For citation purposes, the electronic version is the definitive version of this article:

Transcription

1 Applied R e s e r c h Techniques for Mnging Behviour in Peditric Dentistry: Comprtive Study of Live Modelling nd Tell Show Do Bsed on Children s Hert Rtes during Tretment Nd Frht-McHyleh, DDS, DEA, PhD; Alice Hrfouche, DDS, CAGS, MSc; Philippe Souid, DDS, MSc Contct Author Dr. Frht-McHyleh Emil: ndmch@ hotmil.com ABSTRACT Bckground nd Objectives: Tell show do is the most populr technique for mnging children s behviour in dentists offices. Live modelling is used less frequently, despite the stisfctory results obtined in studies conducted during the 1980s. The purpose of this study ws to compre the effects of these 2 techniques on children s hert rtes during dentl tretments, hert rte being the simplest biologicl prmeter to mesure nd n increse in hert rte being the most common physiologic indictor of nxiety nd fer. Mterils nd Methods: For this rndomized, controlled, prllel-group single-centre clinicl tril, children 5 to 9 yers of ge presenting for the first time to the Sint Joseph University dentl cre centre in Beirut, Lebnon, were divided into 3 groups: those in groups A nd B were prepred for dentl tretment by mens of live modelling, the mother serving s the model for children in group A nd the fther s the model for children in group B. The children in group C were prepred by peditric dentist using the tell show do method. Ech child s hert rte ws monitored during tretment, which consisted of n orl exmintion nd clening. Results: A totl of 155 children met the study criteri nd prticipted in the study. Children who received live modelling with the mother s model hd lower hert rtes thn those who received live modelling with the fther s model nd those who were prepred by the tell show do method (p < 0.01). The model used for live modelling (fther or mother) nd the child s ge were determining fctors in the results obtined. Conclusions: Live modelling is technique worth prctising in peditric dentistry. For cittion purposes, the electronic version is the definitive version of this rticle: For mny children, visit to the dentist s office is stressful event tht cn elicit feelings of fer nd nxiety. These emotions cuse behviourl chnges during dentl tretment, which cn ffect the qulity of cre. 1 5 Severl techniques for mnging children s behviour in dentl offices hve been developed to ddress this problem. However, it ws pointed out t the Americn Acdemy of Peditric Dentistry conference JCDA My 2009, Vol. 75, No

2 Frht-McHyleh in 2003 tht over the pst few decdes, there hve been more studies on phrmcologic mngement techniques thn on nonphrmcologic techniques. 6 In ddition, the clinicl protocols for mny of these studies hve lcked rigour. 6 9 Severl epidemiologic inquiries hve reveled tht the nonphrmcologic technique clled tell show do, which consists of explining nd demonstrting the opertion of the instruments used during tretment, remins the most commonly used technique in peditric dentistry. 6,10 12 The literture refers to modelling s nonphrmcologic technique worth exploring. According to recent review by Bghddi, 4 modelling ws described by Bndur in 1967 s the process of cquiring behviour through observtion of model. Greenbum nd Melmed 13 reported tht the first study of modelling in peditric dentistry ws conducted in 1969, nd severl other studies followed in the 1980s. 11,14 According to these studies, 2 forms of modelling, live nd filmed, re effective in reducing children s fer nd nxiety bout dentl tretments nd promoting dptive behviour. 8,13 16 Although modelling hs become firly stndrd in number of fields such s medicine, 17,18 sports, 19 dietetics 20 nd others, 16 it is not yet commonly prctised in peditric dentistry. 4,16,21 In response to the recommendtions of the Americn Acdemy of Peditric Dentistry 6,7 on the need to study nonphrmcologic behviour-mngement techniques by mens of rigorous clinicl protocols, we undertook clinicl study with the primry gol of compring the effects of live modelling nd the tell show do method on children s hert rtes during dentl tretment. Hert rte ws chosen for nlysis becuse it is the simplest biologicl prmeter to mesure nd becuse n increse in hert rte is the most common physiologic indictor of nxiety nd fer The secondry objectives of the study were to identify which of the child s 2 prents represented the model most suitble for live modelling nd to determine whether the child s ge ws determining fctor in the results obtined. Mterils nd Methods Study Smple The study smple consisted of children 5 to 9 yers of ge, rndomly divided into the following 3 groups: Group A: children who were prepred for dentl tretment by the live modelling technique with the mother s model Group B: children who were prepred for dentl tretment by the live modelling technique with the fther s model Group C: children who were prepred for dentl tretment with the tell show do technique, presented by the peditric dentist who performed the tretment The study ws rndomized, controlled, prllelgroup single-centre clinicl tril with comprtive nlysis of the 3 ptient groups. Ech group ws subdivided by ge (5 to < 7 yers nd 7 to < 9 yers) to determine whether ge ws determining fctor. Selection Criteri Children were eligible for the study if they presented for first visit to the dentl cre centre within the fculty of dentistry t Sint Joseph University in Beirut, Lebnon, ccompnied by both prents. Eligibility for inclusion ws lso contingent upon the prents hving the mentl nd physicl cpcity to serve s models. The following children were excluded from the study: those from singleprent fmilies, those with mentl or cognitive problems tht could compromise their understnding of the tril or its conduct, those who were undergoing medicl tretment tht might ffect hert rte nd those with hertbet disorders. Children were lso excluded if either the mother or the fther hd mentl problems or lnguge brriers tht might compromise their understnding of the tril or its conduct or if they hd helth problem tht might prevent them from prticipting s models. Children were excluded from the nlysis if they or their prents bndoned the study by choice or for ny other reson. Dt Collection Ech child s hert rte ws monitored during the entire tretment (orl exmintion nd clening) with pulse oximeter. The oximeter ws clipped to the thumb of the child s left hnd. To reduce the risk of recording errors, peditric dentist ensured tht the child did not move by gently holding the child s hnd. 26 An ssistnt mnully trnscribed the dt posted on the oximeter screen into the child s file t 30-second intervls for totl of 12 dt points. Study Procedure Prents were sked to complete questionnire covering the following elements: mritl sttus, level of eduction, number of children in the fmily, the child s orl hygiene hbits nd the child s previous behviour in medicl setting. Both prents were informed in detil bout how the study would be conducted nd bout their right to refuse or discontinue prticiption t ny time nd were then sked to sign consent form. The durtion of ech tril ws 14 minutes: 5 minutes for the psychologicl preprtion (either live modelling or tell show do), 3.5 minutes for ttching the oximeter nd 5.5 minutes for performing the dentl tretment (orl exmintion nd clening). For groups A nd B, the child observed the mother or fther, respectively, sitting in the dentl chir nd undergoing orl exmintion nd clening (by the 283 JCDA My 2009, Vol. 75, No. 4

3 Behviour-Mngement Techniques Tble 1 Distribution of children undergoing nonphrmcologic methods of behviour mngement during dentl cre, by group nd ge Age clss; no. (%) of group Group 5 to < 7 yers 7 to < 9 yers Totl A 32 (60) 21 (40) 53 (100) B 23 (45) 28 (55) 51 (100) C 20 (39) 31 (61) 51 (100) Totl 75 (48) 80 (52) 155 (100) Group A = live modelling with mother s model, group B = live modelling with fther s model, group C = tell show do method. Tble 2 Multiple comprisons of men hert rtes for children prepred for dentl tretment in 3 different wys (Bonferroni test) Hert rte mesurement Comprison of study groups b group men hert rtes (bets/min) p vlue Men T1 T3 Group A v. group B Group A v. group C Group B v. group C Men T10 T12 Group A v. group B Group A v. group C < Group B v. group C Men T1 T12 Group A v. group B Group A v. group C Group B v. group C The letter T followed by number from 1 to 12 represents the time of specific mesurements of hert rte (t 30-second intervls during tretment). b Group A = live modelling with mother s model, group B = live modelling with fther s model, group C = tell show do method. tell show do method). The child ws encourged to prticipte in the session by sking questions bout the instruments nd how they work. He or she then st in the chir nd underwent orl exmintion nd clening. The child s hert rte ws recorded s described bove. For children in group C, the tell show do procedure ws performed by the peditric dentist without live modelling but with the child s ctive prticiption nd with recording of hert rte, both s described bove. The sme peditric dentist (N.F.-M.) exmined ll children. Sttisticl Anlysis The dt from the 3 groups were subjected to the following sttisticl tests. The Kolmogorov Smirnov test ws used to estblish the normlity of distribution of the results, nd Levene s test ws used to estblish homogeneity of vrinces. The 3 groups were compred by nlysis of vrince (ANOVA), nd the Bonferroni test ws used for multiple pirwise comprisons between the groups. Results A totl of 155 children (69 girls nd 86 boys) met the study criteri nd prticipted in the study: 53 in group A, 51 in group B nd 51 in group C (Tble 1). All exmintion nd clening ppointments were completed for ech group. The Kolmogorov Smirnov test confirmed the normlity of distributions, nd Levene s test confirmed the homogeneity of vrinces. Averge hert rte over the entire tretment period ws significntly lower mong children in group A (live modelling by mother) thn mong those in group B (live modelling by fther; p = 0.034) nd group C (tell show do method; p = 0.005) (Tble 2). This difference ws prticulrly evident during the clening, which involved the use of rotting instruments nd ws therefore JCDA My 2009, Vol. 75, No b

4 Frht-Mchyleh Group A Group B Group C T1 T2 T3 T4 T5 T6 T7 T8 T9 T1 0 T1 1 T1 2 Figure 1: Men hert rte of children in group A (live modelling with mother s model), group B (live modelling with fther s model) nd group C (tell show do) t 12 time points (T1 through T12) over 5.5-minute dentl tretment (30-second intervls). considered the most stressful prt of tretment. This period ws represented by hert rte mesurements from T6 (t 2 minutes, 30 seconds) to T12 (t 5 minutes, 30 seconds); the men difference between groups A nd C for T12 ws 11.1 bets/min (Fig. 1). ANOVA by single fctor (ge), followed by comprtive nlysis of the subgroup verges, reveled tht ge influenced the results in 2 wys (Tbles 3 nd 4). First, the effect of live modelling with the mother, reltive to tell show do, ws less powerful for the subgroup of 5 to < 7-yer-olds thn for the subgroup of 7 to < 9- yer-olds (Tble 3). However, for children 5 to < 7 yers of ge, the difference between groups A nd C during use of rotting instruments remined highly significnt, t 9.14 bets/min for the combined men of T10, T11 nd T12 (i.e., from 4 minutes, 30 seconds to 5 minutes, 30 seconds) (p = 0.004) (Tble 4). Second, for the subgroup of 7 to < 9-yer-olds, the effect of live modelling with the fther incresed when rotting instruments were used (Tble 4), nd the difference between groups B nd C becme sttisticlly significnt (p = 0.038). Discussion This study ws undertken to compre the effects of live modelling nd the tell show do method in reducing children s nxiety during dentl tretments nd to determine whether the prticulr model (mother or fther) used in live modelling nd the ge of the child were determining fctors. The comprison between groups A nd C (Tble 2) showed tht live modelling with the mother s the model ws more effective in reducing hert rte thn the tell show do method (p = 0.005). Of the 2 ctegories of live models used, mothers represented the most stisfctory model (p = 0.034). Although the effect of live modelling with the fther incresed when rotting instruments were used for the subgroup of 7 to < 9-yerolds, the results generlly fvoured group A (mother s model) over groups B nd C for ech of the 2 subgroups bsed on ge. Severl ssumptions my explin these results: Lerning cpcity (i.e., copying the model s behviour) improves with ge. 4,27,28 The child s reltionship with his or her fther evolves with ge, such tht use of the fther for modelling is fvoured t older ges, when the fther hs become more integrted in the child s life. A future study might investigte whether children 5 to < 7 yers of ge re more influenced by models their own ge. The results for ge subgroups my be confirmed or rejected through future reserch with lrger smples. The procedure used in this study ws crefully developed to reduce bis nd flse results. Rndomiztion nd inclusion nd exclusion criteri were estblished to llow for pproprite smpling. The min outcome ws biologicl prmeter, hert rte. This quntittive criterion hs metrologic properties tht llowed us to follow physiologic chnges occurring during the study. Hert rte hs been used s n outcome mesure in numerous medicl, prmedicl nd dentl studies of fer nd nxiety The mesurement tool ws the pulse oximeter. This tool is considered n excellent mens of monitoring hert rte. 26 Similrity in terms of tril conditions, the time llowed for ech stge of the tretment nd interctions between the opertor nd the child ws mintined for the 3 study groups. 283c JCDA My 2009, Vol. 75, No. 4

5 Behviour-Mngement Techniques Tble 3 Multiple comprison (Bonferroni test) of men hert rtes in subgroups by ge clss, for specific time periods Age 5 to < 7 yers Age 7 to < 9 yers Hert rte mesurement Comprison of study groups b group men hert rtes (bets/min) p vlue group men hert rtes (bets/min) p vlue T1 Group A v. group B Group A v. group C Group B v. group C T2 Group A v. group B Group A v. group C Group B v. group C T3 Group A v. group B Group A v. group C Group B c. group C T4 Group A v. group B Group A v. group C Group B v. group C T5 Group A v. group B Group A v. group C Group B v. group C T6 Group A v. group B Group A v. group C Group B v. group C T7 Group A v. group B Group A v. group C Group B v. group C T8 Group A v. group B Group A v. group C < Group B v. group C T9 Group A v. group B Group A v. group C Group B v. group C T10 Group A v. group B Group A v. group C < Group B v. group C T11 Group A v. group B Group A v. group C < Group B v. group C T12 Group A v. group B < Men T1 T12 Group A v. group C < Group B v. group C Group A v. group B Group A v. group C Group B v. group C The letter T followed by number from 1 to 12 represents the time of specific mesurement of hert rte (t 30-second intervls during tretment). b Group A = live modelling with mother s model, group B = live modelling with fther s model, group C = tell show do method. JCDA My 2009, Vol. 75, No d

6 Frht-Mchyleh Tble 4 Multiple comprison (Bonferroni test) of men hert rtes in subgroups by ge clss, grouped by time period of mesurement Hert rte mesurement Comprison of study groups b group men hert rtes (bets/minute) p vlue 5 to < 7 yers Men T1 T3 Group A v. group B Group A v. group C Group B v. group C Men T10 T12 Group A v. group B < Group A v. group C Group B v. group C Men T1 T12 Group A v. group B Group A v. group C Group B v. group C to < 9 yers Men T1 T3 Group A v. group B 1,03 0,05 Group A v. group C Group B v. group C Men T10 T12 Group A v. group B Group A v. group C < Group B v. group C Men T1 T12 Group A v. group B Group A v. group C Group B v. group C The letter T followed by number from 1 to 12 represents the time of specific mesurement of hert rte (t 30-second intervls during tretment). b Group A = live modelling with mother s model, group B = live modelling with fther s model, group C = tell show do method. Most studies of live modelling dte bck to the 1980s nd 1990s 8,11,13 16 nd recent results re therefore unvilble; s such, comprisons of the current results with those of more recent studies were not fesible. However, t the conference of the Americn Acdemy of Peditric Dentistry in 2003, severl generl principles were estblished to guge the vlidity of behviour-mngement techniques: 6 effectiveness: the potentil of the technique to mnge children s behviour in the dentist s office socil vlidity: cceptnce of the technique by prents, s well s public perception of the technique risks ssocited with the technique cost: time spent prctising the technique nd cost of ny mterils nd equipment used These principles llowed us to ssess the vlidity of the live modelling technique used in this study, s follows: effectiveness: children who were prepred for dentl tretment by live modelling hd lower hert rtes thn children who were prepred by mens of the tell show do method, even though the tell show do method is still considered the technique with which dentists nd prents re most comfortble 6,10 socil vlidity: ll of the prents selected for modelling were willing to prticipte in the study (the dvntge of ctive prticiption hs been described in severl recent studies 6,8 ) risk: the risks ssocited with the behviourmngement technique were reduced to lmost zero 283e JCDA My 2009, Vol. 75, No. 4

7 Behviour-Mngement Techniques cost: the time tken to explin the modelling method to prents llowed their prticiption to be optimized. 6,8 The dditionl cost of clening the work re between ptients ws miniml compred with the dvntges offered by the modelling technique. Conclusions Live modelling is technique worth prctising in peditric dentistry. The model used (e.g., mother or fther) nd the ge of the child represent determining fctors in the success of this technique. Multicentre studies re needed to llow more thorough evlution of the method t ntionl scle. Continuing to study nd perfect nonphrmcologic techniques for behviour mngement will help to fill the need for scientific dt supporting this pproch within peditric dentistry. 6 8,29 32 THE AUTHORS Dr. Frht-McHyleh is hed of the deprtment of peditric nd community dentistry, fculty of dentistry, Sint Joseph University, Beirut, Lebnon. Dr. Hrfouche mintins peditric dentl clinic in Brossrd, Quebec. Prof. Souid is director of the orthodontic nd peditric progrm, College of Dentistry, Hzmié, Beirut, Lebnon. Acknowledgements: The uthors would like to thnk the Reserch Council of the fculty of dentistry t Sint Joseph University in Beirut, Lebnon, for subsidizing their clinicl study. The uthors hve no declred finncil interests. This rticle hs been peer reviewed. References 1. Sonis AL, Ureles SD. Workshop on prenting methods to minimize disruptive behvior. Peditr Dent 1999; 21(7): Bier K, Milgrom P, Russell S, Mncl L, Yoshid T. Children s fer nd behvior in privte peditric dentistry prctices. Peditr Dent 2004; 26(4): Wogelius P, Poulsen S, Sorensen HT. Prevlence of dentl nxiety nd behvior mngement problems mong six to eight yers old Dnish children. Act Odontol Scnd 2003; 61(3): Bghddi ZD. Principles nd ppliction of lerning theory in child mngement. Quintessence Int 2001; 32(2): Chpmn HR, Kirby-Turner NC. Dentl fer in children proposed model. Br Dent J 1999; 187(8): Adir SM. Behvior mngement conference pnel I report Rtionle for behvior mngement techniques in peditric dentistry. Peditr Dent 2004; 26(2): Ng MW. Behvior mngement conference pnel IV report Eductionl issues. Peditr Dent 2004; 26(2): Wilson S, Cody WE. An nlysis of behvior mngement ppers published in the peditric dentl literture. Peditr Dent 2005; 27(4): Ninr SM. Profile of peditric dentl literture: thirty-yer time trends ( ). ASDC J Dent Child 2001; 68(5-6): Eton JJ, McTigue DJ, Fields HW Jr, Beck M. Attitudes of contemporry prents towrd behvior mngement techniques used in peditric dentistry. Peditr Dent 2005; 27(2): Allen KD, Stnley R T, McPherson K. Evlution of behvior mngement technology dissemintion in peditric dentistry. Peditr Dent 1990; 12(2): Adir SM, Wller JL, Schfer TE, Rockmn R. A survey of members of the Americn Acdemy of Peditric Dentistry on their use of behvior mngement techniques. Peditr Dent 2004; 26(2): Greenbum PE, Melmed BG. Pretretment modeling. A technique for reducing children s fer in the dentl opertory. Dent Clin North Am 1988; 32(4): Weinstein P, Nthn JE. The chllenge of ferful nd phobic children. Dent Clin North Am 1988; 32(4): Rouleu J, Ldouceur R, Dufour L. Pre-exposure to the first dentl tretment. J Dent Res 1981; 60(1): Do C. Applying socil lerning theory to children with dentl nxiety. J Contemp Dent Prct 2004; 5(1): Lynch L. Fust J. Reduction of distress in children undergoing sexul buse medicl exmintion. J Peditr 1998; 133(2): Chrlop-Christy MH, Le L, Freemn KA. A comprison of video modeling with in vivo modeling for teching children with utism. J Autism Dev Disord 2000; 30(6): Bois JE, Srrzin PG, Bustrd RJ, Trouilloud DO, Cury F. Elementry schoolchildren s perceived competence nd physicl ctivity involvement: the influence of prents role modelling behviours nd perceptions of their child s competence. Psychology of Sport nd Exercise 2005; 6(4): Hendy H M, Rudenbush B. Effectiveness of techer modeling to encourge food cceptnce in preschool children. Appetite 2000; 34(1): Colres V, Richmn L. Fctors ssocited with uncoopertive behvior by Brzilin preschool children in the dentl office. ASDC J Dent Child 2002; 69(1): Erten H, Akrsln ZZ, Bodrumlu E. Dentl fer nd nxiety levels of ptients ttending dentl clinic. Quintessence Int 2006; 37(4): Crmichel KD, Westmorelnd J. Effectiveness of er protection in reducing nxiety during cst removl in children. Am J Orthop 2005; 34(1): Kim MS, Cho KS, Woo H, Kim JH. Effects of hnd mssge on nxiety in ctrct surgery using locl nesthesi. J Ctrct Refrct Surg 2001; 27(6): Wells A, Ppgeorgiou C. Socil phobic interception: effects of bodily informtion on nxiety, beliefs nd self-processing. Behv Res Ther 2001; 39(1): Fukym H, Ygiel J. Monitoring of vitl signs during dentl cre. Int Dent J 2006; 56(2): Hrper DC, D Alessndro DM. The child s voice: understnding the contexts of children nd fmilies tody. Peditr Dent 2004; 26(2): Sheller B. Chllenges of mnging child behvior in the 21st century dentl setting. Peditr Dent 2004; 26(2): Adir SM, Schfer TE, Rockmn RA, Wller JL. Survey of behvior mngement teching in predoctorl peditric dentistry progrms. Peditr Dent 2004; 26(2): Adir SM, Rockmn RA, Schfer TE, Wller JL. Survey of behvior mngement teching in peditric dentistry dvnced eduction progrms. Peditr Dent 2004; 26(2): Wilson S. Strtegies for mnging children s behvior how much do we know? Peditr Dent 1999; 21(6): Pinkhm JR. Behvior mngement of children in the dentl office. Dent Clin North Am 2000; 44(3): JCDA My 2009, Vol. 75, No f