1. Introduction

Behavior management is a mainstay of effective treatment in pediatric patients. The level of cooperation and compliance with instructions from the treating pediatrician directly influence the quality of any dental procedure performed [1]. Dental anxiety and fear have been reported to be the two major barriers preventing patients from accessing dental health service and are intimately related to general anxiety/fear, sensory over-responsivity, and oral health behaviors and outcomes. It is important to be aware of these factors as they may add to the problems faced in the dental clinic [2]. A recent systematic review had suggested a global pediatric dental anxiety rate of 23.9% and the reported prevalence for preschool children was found to be as high as 36.5%, while that for school going children was reported to be 25.8% [3].

Keeping anxious pediatric patients calm and efficiently managing dental needs for such children is reported to be a highly challenging task [3]. Moreover, dental anxiety leads to high unmet dental needs among children, negatively impacting the oral health related quality of life. The pain and discomfort associated with inability to provide appropriate treatment leads to children taking days off from school, affecting their studies and social grooming as well [4].

Managing dental anxiety in the clinical setting involves pharmacological and non-pharmacological interventions [5]. Pharmacological methods are found to be more aggressive including general anesthesia, chairside sedation and relative analgesia. However, non-pharmacological behavioral management techniques involve strategies that aim to cognitively modify the patient’s behavior [5].

The American Association of Pediatric Dentistry (AAPD) defined behavioural management as “a continuum of interaction involving the dentist and dentist team and the patient, directed toward communication and education while ensuring the safety of both oral health professionals and the child, during the delivery of medically necessary care” [6].

Several different behavioral management techniques (BMT) have been advocated in literature. In order for the dentist to employ any BMT on a child, obtaining written informed consent from the parents is mandatory. Thus, it is of utmost importance that the parents understand the merits of using these techniques and the complications of pharmacological interventions that would have to be used if the child cannot be managed through BMT [7].

Parental attitude towards their child’s conduct at the dental office may be influenced in several ways. Thus, a positive experience on a dental chair is the stepping stone for achieving successful oral health care. Early precautionary measures can lead to better oral health and fewer chances of dental disease. Thus, less treatment needs arise leading to less chances of emotionally traumatic dental experiences [7].

One of the reasons of parental reluctance to bring their children for routine dental check-ups is economic hardships. Parents are unable to afford multiple visits to dentist owing to the loss of days at work. It leads to failure of getting an opportunity to know about the simple techniques available for timely pediatric dental care [7]. Havelka et al. [8] examined the effect of parental social status in acceptance of behavioral management techniques and found that parents from high socio-economic differences had higher acceptances rates than their counterparts from low socio-economic strata.

The choice of BMT is not made by the dentist alone. The consent of the child and parents is equally important [9]. Past dental experiences of parents may influence the child’s behavior adversely affecting the attitude and response of children towards dental treatments [10].

Parental attitudes and acceptance rates may vary in different cultures. There is no published study in Pakistan reporting the parental acceptance of different BMTs. Therefore, the present study aimed to educate and assess the parental acceptance regarding tell-show-do, positive reinforcement, voice control and modelling BMTs.

2. Null hypothesis

There is no significant difference between parental acceptances of various non-pharmacological behavior management techniques.

3. Materials and methods

4. Results

A total of 303 parents participated in the study. Out of these participants, there were 165 (54.5%) females and 138 (45.5%) males. The majority of the participants were either from Islamabad (n = 127, 41.9%) or Lahore (n = 67, 22.1%). Most of the parents (n = 90, 29.7%) belonged to the group of 20–30 years. The monthly income for majority of the participants (n = 125, 41.4%) was less than Rs. 50,000. The characteristics of the participants have been illustrated in (Table 1).

PAS were calculated by adding the individual responses for the seven items, thereby having a maximum score of 35. Positive reinforcement had the greatest PAS (27.17 ± 4.71), followed by tell-show-do (27.01 ± 4.54), modelling (26.76 ± 5.94) and voice control (23.47 ± 7.16).

There was no difference in the PAS for any of the techniques between male and female parents (Table 2). The higher SES was found to have a significantly lower PAS as compared to the lower SES (Table 3).

The inter-group mean differences were calculated for Voice Control since the ANOVA calculated significant results for the PAS of Voice Control (p-value = 0.006). The PAS for Voice Control was significantly greater for low SES as compared to the high SES (p-value = 0.004) (Fig. 1).

Fig. 1.PAS for different socio-economic classes. SES: socio-economic status.

5. Discussion

For children dental anxiety is the primary hurdle in not seeking dental care. It needs to be addressed efficiently as the famous axiom goes “a stich in time saves nine”. An in-depth assessment can make the difference between a pleasant and a nerve-racking experience for the children as well as their parents at a dental clinic. The present study provided the parents with an opportunity to familiarize themselves with special tools available to cater for the specific needs of their children [12].

The success of any pediatric dental treatment is contingent on the child’s cooperation level. Behavior management plays a key role in successful management of pediatric cases. Most of the parents are unaware of the presence of non-pharmacological techniques offered for this purpose and when confronted with such a situation find it difficult to make well informed decisions. Therefore, dentists treating pediatric patients should increase the cooperation level of the patients by applying various behavior guidance techniques [12].

In this study, positive reinforcement has been widely accepted by the parents because of the praise and rewards granted to their children associated with this technique and the result is in agreement with the study carried out by Peretz B et al. [13]. Tell-show-do was the next most accepted technique in this study. Since the dentist explains each step to the children and shows them in a way that makes them more comfortable. Similar findings were noted in a recent study conducted by Shukla H et al. [12] and Seangpadsa K et al. [14].

Voice control was the least accepted technique in this study. Parents may not be quite comfortable with a dentist talking to their child in a loud tone and thus, the reported less acceptance levels. Same results could be seen in the study conducted by Acharya et al. [15].

Interestingly, the parents of low SES had significantly higher PAS for voice control as compared to their counterparts from high SES (p-value = 0.004). This suggests that parents from low SES are willing to let the dentist use Voice Control as long as their child’s treatment is completed probably from the fear of losing days at work. On the other hand, parents from the high SES would rather have the dentist use other BMTs for treating their child.

The strength of the study is that a diverse group among the Pakistani population was included from all walks of life. It was tailored according to the understanding of the local population and customized videos were made. The limitations of this study are that it was conducted on a relatively small sample and also hard copies were circulated among the parents of Islamabad only. Future studies should focus on encompassing a wider area, so that a more representative sample of Pakistan may be included. It is recommended that educational level of parents may also be taken into account that may have an impact on choice and understanding of various BMTs.

6. Conclusions

Non-pharmacological BMTs were generally found to be well accepted by parents and they preferred more positive approaches demonstrated to them beforehand. However, they were not very comfortable with voice control being used on their children. The most significant finding of the study was that parents from the higher SES reported a greater hesitancy towards the use of voice control for their children as compared to the parents from low SES probably due to inability to afford multiple visits to the dentist.

Availability of Data and Materials

The data presented in this study are available on reasonable request from the corresponding author.

Author contributions

RQ, AI, MK, TA and SR—designed the research study. MK, TA, SR, MMC and SS—performed the research. RQ, RI and OK—analyzed the data. RQ, AKB, MNB, KR and GRAA—wrote the manuscript. All authors read and approved the final manuscript.

Ethics approval and consent to participate

The study was initiated after approval of the ethical review committee of RIHS, Islamabad, Pakistan (approval no. RIHS/009/21). An informed consent was obtained from the parents who were willing to participate in the study.

Acknowledgment

Not applicable.

Funding

This research received no external funding.

Conflict of interest

The authors declare no conflict of interest.