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Chapter 1 Introduction
I. Background
Dental treatment often arouses overwhelming fear and anxiety in children [1]. Therefore, managing uncooperative children is important in any pediatric dentistry practice. As such, the significance of effective communication skills with these children has been widely acknowledged [2]. Unlike adult, children will react to dental intervention in various ways, which could be really tricky to identify and manage. However, such emotional reactions should be recognized and paid attention to, for they reflect individuals’ needs in the healthcare communication [3-5]. Hence, assessment tool for children’s behaviors is of utmost important to dentists. This will help the dentist to execute required treatment plan in the most appropriate manner in children.
One essential component of pediatric research program is a reliable and well-validated tool for assessing the child’s response to dental treatment. Unfortunately, few approaches have yet emerged to objectively observe and quantify the child’s response in the dental setting. Therefore, the development of valid and reliable child assessment techniques is a major prerequisite for refining pediatric behavioral research and ultimately for improving the clinical management of children’s dental anxiety and behavior.
II. Significance of the study
The assessment of healthcare communication between dentist and children has been widely explored using various methods, such as rating scales (eg. the behavioral profile rating scale [6]), checklists (eg. the child behavioral problem checklist [7]) and coding instrument (eg. Weinstein et al. [8]). Frankl behavior rating scale is widely known and used by many researchers, in which the child’s reaction to dental treatment is rated on a four-point scale ranging from definitely negative to definitely positive. However, descriptive based evaluating scale makes the results heavily dependent on the observers, a tabulation of discrete behaviors of children may be unable to reveal.
In assessing the usefulness of a rating technique, several features are important including reliability and validity. Reliability reflects the extent to which a scale is consistent and repeatable in assessing a trait. A highly reliable scale will provide similar results when use to assess the same sample of behavior at different times (test-retest reliability) or by different raters (inter-observer agreement).
Validity reflects the degree to which a scale actually measures what it purports to measure. A valid scale therefore is one which accurately and specifically measures the unique trait it was designed to measure.
Also, one of the most recognized influencing factors, the child-caregiver-dentist rapport, is seldom considered when evaluating children’s fear and behavior. This should be very carefully considered and integrated into the assessment tool for the better treatment plan.
III. Objectives of the study
Therefore, an objective point rating scale with good reliability and validity, which takes into account of child-caregiver-dentist rapport, will be very crucial and ideal for children behavioral assessment during dental treatment.
This study, hence, serves two main purposes. First, we aim to establish an objective, reliable, complete and concise observational coding system and rating scale for better evaluation of dental fear in children. Second, we aim to investigate the relationship between the total score of our observational rating scale and others factors.
Chapter 2 Review of literatures
I. Origins of childhood dental fear
i. Patient characteristics
Gender differences have been reported previously for dental fear [9]. Females were reported being more fearful than males [10]. However, in a study with sample 603 elementary and middle school children [11] did not reveal any gender differences for dental fear.
ii. Different pathways of fear
Rachman (1990) has proposed three different pathways that can acquire fear; through direct conditioning, threatening information or vicarious experiences.[12] Peter (1995) concluded that dental treatment experiences may be the source of more general fears whether acquired directly or through modeling by parents. [10]
Repeated studies of the dental fear survey instrument [13] have found three groupings of concerns: highly invasive procedures, fear of potential victimization, and fear of less invasive procedures [10]. Fear of highly invasive procedures includes injections and drilling. Fear of potential victimization includes fear of strangers, choking and hospitals. Fear of less invasive procedures includes opening mouth and being examined by dentist.
However, fear induced through vicarious experiences does play a major role too, as it is found that not all dental visits are equal in their likelihood of generating fear. According to Peter [10], while over 92% of the children in his study had been treated by a dentist, poorer oral health status results in greater treatment needs, and hence associated with greater possibly bad experiences. One particular model as proposed by Weinstein [8] is plausible for which fear may be generated. This cyclical model suggests that severe dental problems may be treated with more invasive procedures, perhaps accompanied by greater pain and therefore resulting in more fear and subsequent avoidance.
From another point of view, it is possible that providing benign dental experience may be very effective in preventing dental fear [14]. Dental procedures such as radiographs and fluoride treatments, though may be invasive, they generate far less fear. Perhaps, such dental experiences could be put to good use for hyper-sensitive children, to generate a positive cyclical dental experience.
iii. Psychological aspects of fear [15]
1. Fear of pain or its anticipation
There is a significant association between actual or misinterpreted pain, or the anticipation of pain, and dental fear [16, 17]. Unfortunately, it is undeniable that discomfort and pain have been anchored deeply in dental treatment, no matter how adequate analgesic medications are [18]. This gives us an insight into the genuine basis for the children’s anxiety.
2. Lack of Trust or Fear of Betrayal
Trust of the dentist has a significant association with dental fear as researched in adult population [19]. Since children mostly get influence and learn from their parents, it is highly probable that children learn to trust or distrust from their parents before they have any direct contact with medical personnel. Such distrust may generalize to all dentists. Although there is no formal evidence of such trend in children, clinical experience strongly suggests that lacking of trust is important in generating fear.
3. Fear of Loss of Control
Human is constantly urging for control, over one’s self or others. It is hard to suppress one’s fear of losing control over ourselves is anticipated, especially for children. Sitting onto the clinical unit, indirectly suggests the losing control of ourselves, particularly our mouths. The mere thought of the need to cooperate and immobilize even under intrusive approaches is frightening. Such sense of helplessness will be even more amplified in children.
4. Fear of Unknown
Peter Wright [10], a certified NLP Practitioner and TimeLine (TM) therapist and an accredited Hypnotherapist and Sports Hypnosis specialist, wrote an article explaining the human mind does not process negative instructions or deletions. If we say "Don''t think of a black cat", we have to first of all think of a black cat, in order to carry out the instruction. Chapman [15] presented the idea that any reassuring statement made of the situation may have the exact opposite effect as they remind that state in the child’s mind. Apparently helpful comments from the mother such as, ‘It won’t hurt,’ even before an examination, are going to raise the possibility in the child’s mind of being hurt. The unknown level of pain will even exacerbate the intensity in the mind. Provision of such information a long time in advance may only serve to increase fear of the unknown and the anticipation of pain.
5. Fear of Intrusion
Fear of intrusion is the most obvious, and the most difficult part of the origin of fear to deal with. Dentistry is invasive and intrusive, both physically and mentally. Firstly, it involves impinging on the patient’s personal space, and it involves extensive touching. Some children find this invasion of personal space very threatening. Secondly, constant criticism from the dentist about how poor the children’s diet and how inadequate their cleaning, is very demoralizing.
II. Managing dental fear
i. Providing information
Poor information provided about dental situation will increase the likelihood of misinformation from others. The provision of an appropriate level of information will not only reduce fear of the unknown, but also foster a sense of control. And the most usual way is through the ‘tell-show-do’ technique.
ii. Tell-show-do
Tell-show-do is a technique of behavior shaping used by many pediatric professionals. The technique involves verbal explanations of procedures in phrases appropriate to the developmental level of the patient (tell);demonstrations for the patient of the visual, auditory, olfactory, and tactile aspects of the procedure in a carefully defined, nonthreatening setting (show); and then, the procedure is performed exactly as described. (do). The tell-show-do technique is used with communication skills (verbal and nonverbal) and positive reinforcement. [20, 21, 22]
iii. Explain-show-do
Chapman [15] suggested ‘explain-show-do’ is better in managing dental fear. It suggests a less didactic approach with a broader information base; not only what an item of equipment is and how it feels, but what it does. It offers an opportunity to try equipment in a non-threatening way in the mouth as well as on a finger.
iv. Providing some form of control
Chapman [15] mentioned that perceived or experienced control is the critical factor to reduce the fear in children. One way to accomplish is to offer children the opportunity to ask questions, whereby enhances their control over information gain. Provide them with appropriate level of corresponding answers will help in managing the fear.
Next is to give them appropriate decisional control. Chapman [15] provides an interesting example of explaining the appropriateness; letting a four year old child choose which tooth to polish first (not whether they have the polish or not), a six-year-old child deciding whether or not to have a local anesthetics for a particular restoration (but not whether or not to have the restoration) and a 10-year-old child fulfilling the request of completing easy treatment first because they have exams afterwards or they are not feeling well. Providing appropriate level of control gives a sense of trust to the children. Older children may understand and appreciate the gesture, which further enhances their cooperativeness with the dental treatment.
Introducing hand-up stop signal offers children to have control over the procedure. However, there is evidence that introducing a stop signal for a non-stressful situation may heighten anxiety [23]. Presumably, this is because it raises the awareness of the possibility of pain or threat. Chapman [15] concluded that the introduction of a stop signal during a prophylaxis would be appropriate for children who were showing signs of fearfulness, but would be inappropriate for those who are obviously confident.
v. Voice control
Voice control is a controlled alteration of voice volume, tone, or pace to influence and direct the patient’s behavior. The attention of a disruptive child is gained by changing the tone or increasing the volume of the voice. Parents unfamiliar with this possibly aversive technique may benefit from an explanation prior to its use to prevent misunderstanding. [20-22,24]
vi. Positive reinforcement
To reinforce desired behavior. In the process of establishing desirable patient behavior, it is essential to give appropriate feedback. Positive reinforcement is an effective technique to reward desired behaviors and, thus, strengthen the recurrence of those behaviors.
Social reinforces include positive voice modulation, facial expression, verbal praise, and appropriate physical demonstrations of affection by all members of the dental team.
Non-social reinforces include tokens and toys. [20, 24-26]
vii. Distraction
The objectives of distraction are to decrease the perception of unpleasantness and avert negative or avoidance behavior. Distraction is the technique of diverting the pa¬tient’s attention from what may be perceived as an unpleasant procedure. Giving the patient a short break during a stressful procedure can be an effective use of distraction prior to considering more advanced behavior guidance techniques. [24-26].This technique can be used with any patient.
viii. Mouth props
A device is placed in the child’s mouth to eliminate closing when a child refuses or has difficulty maintaining an open mouth.
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ix. Hand-over-mouth-exercise (HOME)
HOME is used to establish communication and obtain cooperation with highly disruptive or defiant children. The disruptive child is told that a hand is to be placed over the child’s mouth. When the hand is in place, the dentist speaks directly into the child’s ear and tells the child that if the noise stops the hand will be removed. When the noise stops the hand is removed and the child is praised for cooperating. If the noise resumes the hand again is placed on the mouth and the exercise repeated [27] but this technique is not widely accepted by parents so it is rarely used by dentists [28]. In May 2006, the American Academy of Pediatric Dentistry eliminated the HOME technique from its clinical guidelines on behavior management [29].
x. Physical restraint by the dentist
The dentist restrains the child from movement by holding down the child’s hands or upper body, placing the child’s head between the dentist’s arm and body, or positioning the child firmly in the dental chair.
xi. Physical restraint by the assistant
The assistant restrains the child from movement by holding the child’s hands, stabilizing the head, and controlling leg movements.
xii. Papoose boards and pedi-wraps
These are restraining devices for limiting the disruptive child’s movement. The child is wrapped in these devices and placed in a reclined dental chair.
xiii. Sedation
Sometimes drugs are used to sedate a child who does not respond to other behavior management techniques or is unable to comprehend the dental procedures. Often, these drugs are administered orally.
xiv. General anesthesia
The dentist performs the dental treatment with the child anesthetized in the operating room.
III. Assessment Tool
An ideal assessment tool should be valid, allow for limited cognitive and language skills, and have to be easy for clinical use. No single assess¬ment tool is perfect in predicting a children’s anxiety level, but awareness of the multiple influences will definitely help in understanding the children’s behaviors. In general, dental anxiety can be assessed mainly in two ways.
One is through indirect ratings done by observers, and the other is through direct ratings done by respective individual involved in the treatment. There are various tools to be used for evaluation. Here we will discuss a few of them.
i. Direct assessment tools
1. Facial rating scale
Facial expression drawings (‘‘faces scales’’) are a popular method of pain severity assessment in pediatric populations. Faces scales use a series of facial expressions to illustrate a spectrum of pain intensity. Numerous face-based rating scales are available [30].
Faces scales are ordinal outcome measures consisting of a limited number of categorical responses ordered in a specific pattern. Although there is debate about the optimum design of the facial expressions, the literature suggests that they are the preferred method of pain reporting by children.
The most widely used and best validated faces pain scales are now the FPS-R, the Oucher, and the WBFPRS.
The Wong-Baker FACES Scale (WBFPRS) is one of several faces scales that have been demonstrated in multiple pediatric settings for pain assessment.
Badr et al [31] reported that dolls with drawn-on faces to represent the pain faces were preferred to the printed WBFPRS, but it is interesting to note that in one study other scale (the pieces of hurt) was more preferred than the WBFPRS among Jordanian girls, whereas boys preferred other faces scales, and the authors suggested that this result may be a product of Jordanian cultural differences [32].
The WBFPRS has adequate psychometric properties, and it is easy and quick to use [33,34], and inexpensive to reproduce. The greatest strength of this scale may be its acceptability, given the consistent finding that the WBFPRS was preferred by children in any age, parents, and practitioners when compared with other faces pain scales [30, 35, 36].
The major concern with the WBFPRS is the confounding of emotion with pain intensity in the representation of the faces. Children who do not cry with intense pain, especially older boys, may be reluctant to pick the face scored 10 of 10 because it shows tears [37].
Fig1. The Wong-Baker FACES Scale (WBFPRS)
2. Children’s Fear Survey Schedule-Dental Subscale (CFSS-DS)
Among the psychometric methods, the Dental Sub-scale of Children’s Fear Survey Schedule (CFSS-DS), developed by Cuthbert & Melamed in 1982 [38], has been shown to be reliable and valid, and better in some ways than other scales such as VPT (Venham Picture Test) and DAS (Dental Anxiety Scale) [39].
The CFSS-DS questionnaire consists of 15 items, each covering different aspects of dental and medical situations and was used to measure dental anxiety [38]. The possible response to each item is a score between 1 and 5, the total scores ranging between 15 and 75, with a high score indicating dental anxiety.
Extensive research in several countries has indicated the CFSS-DS to be reliable; the internal consistency as well as the test-retest reliability proved to be high, and also the validity of the scale was found to be acceptable.
Fig.2 Children’s Fear Survey Schedule-Dental Subscale (CFSS-DS)
3. Venham picture test (VPT) [41]
It is a test to measure state of dental anxiety, which has been used in a number of studies. It comprises eight cards, with two figures (cartoon boys) on each card, one ‘anxious’ figure and one ‘non-anxious’ figure with pictures of children in various dental situations.
Each child was asked how they would feel about visiting the dentist and to point out the figure they liked the most. A score was recorded for each card when "high fear" picture was selected and summed to give total out of eight. Higher scores indicate greater fear.
The advantage of VPT is that it is relatively easy to administer and score. Validity has been demonstrated by showing that the VPT distinguishes well between children referred to a dental hospital for specific anxiety/cooperation problems, and those referred for other reasons. The VPT does have some limitations. The figures on the cards are all male, this may present problems when the child is a girl. In addition, some of the figures are ambiguous in what they are portraying. Finally, the scale still takes some time to complete, this is a salient issue when considering very young patients.
Fig.3 Venham picture scale
ii. Indirect assessment tools
1. Frankl behavioral rating scale
One of the more reliable and frequently used behavior rating systems in both clinical dentistry and research is the Frankl Scale [42, 43]. This scale separates observed behaviors into four categories ranging from definitely negative to definitely positive [42, 44].
Fig.4 Frankl behavior rating scale
2. Sound, Eye and Motor Scale (SEM)
SEM is an objective method for pain assessment where three types of observations; sounds (S), eyes (E) and motor (M) are taken into account of for measurement of comfort level [45]. The score in each category ranged from 1 (none) to 4 (intense). The level of response for each observation is then given a score. The average of these scores is obtained to indicate the overall comfort level.
Sounds and movements accompanied one another and rarely were desperate responses were seen. However the application of this scale in younger children may be difficult as their response to painful situations may not only be dependent on the pain experienced during the procedure but may also be influenced by many other factors.
Wright [45] reported that the SEM Scale corresponded favorably to the Frankl Behavior Rating Scale.
Fig.5 Sound eye motor (SEM) scale
Chapter 3 Materials and Methods
I. Participants
This study was subjected to the ethical rules and guidelines of Institutional Review Board of Kaohsiung Medical University Chung-Ho Memorial Hospital and parents and children provided written informed consent and assent as appropriate.
This study consists of 60 children (2-12 y/o) and they were selected as a convenience samples ie all children that came for treatment during the study period and who met the selection criteria. All the children were treated by 8 pediatric specialists. There were two groups of dentists, one group consists of 2 dentists with more than 10 years working experience, another group consist 6 dentists with less than 10 years working experience.
The study was conducted at Kaohsiung Medical University Dental Pediatric Department and one pediatric local clinic between November 2012 and October 2013.
To participate in this study the children had to meet the following criteria: age between 2 and 12 years, exclusion criteria included children with chronic illness, children with developmental delay, children taking psychiatric medication.
Participation was voluntary and not awarded. Patients’ parents were told that refusal to participate would not interfere with the choice of treatment made.
II. Materials
i. Hidden video recording camera
Hidden video recording equipment, placed approximately 4 to 6 ft (1.2 to 1.8 m) from the foot of the treatment chair and focused to include the child''s head and body, recorded the entire dental session.
ii. Measurement of anxiety (Direct method)
Two anxiety measurement scales were also included in the questionnaire as a self-report measure of anxiety.
1. Children’s Fear Survey Schedule-dental subscale; CFSS-DS
To assess dental fear the Chinese version of the Children’s Fear Survey Schedule-Dental Subscale was used. The Fear Survey Schedule for Children (FSS-FC)* was developed by Scherer and Nakamura, and the CFSS-DS* (Cuthbert & Melamed, 1982) is a shorter, revised version of the FSS-DC, to obtain a specific dental fear questionnaire for children. The Chinese version was modified by Lee, et al, 2007.
The Cronbach‘s α is 0.90 and after using the ROC curve analysis, the cut off score is 39, the sensitivity is 0.86, the specificity is 0.88. Overall predictive accuracy is 91%.
The CFSS-DS was filled out by children with assistance from parents/caregivers as a routine part of intake procedure in the KMUH pediatric department and local clinic.
2. Visual analog scale; VAS
The Wont-Baker Scales (WBS) assign a numerical value to each face, on which the child pointed out which face corresponded the best to its present degree of pain after treatment. These scales represent six faces with increasing degrees of pain from left to right. Each face was attributed a score from 0 to 5 as indicated on the scales and also adds word descriptors to each face in Chinese (no hurt, hurts a little, hurts a whole lot, etc.)
iii. Chart recording
Including first visit or follow up (times), patient profile, chief complaint, present illness, past history / family history, tentative diagnosis, treatment plan.
III. Study Protocol
The procedures, potential risks, and benefits of participating in this study were fully explained to the subjects involved, and their informed consensus was acquired prior to the investigation.
CFSS-DS was completed by the children under the guidance and help from their respective care-givers.
With the use of the hidden video recorder, all behavioral interactions between child-caregiver-dentist in the dental environment were recorded during the dental procedure. At the end of the treatment, VAS score sheet was given and completed by the children with the help of their care-givers.
Each case-based recorded video was then examined and transcribed into observational records by a well-trained researcher. The observer was extensively trained using videotapes not included in the study. Each observational record will be coded and organized into a point rating scale.
i. Narrative recording
Review each case through video recording. Use narrative approach to describe every emotional reaction presented during dental treatment. Put particular emphasis on: children’s motor movement, verbal content, emotion, child-caregiver-dentist rapport. Review all the different types of reactions, and categorize them into an organizing format.
ii. Rating recording
To define each observational code, term and condition and design a point rating scale as well as a checklist to evaluate the strength of each factor for each case. The observational code includes 9 major scales: 1. Head movement; 2. Body movement; 3.Upper extremities movement; 4. Lower extremities movement; 5.Sound; 6. Emotion; 7.Child-caregiver on-treatment relationship; 8. Child-dentist on-treatment rapport; 9. Dentist-caregiver on-treatment relationship. And Set a range of scores for different level of cooperativeness behavioral pattern.
iii. Measurement of anxiety (Indirect methods)
1. Frankl rating scale
The 4-point Frankl scale was used as a measure of anxiety.[38] Numerical equivalents of 1(definitely positive), 2(positive), 3(negative) and 4(definitely negative) were used during the whole dental procedure. Children rated into the negative categories were considered to be anxious.
2. Observational behavioral rating scale
This rating scale in this study was developed by the researcher after reviewing all the video tapes and organizing all the reactions into a rating scale. Including 9 items, each covering different reactions of children, parents and dentist in dental procedure and was used to measure dental anxiety (Fig.6). The possible response to each item is a score between 1 and 4, the total scores ranging between 9 and 36, with a high score indicating dental anxiety.
Fig.6 Observational behavioral rating scale
IV. Statistical analyses
Statistical analysis was performed using the SPSS 20.0 software package.
Descriptive analyses were used to describe children’s and children’s parents’ basic characteristics, Children’s dental anxiety (score of CFSS-DS) and pain experience due to the dental treatment (score of WBFPRS).
The relationship between observation total score-gender, dentist’s seniority and location were evaluated using independent t-test and the Mann-Whitney U test.
One-way ANOVA and the Mann-Whitney U test analysis were used to evaluate the relationship between observational total score and treatment type.
A Pearson correlation matrix was employed to assess the correlation of observational total score with WBFPRS、CFSS-DS total score、age、number of behavior treatment type and Frankl scores.
Multiple regression test was used to assess the relation of observational total score with CFSS-DS total score、age、number of behavior treatment type and Frankl scores.
Chapter 4 Results
I. Subject’s characteristics
The study population comprised 36 males (60%) and 24 females (40%), aged 2-12 years (mean age 5.36 ears, SD 8.36). (Table 1)
When asked to report the highest level of education the children’s parents had completed, 2 parents reported earning a doctor’s degree, 6 of them had a master degree, 19 reported graduating universities, 16 revealed completing bachelor’s degrees, 17 indicated completing high school.(Table1)
In Table 1, most of the children, with a percentage of 85 (n=51), came for follow-up treatment as opposed to their first visit. The most common treatment item was restorative treatment (53.3%, n=32), with routine examination came in second (28.3%, n=17), and lastly endodontic treatment (15.0%, n=9).
II. Measure of anxiety
According to WBFPRS (Table 3) for pain evaluation in this study, 37(61.7%) of the children experienced no hurt, 10(16.9%) experienced hurt little bit with pain score of 2, and 6(10%) experienced severe pain with pain score of 10.
Table 4 shows CFSS-DS score for each item. 48.4% of the children expressed high level and highest level of fear (pretty much afraid + very afraid) for the item “Injections”, followed by “The sight of the dentist drilling” (20.0%) and “Having a stranger touch you” (18.4%).
The possible response of the observational rating scale to each item is a score between 1 and 4, the total scores ranging between 9 and 36, with a high score indicating dental anxiety. According to the ROC curve (Fig.7) to analyses, the cut off score is 15.5, with area under the curve=0.975, sensitivity=1, specificity=0.95. Therefore, the children with scores>= 16 were defined as dentally anxious.
About the cut off score, we used the Frankl score as the validity criterion, after using ROC curve to analyses, we found that the score 15.5 have the highest sensitivity and specificity, so we chose this number as our cut off score.
According to our observational behavioral rating scale, 38(63.4%) children were rated as not anxious while 22(36.7%) of them rated as anxious children from dental treatment. In Frankl rating scale, 40(66.7%) children were rated as not anxious and 20(33.4%) children rated as anxious. (Table 6)
III. Relationship between observational total score and other factors
Both independent t-test and the Mann-Whitney U test analyses show that there are no significant differences between observation total score-gender, dentist’s seniority and location.
One-way ANOVA and the Mann-Whitney U test analysis show no significant relationship between observational total score ant the treatment type.
i. Correlation analysis
Pearson correlation matrix found that no significant relationship between observational total score and WBFPRS(r=.207, P=.112).
In spite of that, Pearson correlation matrix found that the observational total score has significantly positive correlations with CFSS total score(r=.526, P<.0005); number of behavior treatment type(r=.442, P<.0005); Frankl score(r=.881, P<.0005) and has significantly negative correlations with age(r=-.532, P<.0005) as shown in Table7.
Multiple regressions shows that the observational total score has significant relation with Frankl score and CFSS-DS score but no significant relation with age and number of behavior treatment type.
Fig.7 ROC curve and the area under the curve
IV. Narrative recording
Here is an example of one video record, the full content are in the appendix.
Case No 1.
3-year-old boy Gu, was brought here by his mother on 1 April 2013 for caries treatment. He was mildly nervous while entering the dental unit by himself, with caregiver stood by the side watching.
During the course of treatment, his facial expression was moderately nervous with anxiety, and he presented moderate interruption to the treatment. His head was tensed. His hands tend to move to localised pain. His legs were relaxed. Verbally, direct complaints were noted.
Child-dentist behavioural interactions: Gu was inattentive, but still can obey commands most of the time. Behavior treatment used by dentist: Tell-show-do, positive feedbacks, negative feedbacks, voice control, counting down 123, emotional support, distraction (casual conversation about favorite games and hobbies), and appropriate pause/rest.
Child-caregiver behavioural interactions: The need of caregiver accompaniment throughout the treatment; Caregiver provided consolation, positive feedbacks, and direct command to cooperate with dentist.
Dentist-caregiver behavioural interactions: Caregiver did not interrupt the treatment. On the other hand, the caregiver helped to console and command better cooperation from the child. Caregiver understood the objectives and the procedures of the dental treatment. Caregiver presented cooperative attitude.
The whole procedure took 32 minutes 26 seconds.
Chapter 5 Discussion
This study is the first study that deals with combination of narrative recording and rating recording of children anxiety with dental treatment in Taiwan.
I. Type of treatment
Type of treatment is considered to be one of the variables that effect amount of anxiety during dental treatment [45]. Little data is available regarding anxiety associated with various dental procedures.
In our study, no statistical significance was found between the anxiety of children and the treatment options they were treated.
Wong and Lytle (1991) found that that an oral surgery treatment was the most unpleasant treatment whereas root canal therapy was the second unpleasant experience [46].
A survey conducted by the American Association of Endodontics [47], showed that the general public’s perception of endodontic therapy is negative due to its association with pain before and following the treatment. Patients who had experienced endodontic therapy were found to be less frightened of the treatment than patients with no such experience [46].
II. Gender
Some studies found that female generally demonstrate higher levels of dental anxiety than male [47,48], although Wong and Lytle [46] found no significant gender differences when endodontic treatment or extraction was anticipated. They showed that when a difference in dental anxiety did occur between the genders, it was due to low anxiety procedures like tooth cleaning or dental examination, where female patients were found to be more anxious.
The gender differences in dental anxiety support psychopathologic studies which have revealed that female are over-represented in neurotic categories involving anxiety, worry and fear, a phenomenon that, regardless of its basis, is widely found in different cultures [50].
In our study, we found no gender difference in the level of dental anxiety was observed. This observation is in some agreement with the findings of previous studies.
Since our sample size is rather small than the studies mentioned above, so it may have some effect, further study is need for this issue rather gender have effect on dental anxiety among children.
III. Age
Studies found that children 6 years and younger are more likely to behave negatively [49,51-53], and this consistent with the result of this study. The younger the child is the higher score he/she gets in the rating scale.
IV. Parents’ factor
It is important to investigate the parents’ factor because they play an important role in our rating scale which makes our scale unique from the others.
According to our scales, we found out that only 5% of parents showed mediocre or no cooperation and the reason behind this could be partly due to the requirement of video recording in this study. As we have observed, those who agreed to participate in our study (video recording) are largely cooperative, and those who turned down our study are more likely to be less cooperative. Therefore, this is by nature a significant confounding factor need to be considered upon when interpreting the results.
The parents’ factors were reported to be highly important in the development of child dental fear [54]. Some of the parents, however, indicated temperamental factors and the anxiety related to dental procedure to have played a role, suggesting that subgroups of dentally fearful children exist. Therefore, these factors are cofounding factor to affect our result and these factors were not measured.
V. Rating scales comparison
Although we found that the score of Frankl scale and the observational behavioral rating scale we developed is highly correlated, there are some differences between both scales.
i. Advantages:
In the scale we developed, it includes some factors such as parenting style, relationship between child-caregiver-dentist were not measured in Frankl scale.
The characteristics of the children’s parents participating in this study may affect the application of the result of our observational scale. It is considered necessary to take into account of parenting style because of their impact on both children and dentists. They can affect the successful rate and smoothness of dental procedure.
Furthermore, our rating scale includes 6 items of different aspect of children’s reactions such as movement, verbal content and emotion. In our rating scale, the rater is able to take account of individual response styles in behavior and to consider infrequent but significant behaviors.
Therefore, the rating represents a high degree of abstraction from the basic observational process.
ii. Disadvantages:
Although comparing to Frankl rating scale, our scale appears to be a more objective, accurate and reliable assessment, there are still some disadvantages of our rating scale.
The advantage of Frankl rating scale includes ease of administration and conceptualization. The dentist uses the trait as an organizing concept to select relevant cues and to superimpose a dimension on the subject’s behavior.
It is easier and faster for dentist to use Frankl scale than our observational scale.
VI. Facial rating scale
Numerous faces scales have been developed for the measurement of pain intensity in children and have been extensively studied [55]. It remains unclear whether any one of the faces scales is better for a particular purpose with regard to validity, reliability, feasibility, and preference.
In this study, we chose Wong-Baker Faces Pain Scale to evaluate pain intensity in children about the dental procedure. It was because the WBFPRS was generally preferred by investigators in pediatric pain. Another reason was the WBFPRS was published earlier, and in much more widely distributed publications and textbooks, than the other scales and, hence, was more familiar.
Children’s self-reports of pain are influenced by developmental, social, and contextual influences [55]. In our result according to the WBFPRS, there was no one to choose the face of 4 points (hurt whole lot). There are many factors having impact on this result. The small sample size, the way the staff explaining to the children and parents, the children age, the emotion of the children and etc.
VII. Staff behavior
Findings confirmed that there were relationships between dental staff behaviour that occurred in a routine clinical practice and the anxiety and/or behaviour of child dental patients [56].
Some staff behaviours (e.g., punishment) that were found to raise child fear also induced uncooperativeness while most of the staff behaviours bring about cooperative behaviours in children.
In our study, we did not investigate this part of impact. Future investigation is required with this approach on children of various ages and behavioural or emotional difficulties.
VIII. Further study
Since the reliability and validity of observational rating scale we developed are not tested in this study. Before this rating scale can be used in clinically, further procedures are need for this part of issue. It is suggested that there should be more dentist or specialist with different background to join this study and produce inter- and intra-coder reliability test in the near future.
Chapter 6 Conclusion
We developed a behavior coding system and rating scale for interactive behaviors between child, caregiver and dentist.
Total score of CFSS-DS, age, number of behavior treatment type, Frankl score have moderately to highly correlated relationship with our observational total score. Among these items, total score of CFSS-DS and Frankl score have higher correlation with observational total score.
Compared to other rating scale, such as the Frankl, it has shown some strengths and limitations.
The rating scale is objective and suitable for dentist to be used as behavior assessment tool and it may be used in other Pediatric medical treatment after modification. Further modification is need before using clinically and inter- and intra-coder reliability are needed to be tested in the future.
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