Behavior Management Techniques Adopted by Pediatric Dentists in Egypt

Background: Dental treatment exposes the patients to an environment that may trigger natural response of fear, leading to difficulties in accepting treatment or even dental avoidance. The study aimed to identify the most common behavior management techniques (BMT) adopted by pediatric dentist in Egypt for managing uncooperative children. Methods: Questionnaires were hand delivered to pediatric dentists, which designed to record participants demographic and practice information, their current use of BMT, to determine the most common behavior management techniques used for each patient age; and their relationship to practitioner gender, total year in practice and position in the faculty. Results: Surveys 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 was considered the most used technique (95.8%) for patients 3-5 years. Their employment of advanced techniques by respondents was less than basic techniques, being least for sedation and highest for general anesthesia mainly for the very young patients (73.2%). Conclusions: Presence of parents at the operatory became imperative for patients less than two years to gain their cooperation, unless general anesthesia will be used for them.


Introduction
Dental treatment expose the patients to an environment that may trigger natural response of fear, leading to difficulties in accepting certain types of treatment or even dental avoidance 1 . The nature of dental anxiety is different among children, some of them present with fear or phobia in relation to specific dental stimuli such as needles 2 and other children report more generalized anxiety related to dental setting 3 . So, as the etiology of dental anxiety is multi-factorial, it is important to have a wide variety of behavior management techniques (BMT) tailored according to the need of child patient and skills of pediatric dentist.
Behavior guidance techniques are set of procedures employed by dental practitioners used to alleviate anxiety, establish communication, instill positive dental attitude and to enable performing quality oral health care safely and efficiently for children and persons with special health care needs 45 6 .
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 pre-visit imagery, direct observation, ask-tell-ask, voice control, nonverbal communication, tell-show-do, positive reinforcement & descriptive praise, memory restructuring, distraction, parental presence/absence and nitrous oxide/oxygen analgesic. These techniques 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 6 . Hand over mouth technique has lost its popularity being used less by pediatric dentistry practitioners 7 , until it was eliminated from the clinical guidelines of American Academy of Pediatric Dentistry 6 . The aim of this study was to identify the most common behavior management techniques adopted by pediatric dentist in Egypt in management of uncooperative children.

Methodology
The survey was conducted in Egypt at pediatric dentistry department of Cairo, Ain-Shams and Al-Azhar governmental Universities. The ethical approval was obtained from the Research Ethics Committee, Faculty of Dentistry, Cairo University on 24/10/2016, furthermore, approvals from Ain-Shams and Al-Azhar Universities to be include in the study were granted. All research methods were performed in accordance with Cairo University Guidelines and regulations. Ninty two (92) questionnaires were hand delivered to pediatric dentists, which were either university staff members (master degree or PhD holding) or PhD students. Questionnaire was in English language and designed to record participants demographic and practice information and their current use of BMT to determine the most common techniques used for each patient age; and their relationship to practitioner gender, total year in practice and position in the faculty. Descriptive statistics, Chi-square ( 2 ) test and Friedman's test were used to compare participant's gender, total years of practice, position in faculty and use of behavior management techniques at p-value less than 0.05 (statistically significant) or less than 0.01 (highly statistically significant).

Results
Surveys were returned by seventy two pediatric dentists (78.3% response rate), of those 20 (27.8%) were males and 52 (72.2%) were females. Further details on personal and demographic characteristics are described in for patients 6-8 years, but their degree of employment was less than Tell-Show-Do.
Distraction was selected by 90.3% of participants to be used for 3-5 years patients.
Nitrous oxide / oxygen inhalation sedation has been used by very few practitioners mainly for patients 3-5 years.
The use of advanced BMT by respondents was less than basic techniques, being least for sedation and highest for general anesthesia mainly for the very young patients with percentage of 73.2% and 71.8% for patients 0-2 years and 3-5 years respectively. The results were highly statistically significant for all techniques between different patients age (P<0.001). Techniques percentages for different ages are described in table (3).
Ragarding association between use of BMT and practitioner gender, total years in practice and position in faculty, there was no statistically significant difference between gender distribution and BMT except for Tell-Show-Do with a P-value = 0.030 (P<0.05). As well as, no statistically significant difference between pediatric dentist's experience and different use of behavior management techniques except for general anesthesia with a P-value = 0.011 (P<0.05).
Sedation or general anesthesia was selected to be the first alternative to hand over mouth exercise (HOME) after its elimination from AAPD clinical guidelines, as shown in figure (1).

Discussion
Most pediatric dentists preferred parental presence technique followed by general anesthesia for the management of uncooperative 0-2 years patients, as the major problem in providing treatment for them is their infantile behavior and immature communication ability 8 . According to Walter, 1999infants are docile and easy to manage requiring the presence of their mothers since separation will influence the children's reactions to new situations 9 . General anesthesia can provide comprehensive mean for their management in a single visit and immediate relief of dental pain when other behavior measures fail 10 .
Tell-show-do (TSD) technique was the most used technique for patients 3-8 years, as it is safe, noninvasive and being acceptable among practitioners and parents 11 4 6 11 .
Low proportion of pediatric patients employed nitrous oxide analgesia for their patients which reveal its unpopularity in Egypt. Although according to AAPD guidelines on nitrous oxide sedation, it was considered as having excellent safety when used by trained practitioner for carefully selected patients with suitable equipment and technique 12 .
The least used technique was sedation compared with other behavior techniques and this might reflect the more psychological trend in managing young patients and less pharmacological mean of controlling child behavior. Sedation was associated with cases that resulted in permanent neurologic damage especially when used with very young patients less than three years old 13 14 . In the contrary, sedation has been selected by most participants to be the first alternative to Hand over mouth exercise (HOME). The reason for eliminating and rejecting HOME was the possibility of inducing fear or psychological trauma to the child 15 .
Tell-Show-Do technique was preferred by females more than males, as well as practitioners with more than 10 years in practice are using general anesthesia more than less experienced practitioners.Yet, their position in faculty was not associated with statistically significant difference regarding use of BMT. According to Adair et al., 2007 significant differences by age and sex were observed for the use of non-verbal communication and advanced behavior management techniques, but no significant differences were seen in respect to the use of most basic behavior management techniques 7 .
The high response rate to this survey (78.3%) was a good indication of participant's cooperation and interest in the topic of BMT for child dental patients. This interest has been documented in previous surveys for BMT with response rates 66% with Adair et al.,

Conclusions
Within all limitations of this study, it has been concluded that: Presence of parents at the operatory has became imperative during management of patients less than two years old to gain their cooperation, unless general anesthesia will be used.   Figure 1 A bar chart showing percentages of pediatric dentist's opinions regarding 1st alternative to hand over mouth exercise (HOME)

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