Abstract

Aim: The objective of the present study was to investigate the influence of dentists’ age, gender, working experience, and practitioner type on the use of non-pharmacological behaviour management techniques in the treatment of paediatric dental patients.

Materials and methods: An anonymous, self-completion survey was mailed to 200 randomly selected dentists. The recorded information included items on practitioner’s gender, age, working experience, specialty status, and frequency of using different non-pharmacological behaviour management techniques as well as the factors influencing the choice for specific behaviour guidance techniques.

Results: Significant differences between age/gender distributions were seen in the use of the basic non-pharmacological behaviour management techniques. Younger females were more likely to indicate that they were comfortable using communicative guidance techniques. The respondents in the over-40 age group did not rely at all on negative reinforcement and parental presence/absence techniques during the dental treatment of children (p<0.05). Dental practitioners with working experience of fewer than 10 years were more likely to utilize behaviour guidance techniques in attending paediatric dental patients compared to their older colleagues. No significant difference by practitioner types was seen in the use of the basic behaviour management techniques (p>0.05).

Conclusions: The present study showed age, gender, working experience, and practitioner type statistically significant differences in the use of behaviour management techniques during the dental treatment of children. The choice of a technique was influenced mainly by personal factors associated with the physical and psychological health of the child.

age, behaviour management, gender, paediatric dentistry, practitioner

Knowledge of the behaviour management technique (BMT) utilization rates could be useful to the oral care providers desiring evidence base to change or promote their methods in the treatment of paediatric dental patients (PDPs) within the current social and parental trends as well as legal/ethical concerns.^[1] A considerable number of studies in the contemporary scientific literature investigating the relationship between the individual covariates of the dental practitioners (DPs) themselves and the management of children’s behaviour in the dental office focuses mainly on the impact of age, gender, working experience, and practitioner type.^[1–7] A review of the literature in behavioural paediatric dentistry showed significant evidence that there were apparent differences associated with the different age groups among the dentists.^[2] Most studies investigating gender differences demonstrated contradictory results.^[2,4,5] Interestingly, in countries with different cultural modulation, it is reported that there is а statistical relationship between gender and treatment attitude of PDPs.^[8,9] The education or the presence of educated women in modern life modify the traditional structures and views. As women participated more and more actively in the family, social, and professional life, women’s leadership is no longer an exception but a normal situation.^[5] A clearly distinguishable trend shows that female dentists are actively involved in the treatment of patients not only as part of the nursing team. Women’s equal participation in dentistry is not only a demand for simple democracy but can also be seen as a necessary condition for women’s interests to be taken into account concerning different fields of development and specialties of dental medicine. It is accepted that paediatric dentistry has the highest representation of women compared to males compared to the other advanced dental areas and predoctoral programs.^[5]

There is not enough information describing the use of different BMTs in the dental practice based on the personal factors of the dentists.

Thus, the purpose of the present study was to investigate the influence of the practitioners’ age, gender, working experience, and practitioner type on the use of non-pharmacological BMTs as well as the factors influencing the choice for specific behaviour guidance techniques in the treatment of PDPs.

The cross-sectional study consisted of an anonymous, self-completed mailed survey. Potential subjects were sent an email describing the study and inviting their participation. The participants were randomly selected from the official register of the Bulgarian Dental Association in Plovdiv, Bulgaria. Two hundred dentists were invited to participate in the study, extrapolated using a randomization program from the complete email list of the scientific society’s members. The mail included a brief cover letter explaining the purpose of the survey. It stressed the anonymity of the survey and that the responses would be aggregated. The surveys were mailed within three weeks. The study was conducted in September 2020 and consisted of two sections, including multiple-choice and close-ended questions. Section I included demographic questions, including gender, age, working experience, specialty status - general practitioner versus specialist. Information concerning the use of the different non-pharmacological BMTs was collected from section II. To limit the survey to DPs who provide dental care to children, the first question was ‘Do you provide dental care to children at your dental practice?’ In case of a negative answer, the respondent was excluded from the study. Before circulating the questionnaires, the study was approved by the Committee for Scientific Research Ethics, Medical University of Plovdiv, Bulgaria (No. P-1371/30.04.2018).

Out of the 200 surveys that were mailed, 118 subjects (59% response rate) were included in the statistical analysis for this study. The sample size was N=118 dentists. The demographic information about the responders is shown in Table 1. Overall, the mean age of 118 subjects responding to this item was 36.75±9.16 years. The subjects were asked to indicate one of the two categories of total years in practice (0-10 years and over 10 years). The larger group had 0-10 years of clinical experience (65.3%). Female respondents outnumbered male respondents (ratio 1.5:1).

Age categories were dichotomized as <40 years and ≥40 years. Four age/gender categories were used (Table 2). No significant difference by groups was seen in the use of distraction and stop signals (p>0.05). No one reported that he/she used modelling as a BMT. A significant difference between age/gender distributions was seen in the use of the basic non-pharmacological BMTs. Younger females in the present investigation were more likely to indicate that they were comfortable in using communicative BMTs – voice control (VC) and positive reinforcement (PR).^[4]

Tell-show-do (TSD) was the most frequently employed technique by the age group of DPs younger than 40 years (male 33.7% and female 42.4%) and the least employed by the male over-40 age group (4.3%) (p<0.05). The results concerning negative reinforcement (NR) and parental presence/absence (PPA) showed that the over-40 age group did not rely at all on these BMTs during the treatment of PDPs (p<0.05). The respondents in the group of the older females indicated no use of nonverbal communication (NC), (0%), while in the other groups the use of this BMT was reasonably well distributed.

The results about the influence of practitioner type on the use of BMTs are shown in Table 3. There were significant practitioner type differences for the less frequently used BMTs (except for TSD) during the dental treatment of children. The use of NC, TSD, NR and PPA for behaviour guidance was reported by more than 60% of the DPs and other specialists not including paediatric dentistry and less than one-third of the paediatric dentists (p<0.01). No significant difference by practitioner types was seen in the use of the basic BMTs (p>0.05).

The attitudes of respondents to the use of non-pharmacological BMTs associated with their working experience are shown in Table 4. Except for NC, significant working experience differences were observed regarding all investigated BMTs (p˂0.01). DPs with working experience of fewer than 10 years were more likely to utilize behaviour guidance techniques in attending PDPs compared to their older colleagues. The respondents with more than 10 years working experience indicated NR and PPA as totally ineffective in the management of children’s behaviour.

Almost all DPs who participated in the study reported that they were influenced by children’s emotional state, their past dental experience, and age in the selection of a BMT during handling of a particular child. Parents’ preferences were reported by only 2.54% of the DPs to influence their choice of a BMT (Table 5).

The response rate to this survey (59%) is an indication of the considerable interest that DPs have in the topic of behaviour management of PDPs. The gender differences in BMTs were apparent. The present study found that, regardless of age, female dentists used more frequently BMTs during the treatment of PDPs compared to male DPs. Women were more comfortable in using communicative BMTs (TSD, VC, and PR/NR). Interestingly, a lack of NC as a particular BMT was seen in the answers of the female dentists older than 40 years. It is suggested that the aging experience in women in taking care of their children and grandchildren has become a part of their everyday behaviour. In comparison to males, they do not treat NC as a special BMT and this is considered to be the possible reason for our results. In a study among the members of the American Academy of Pediatric Dentistry (AAPD) in 2014, both genders reported that parenthood affected their behaviour guidance styles.^[10] As less talkative, almost 40% of male GPDs over 40 years old indicated that they were more likely to use ‘body language’ and rely on the non-verbal cues in attending children. The results of our investigation demonstrated that older DPs were more likely to exclude all parents in general compared to younger colleagues. This is in line with a reported survey in the USA and Canada, where paediatric dentists over 46 years were significantly less likely to allow parental presence for dental procedures.^[4] However, other studies indicated that DPs of almost all age groups utilized parental presence to respond to the parental demand for presence in the operatory.^[5,6,10] Also, DPs find this technique as a useful alternative to more aversive options.^[6,11] None of the respondents older than 40 years in our study reported using NR in the treatment of their PDPs. Our study corresponds with the clear trend indicating a decline in the use of this BMT. It was demonstrated by research from 2000 investigating dental anxiety among children in London. The authors indicated an increase in anxiety and avoidance of dental treatment as a result of the use of the technique NR.^[12] Eccles explains the results with the development of ‘sense of inferiority’, as Erikson called it, that ends in permanent intellectual, emotional consequences and avoidance of dental care.^[13] In contrast, in past studies, Allen et al., Ilieva et al., and Peretz et al. found that NR results in reducing dental anxiety, but it showed low acceptability by parents.^[14–16] The results of the present study demonstrated that the respondents under 40 years of age were more likely to use BMTs in their practice and no significant difference by gender in the under-40-year group was reported. Wells et al. also reported that DPs of both genders utilized BMTs at approximately equal rates.^[1,10]

Our study showed that there were practitioner type-related differences in the behaviour management methods employed. The present results showed that general DPs and specialists not including paediatric dentistry more frequently used non-pharmacological BMTs than the paediatric dentists themselves. A significant difference by practitioner types was seen in the use of several less frequently used BMTs (p˂0.01). The reported use of NR was low for paediatric specialists (33.3%).This is not surprising as they follow the clear trend indicating NR as an aversive technique and the debate on the efficiency of its use.^[12,13] As to NC and TSD, the additional training and acknowledgement of paediatric specialists are considered as a possible reason for the lower indication of their use (23.1%). These two BMTs are the most successful yet simple basic BMTs which can be used with all PDPs regardless of their cooperation level.^[17] Thus, paediatric specialists do not treat them as an additional effort but as a normal start of the treatment process. Further exploration of the use of the pharmacological BMTs trends will be interesting as the specialists in paediatric dentistry are considered to be more confident in their sedation training and obtain hospital privileges. In a study among 3000 members of the American Dental Association, significant differences between general DPs and paediatric specialists were found concerning the use of the pharmacological, aversive, and restraint techniques.^[2]

DPs with more years of working experience reported changes in their use of BMTs over time. The paternalistic approach has been more evident in the techniques used more frequently 30 years ago – PPA, VC, restraint, hand over mouth.^[2] Contemporary parents and the immediate access they have to the health care information result in changes occurring during the career even of the most experienced DPs. In the present study, significant differences were apparent in the frequency of usage of the non-pharmacological BMTs reported across the different practitioner experience groups (p˂0.01). The group with less than 10 years of working experience indicated that they use various BMTs two times more frequently compared to the more experienced dentists. Possibly, this group has fewer patients, more time for the treatment procedures and a desire to meet the needs of the individual child. The second group represents DPs who have attained more training and experience parallel to their busy schedule full of diverse patients with different requirements.^[2] Thus, they reported a lower frequency of usage of the investigated non-pharmacological BMTs. The results of the present study confirm those of McKnight-Hanes et al. who found an inversely proportional relationship between the usage of BMTs and the working experience of DPs.^[2] The authors interpreted the results with the busiest time of the professional career, fewer younger patients and received little training in their educational programs. However, dentists who participate in postdoctoral programs and scientific events have greater involvement in paediatric dental treatment and seek to remain up-to-date about the latest and effective techniques regardless of their age and working experience.

The analysis of the results demonstrates that personal factors associated with the physical, emotional and psychological health of the child mainly influence the dental practitioner’s choice of BMT to be used in a particular PDP. This indicates that the child’s emotion and presenting behaviour in the dental setting are important. Of the individual-level factors of the children, the previous dental experience was reported by the majority of authors to influence their choice that underlines the importance of proper child management in pediatric dentistry.^[9] In line with the present findings, Oredugba et al. and Kawia et al. reported that a major factor influencing the choice of BMT was also the child’s age.^[9,18] Unlike the present results, Carr et al. reported the reason for the use of most BMT to be parental influence.^[7] Generally, the personal factors of the child were reported by more dentists than socioeconomic status and medical history to influence their choice for a BMT to be applied.

The present study showed age, gender, working experience, and practitioner type statistically significant differences in the use of BMTs during dental treatment of children. There were considerable variations in the reported use of non-pharmacological BMTs in practice. The choice of a technique was mainly influenced by personal factors associated with the physical and psychological health of the child. Future exploration of the pharmacological BMTs trends will be interesting as the profession begins responding to the loss of the aversive techniques with increases in pharmacological management.