adapt and keep up with the acceptable trends. Aggressive physical management techniques such as protective stabilization and HOME appear to be less favorably accepted and advanced pharmacological techniques are increasing in acceptance (Eaton et al., 2005). In general, pediatric dentists today have changed their usage of BGTs to more non-aversive techniques. This is in large part due to parental preference and ethical and legal concerns. Most pediatric dentists believe that children in today s society are not as disciplined as they were in the past and that their behavior is more negative (Casamissimo et al., 2002). Casamissimo reported that 9 out of 10 Board Certified pediatric dentists felt that parenting had changed considerably and that it was a negative change to some degree; they also felt that patients were worse now than before (Casamissimo et al., 2002). The respondents also reported that they had shifted their behavioral management techniques to less assertive ones as a result of perceived parenting changes

24 16 (Casamissimo et al., 2002). Most pediatric dentists believe that present-day parents are much less likely to use physical discipline and set limits on their child s behavior (Long, 2004). The majority of dentists believe parents are more willing to accept their child s disrespect, are more overprotective of their child, and more likely to try to prevent any suffering their child might experience from a dental procedure (Long, 2004). Additionally, the dentists believed that many parents are unsure of their role as parents, are too busy to spend time with their children, and are self-absorbed or materialistic (Long 2004).

25 3. METHODOLOGY 3.1 Sample Selection A total of 594 subjects were invited to participate in the study. The general dentist sample consisted of 400 randomly selected members of the Illinois State Dental Society current as of October The pediatric dentists consisted of 194 active Illinois pediatric dentists who were members of the American Academy of Pediatric Dentistry. Excluded were AAPD Affiliate members in Illinois, retired dentists, and dentists who did not treat pediatric patients. The goal of the project was to collect a total of 200 surveys (100 surveys from general dentists and 100 surveys from pediatric dentists). 3.2 Survey Tool Dentists participating in the study responded to a mailed questionnaire regarding the usage of various behavior guidance techniques for different age groups. The survey was a modified questionnaire of Dr. Steven Adair of the Medical College of Georgia from his 2004 study. The questionnaire requested demographic information, current, past, and anticipated use of various behavior guidance techniques, and factors that contribute to having parents in the operatory. The practitioners were also asked about their usage of the following nonpharmacological techniques, and definitions of each were given. These included: Tell-show-do, nonverbal communication, voice control, positive reinforcement, distraction, protective stabilization and hand over mouth exercise. 17

26 18 Additionally, the practitioners were asked about their current use of pharmacologic techniques use for various age groups which included nitrous oxide/oxygen inhalation sedation, moderate sedation, and general anesthesia which were not defined in the survey instrument. The questionnaire, prepaid return envelope, and cover letter were mailed to the sample of general dentists and pediatric dentists (400 general dentists and 194 pediatric dentists) in Illinois. Each subject was assigned an ID number. In order to track responses, the number was placed on the outside of the return envelope. Once the survey was received, it was separated from the return envelope and placed blindly in a box. The number was crossed off the list and no further attempts were made to contact the subject. A follow up letter and survey were sent to all non-respondents three weeks after the initial mailing. The study was approved by the Institutional Review Board (IRB), at the University of Illinois at Chicago (Approval # ) on November 24, 2010, Appendix A. The cover letter and questionnaire is found in Appendices B and C. The follow up letter is included in Appendix D. 3.3 Data Collection Once IRB approval was obtained, the initial mailing of cover letters, questionnaires, and pre-addressed return envelopes was completed on January 10, The cover letter explained the purpose of the study, the risks/benefits of participation, and that participation was completely voluntary. If the subject decided to participate in the study, he or she filled out the questionnaire and

27 19 placed it back in the prepaid return envelope to be mailed. A follow up letter and questionnaire were mailed 3 weeks later on January 31, 2011, to those subjects who had not responded to the initial mailing. At the completion of the data collection, data was entered into a SPSS file for statistical analysis.

28 4. RESULTS 4.1. Total Respondents and Response Rate A total of 271 (98 pediatric dentists and 173 general dentists) responses fit the criteria to be included in the study. The total number of invitations was 594 (194 pediatric dentists and 400 general dentists). Eleven questionnaires were excluded (10 general dentists and 1 pediatric dentist) due to bad address, retired status, or practitioner indicated that they did not treat children. The response rate was 51% for pediatric dentists and 44% for general dentists Demographic Data of Respondents The demographic characteristics of the respondents are summarized in Table I. Pediatric dentists were younger and more likely to be female than pediatric dentists. The majority of pediatric dentist respondents were Board certified either by the Illinois state board or American Board of Pediatric Dentistry. dentists were more likely to be in practice longer than pediatric dentists. Both groups were more likely to be reimbursed by commercial dental insurance, followed by self-pay, and lease likely to be reimbursed by Medicaid. 20

29 21 TABLE I COMPARISON OF CHARACTERISTICS OF GENERAL AND PEDIATRIC DENTISTS RESPONDING TO A SURVEY OF BGTS Pediatric (n=98) (n=173) Significance Gender 54% Female 24% Female.000* Age (Mean, SD) (46, 11) (51,12) n.s. Years in Practice (19,11) (24,12).002 (Mean, SD) Board Certification 69% -.000* Insurance % (65,25) (62,22) n.s. (Mean, SD) Medicaid % (Mean, (12,25) (8,22) n.s. SD) Self pay % (Mean, (23,17) (30,17).001 SD) *Pearson Chi-square T-test 4.3. Patient Age and Current Usage of Basic Behavior Guidance Dentists were asked to mark their current usage of basic behavior guidance techniques for various age groups (<3 years, 3-5 years, 6-12 years, >12 years) of pediatric patients. The AAPD Guideline on basic behavior guidance techniques include: tell-show-do, nonverbal communication, voice control, distraction, positive reinforcement, and nitrous oxide/oxygen inhalation. The respondent also was asked to indicate if they did not use the technique for any age groups. Table II describes the differences between general dentists and pediatric dentists current usage of basic behavior guidance techniques. Overall, pediatric dentists were more likely to report use of any basic BGT, especially among younger children. Voice control for the most part was reported equally used by both groups. Over 51% of pediatric dentists reported using all of the basic behavior guidance techniques for pediatric patients of all ages. Over 53%

30 22 of general dentists surveyed reported using the basic behavior guidance techniques for pediatric patients of all ages, with the exception of nitrous oxide/oxygen inhalation (64% did not use). See Table II. TABLE II COMPARISON OF GENERAL AND PEDIATRIC DENTISTS USAGE OF BASIC BGTS AND THE AGE AT WHICH THEY ARE USED: PERCENT REPORTING USE FOR EACH AGE GROUP BGT Specialty Age < >12 Don t Tell-show-do Nonverbal communication Voice Control Positive reinforcement Distraction Nitrous Oxide Status Pediatric (n=96) (n=173) Pediatric (n=93) (n=172) Pediatric (n=94) (n=170) Pediatric (n=92) (n=171) Pediatric (n=95) (n=171) Pediatric (n=96) (n=173) (n.s.) (.03) (n.s.) (.04) (.001) (n.s.) (.05) (.04) (n.s.) (.001) (n.s.) (.001) use 0 2 (n.s.) (n.s.) 1 2 (n.s.) 3 15 (.004) Multiple Pearson Chi-square analyses compared pediatric and general dentists usage for each age group, p<0.05

31 23 The survey also asked the respondent to mark the age groups and list reasons, if any, when parents are allowed in the operatory. The results are shown in Table III. No significant differences were noted between the groups for the age group 6-12 years and for special needs children. All other differences were statistically significant. The majority of both pediatric and general dentists allowed parents in the operatory for children ages 0-5 (66-95%), parental request (70-85%), and for special needs children (79-88%). TABLE III COMPARISON OF GENERAL AND PEDIATRIC DENTISTS USAGE OF PARENTS IN THE OPERATORY AND THE AGE OR REASONS FOR WHICH THEY ARE USED: PERCENT REPORTING USE FOR EACH AGE GROUP Specialty Age >12 Parental Special Status Pediatric (n=98) (n=173) Significance < (.01) (.003) (n.s.) Request (.005) Needs (n.s.) (.04) Pearson Chi-square analyses compared pediatric and general dentists usage for each age group or reason, p< Patient Age and Current Usage of Advanced Behavior Guidance The dentists were asked about their current usage of advanced behavior guidance techniques which included: protective stabilization (non-sedated or sedated), moderate sedation, general anesthesia, and hand over mouth exercise (which is no longer listed in the AAPD Guidelines). See Table IV. Pediatric dentists were significantly more likely to use advanced behavior guidance techniques across all children s age groups. For the Hand-over-mouth exercise,

32 24 neither group was likely to use the technique. The majority of general dentists (82-97%) reported not using advanced behavior guidance techniques. Most pediatric dentists used protective stabilization (70%) and general anesthesia (79%) for children under age 3 years. Additionally, the majority of pediatric dentists did not using moderate sedation (69%) or protective stabilization with sedated patients (56%). Of the pediatric dentists that are using the advanced techniques, most were used for children age 0 to 5 years. See Table IV. TABLE IV COMPARISON OF GENERAL AND PEDIATRIC DENTISTS USAGE OF ADVANCED BGTS AND THE AGE AT WHICH THEY ARE USED: PERCENT REPORTING USE FOR EACH AGE GROUP BGT Specialty Age >12 Don t Protective Stabilization (non-sedated) Protective Stabilization (sedated) Moderate Sedation Anesthesia Hand-overmouth** Status Pediatric (n=96) (n=169) Pediatric (n=96) (n=170) Pediatric (n=96) (n=170) Pediatric (n=95) (n=170) Pediatric (n=95) (n=171) < (n.s.) (.02) (n.s.) 13 2 (.001) (.01) (n.s.) Use (.02) Multiple Pearson Chi-square analyses compared pediatric and general dentists usage for each age group, p<0.05 **No longer listed in AAPD Guidelines

33 Changes in Usage of Basic Behavior Guidance We also asked about the differences in dentists usage of basic behavior guidance technique changes from five years prior. The respondents were asked to rate their change in usage as: never used (value=0), don t use now (value=0), use less (value=1), no change (value =2), or used more (value=3). Never used and don t use now responses were combined to increase the numbers of respondents in each choice. No group differences were noted for tell-show-do or positive reinforcement. Most general dentists and pediatric dentists reported no change in usage of basic BGTs (>55%). Pediatric dentists were more likely to have increased usage of techniques overall than general dentists. Pediatric dentists were likely to have decreased usage of voice control.

34 26 TABLE V BGT COMPARISON OF GENERAL AND PEDIATRIC DENTISTS CHANGE IN USAGE OF BASIC BGTS COMPARED TO FIVE YEARS AGO: PERCENTAGE REPORTING CHANGES IN BGT USAGE Specialty Status Never Used Don t Use Now Use Less No Change Use More Total Significance Tell-Show-Do Nonverbal Communication Voice Control Positive Reinforcement Distraction Nitrous Oxide Pediatric (n=97) (n=172) Pediatric (n=96) (n=170) Pediatric (n=94) (n=171) Pediatric (n=95) (n=171) Pediatric (n=96) (n=169) Pediatric (n=96) (n=171) Mann Whitney U, p< n.s n.s History of Changes of Advanced Behavior Guidance The dentists were asked about the change in usage of advanced behavior guidance techniques as compared to five years ago as well. The advanced

35 27 behavior guidance techniques that were evaluated were: protective stabilization (for non-sedated and sedated patients), moderate sedation, general anesthesia, and Hand-over-mouth exercise (which is no longer listed in the AAPD Guidelines since May 2006). Statistically significant differences were noted between both groups for all advance behavior guidance techniques, with the exception of Hand over mouth exercise. The majority of all general dentists report not using (82-95%) advanced behavior guidance techniques. Of the pediatric dentists that use the advanced techniques, the majority report no change compared to five years prior, with the exception of Protective Stabilization, which they used less now. See Table VI.

36 28 BGT TABLE VI COMPARISON OF GENERAL AND PEDIATRIC DENTISTS CHANGE IN USAGE OF ADVANCED BGTS COMPARED TO FIVE YEARS AGO: PERCENTAGE REPORTING CHANGES IN BGT USAGE Specialty Status Never Used Don t Use Now Use Less No Change Use More Total Significance Protective Stabilization (nonsedated) Protective Stabilization (sedated) Moderate Sedation Anesthesia Pediatric (n=96) (n=172) Pediatric (n=93) (n=170) Pediatric (n=95) (n=172) Pediatric (n=97) (n=172) Hand Over Pediatric Mouth** (n=95) (n=172) Mann Whitney U, p< n.s Anticipated Changes in Basic BGT dentists and pediatric dentists were also asked about their anticipated changes in use of basic behavior guidance techniques over the next few years. See Table VII. Nitrous oxide was the only basic behavior guidance

37 29 technique that had a statistically significant difference between the groups, due to the lack of current use by general dentists. Most of either group did not anticipate any changes in usage over the next 2-3 years. BGT Tell-show-do Nonverbal Voice control Positive Reinforcement Distraction Nitrous Oxide TABLE VII COMPARISON OF GENERAL AND PEDIATRIC DENTISTS ANTICIPATED CHANGE IN USAGE OF BASIC BGTS OVER THE NEXT 2-3 YEARS: PERCENTAGE REPORTING CHANGES IN BGT USAGE Specialty Don t Use No Use Total Significance Status Pediatric (n=98) (n=173) Pediatric (n=97) (n=170) Pediatric (n=98) (n=173) Pediatric (n=98) (n=172) Pediatric (n=98) (n=172) Pediatric (n=98) (n=173) use Mann Whitney U, p<0.05 Less Change More n.s. n.s. n.s. n.s. n.s..000

38 Anticipated Changes in Advanced BGT The anticipated changes in use over the next few years for the use of advanced behavior guidance techniques were compared between general dentists and pediatric dentists. See Table VIII. Comparisons were statistically significant for all advanced behavior guidance techniques. HOME was not significant. As previously discussed, most general dentists do not use the advanced behavior guidance techniques and 98% do not anticipate using more over the next 2-3 years, which explained the differences from pediatric dentists. Of the pediatric dentists currently using the various advanced techniques, most do not anticipate changes over the next 2-3 years, although a substantial proportion anticipated increasing use of general anesthesia.

39 31 BGT Protective Stabilization (nonsedated) Protective Stabilization (sedated) Moderate Sedation Anesthesia Hand over Mouth** TABLE VIII COMPARISON OF GENERAL AND PEDIATRIC DENTISTS ANTICIPATED CHANGE IN USAGE OF ADVANCED BGTS OVER THE NEXT 2-3 YEARS: PERCENTAGE REPORTING CHANGES IN BGT USAGE Specialty Don t Use No Use Total Significance Status Pediatric (n=98) (n=172) Pediatric (n=94) (n=172) Pediatric Pediatric (n=98) (n=172) Pediatric (n=95) (n=171) Use less Mann Whitney U, p<.05 **No longer listed in AAPD Guidelines change more n.s.

40 5. DISCUSSION 5.1. Summary of Methods and Findings A survey of pediatric dentists and general dentists in Illinois reported the current, past, and anticipated utilization of various behavior guidance techniques used for pediatric dental patients. The purpose of this study was to report the current usage of various BGTs of pediatric dentists and general dentists. We also evaluated changes compared to five years prior and anticipated changes over the next few years. Finally, we evaluated differences in BGT usage between the groups. The majority of general dentists and pediatric dentists report using all of the basic BGTs, with the exception of nitrous oxide/oxygen inhalation where 64% of general dentists reported not using it. Overall, pediatric dentists currently use more of the basic and advanced BGTs than general dentists. This finding was also consistent with results found in the study by McKnight et al. (1993). In general, the majority of both groups did not anticipate future changes in their methods of basic behavior guidance, however, 10-15% of dentists anticipated using more of the basic BGTs over the next few years. Additionally, most general dentists currently do not use the advanced behavior guidance techniques. Of the pediatric dentists that use the advanced behavior guidance techniques, most report no anticipated change in usage over the next 2-3 years. A substantial amount of pediatric dentists anticipated an increase in the use of general anesthesia over the next few years. 32

41 Differences in Usage of BGTs Across Practitioner Type Behavior guidance plays an integral part of the pediatric patient s dental experience. Uncooperative behavior can interfere significantly with providing quality dental care, which may result in increased delivery time and risk of injury to child, dentist, or both (Kuhn, Allen, 1994). Furthermore, a positive dental experience is an important part of the psychological and emotional development of a child. It is important, therefore, to understand practices of both general and pediatric dentists so that we may assist in educating all dentists on the currently used and acceptable methods. In regards to current usage of basic behavior guidance techniques, the majority of pediatric dentists and general dentists reported use of all of the nonpharmacologic basic behavior guidance methods for all age groups, which included: tell-show-do, voice control, nonverbal communication, distraction and positive reinforcement. These findings were consistent with the 2004 Adair study (for pediatric dentists). These methods are usually acceptable to parents. Nitrous oxide/oxygen inhalation was the only basic BGT not used by most general dentists. This may be due to inadequate training in dental school, increased malpractice insurance costs, or costs of maintenance of medical gases. Additionally, most general dentists and pediatric dentists reported allowing parents in the operatory for patients age 0-5 years, special needs patients, or at the parent s request. The majority of practitioners did not have parents in the operatory for patients age 6 year and older. This may be because older children and adolescents are more independent and are less likely to request parental

42 34 presence. Studies have shown that most dentists allow parents in the operatory due to parental request. However, they feel that it oftentimes interferes with building a bond with the child and decreases cooperation during the dental visit (Long, 2004). With regards to the current usage of advanced behavior guidance techniques, the majority of pediatric dentists reported using protective stabilization (70%) and general anesthesia (79%) for children under age 3, while a minority (31%) reported using moderate sedation. Compared to the 2004 Adair study, the usage of moderate sedation decreased from 68% to 31% by pediatric dentists. This may be due to the recent deaths of children reported in pediatric dental offices, increase in malpractice insurance, sedation guidelines, or decrease in parental acceptance. The majority (82-97%) of general dentists reported that they currently did not use the advanced behavior guidance techniques. This finding was not surprising considering that most advanced behavioral guidance techniques are taught in pediatric dentistry specialty training programs. Both groups overwhelmingly reported they did not use HOME, which has been removed from the AAPD guidelines and is virtually no longer in use. This study also reveals that general dentists and pediatric dentists differ in utilization of behavior guidance techniques across all age groups. Overall, pediatric dentists use more of the basic and advanced BGTs than general dentists. These findings were also consistent with results found in the study by McKnight et al. (1993). Both groups remained consistent in their BGT usage

43 35 compared to five years ago and both anticipate remaining consistent for the next few years. Although consistency was true for most respondents, 26% of pediatric dentists use less voice control compared to five years prior. This may be due to voice control being interpreted as punishment or a form of discipline by parents. Pediatric dentists perceive parents as being less willing to set limits and provide discipline to their children (Casamassimo et al., 2002). Pediatric dentists also used more tell-show-do, nonverbal communication, positive reinforcement, distraction and nitrous oxide/oxygen inhalation than in prior years, consistent with the previously noted move of BGTs towards more communicative and nonaversive techniques. Pediatric dentists also reported using less moderate sedation (33%) compared to five years prior which may be due to changes in sedation guidelines, changes in parental acceptance, malpractice costs, or recent deaths of children in the dental office during sedation (Litch, 2007). The increase in use of general anesthesia over five years ago by pediatric dentists is likely explained by the decrease in moderate sedation. anesthesia is more predictable and does not require any cooperation from the child. anesthesia has been increasing in acceptance from parents and the reported number of deaths for pediatric dental patients under general anesthesia is extremely rare.

44 Limitations of the Study One limitation to the study was that the sample was limited to those practitioners who were active members of organized dentistry and who responded to surveys, which may have created a response bias towards practitioners more interested in continuing education. Another limitation is that our sample is limited to dentists and pediatric dentists practicing in the state of Illinois. This may not allow our results to be generalized to other regions of the country Strengths This study focused on three significant subgroups of questions relating to usage of various behavior guidance techniques by general dentists and pediatric dentists. The study analyzed the past, present, and anticipated future use of BGTs by both pediatric and general dentists. A strength of the study was that the modified survey instrument (Adair et al., 2004) was previously tested. Current AAPD definitions for the various behavior guidance techniques were also included to minimize idiosyncratic responses.

45 Future Research Behavior guidance techniques in the pediatric dental patient have been documented for nearly 40 years. These techniques have changed from more aversive to more non-aversive methods due to parental objection, ethical and legal concerns, and societal changes. It is important to periodically report the utilization of these techniques for pediatric dental patients. These types of studies assist in developing continuing education courses for both general dentists and pediatric dentists on the BGTs that are currently being used and more likely to be used in the future by dentists. More research should also be completed on the motivational factors or barriers that are considered by general dentists when a BGT is selected for use in the pediatric dental patient. There is limited research on general dentists use of BGTs and the reasons for use. Further research on reporting the various BGTs used for children by general dentists and pediatric dentists in the United States is necessary to determine if our findings are consistent on the national level. In order to adequately update AAPD policies and develop continuing education, it is important to know the BGTs that are being used in other parts of the country because there may be state or regional differences in reported usage of various BGTs.

46 6. CONCLUSION 1. The majority of general dentists and pediatric dentists are currently using nonpharmacological basic behavior guidance techniques for pediatric patients across all age groups. 2. The majority of pediatric dentists are using nitrous oxide/oxygen inhalation for pediatric dental patients, whereas the majority of general dentists are not. 3. The majority of pediatric dentists are using the advanced behavior guidance techniques, whereas the majority of general dentists are not. 4. Hand over mouth technique is virtually no longer in use by either pediatric or general dentists. 5. Most general dentists and pediatric dentists report no change in usage of basic and advanced behavior guidance techniques compared to five years ago. 6. Most general dentists and pediatric dentists report no anticipated change in usage of basic and advanced techniques over the next few years. 38

47 CITED LITERATURE Adair SM, Waller JL, Schafer TE, Rockman RA: A Survey of members of the American Academy of Pediatric Dentistry on Their use of Behavior Management Techniques. Pediatr Dent 26: , Adair SM, Schafer TE, Rockman RA, Waller JL: Survey of Behavioral Management Teaching in Predoctoral Pediatric Dentistry Programs. Pediatr Dent 26: , Adair SM, Schafer TE, Rockman RA, Waller JL: Survey of Behavioral Management Teaching in Pediatric Dentistry Advance Education Programs. Pediatr Dent 26: , Allen KD, Stanley RT, McPherson K: Evaluation of behavior management technology dissemination in pediatric dentistry. Pediatr Dent 12: 79-82, Carr KR, Wilson S, Nilmer S, Thornton JB: Behavior management techniques among pediatric dentists practicing in the Southeastern United States. Pediatr Dent 21: , Casamassimo PS, Wilson S, Gross L: Effects of U.S. parenting styles on dental practice: perceptions of diplomats of the American Board of Pediatric Dentistry. Pediatr Dent 24: 18-22, Davis MJ: Pediatric Dentistry Workforce Issues: a task force white paper. American Academy of Pediatric Dentistry Task Force on Work Force Issues. Pediatr Dent 22: , Eaton JJ, McTigue DJ, Fields HW, Beck MF: Attitudes of Contemporary Parents Toward Behavior Management Techniques Used In Pediatric Dentistry. Pediatr Dent 27: Guidelines for Behavior Guidance for the Pediatric Dental Patient. Amer. Acad. Dent. Reference manual, Guidelines for Use of Nitrous Oxide for Pediatric Dental Patient. Amer. Acad. Dent. Reference manual, Guidelines for Monitoring and Management of Pediatric Dental Patients During and After Sedation for Diagnostic and Therapeutic Procedures. Amer. Acad. Dent. Reference manual, Guidelines for Use of Anesthesia Personnel in the Administration of Office-based Deep Sedation/ Anesthesia to the Pediatric Dental Patient. Amer. Acad. Dent. Reference manual,

48 40 Kuhn BR, Allen KD: Expanding child behavior management technology in pediatric dentistry: a behavioral science perspective. Pediatr Dent 16: 13-17, Lawrence SM, McTigue DJ, Wilson SW, Odom JG, Waggoner WF, Fields HW Jr: Parental attitudes toward behavior management techniques used in pediatric dentistry. Pediatr Dent 13: , Levy RL, Domoto PK: Current Techniques for Behavior Management: A Survey. Pediatr Dent 1: , Litch SC: Aftermath: New Illinois Sedation law. Pediatric Dentistry Today 8-9, Nov Long, N: The Changing Nature of Parenting in America. Pediatr Dent 26: , McKnight CH, Myers DR, Dushku JC: The use of behavior management techniques by dentists across practitioner type, age, and geographic region. Pediatr Dent 15: , The Association of Pedodontic Diplomates: Technique for Behavior Management-A Survey. J Dent Child 39: , The Association of Pedodontic Diplomates. Survey of attitudes and practices in behavior management. Pediatr Dent 3: , Wright GZ, Starkey PE, Gardner DE: Managing Children s Behavior in the Dental Office: Parent-child separation. St. Louis, MO: Mosby, 1983.

49 APPENDIX A 41

50 42