Thesis. Presented in Partial Fulfillment of the Requirements for the Degree Master of Science in the Graduate School of The Ohio State University

Transcription

1 Parental Attitudes Toward Advanced Behavior Guidance Techniques used in Pediatric Dentistry Thesis Presented in Partial Fulfillment of the Requirements for the Degree Master of Science in the Graduate School of The Ohio State University By Monica Rajiv Patel, DMD Graduate Program in Dentistry The Ohio State University 2012 Thesis Committee: Dr. Dennis McTigue, Advisor, Dr. Sarat Thikkurissy, Dr. Henry Fields

2 Copyright by Monica Rajiv Patel 2012

3 Abstract Purpose: To reexamine parental attitudes toward advanced behavior management techniques currently used in pediatric dentistry and determine how factors such as cost, urgency and amount of treatment influence parental acceptability. Methods: Parents bringing children for routine dental care viewed previously validated videotaped clinical vignettes of four advanced behavior guidance techniques: passive restraint, active restraint, general anesthesia and oral premedication (sedation). The study was conducted at both a children s hospital setting and a suburban private pediatric dentistry office. Parents rated overall acceptance of the techniques, as well as acceptance under specified conditions using a visual analogue scale. Results: One hundred five parents completed the survey; fifty-five from children s hospital and fifty from private practice. Overall, oral premedication (sedation) was rated as the most acceptable technique, followed (in order of decreasing acceptance) by general anesthesia, active restraint and passive restraint. As urgency, convenience and previous experience increased, parental acceptability of the technique increased. As cost of treatment increased, acceptability decreased. Acceptability rankings between the children s hospital group and private practice group differed, as did the following demographic variables: insurance, income and race. Conclusions: The hierarchy of acceptability is changing with increasing approval of pharmacological management and decreasing approval of physical management. The ii

4 healthcare delivery system, urgency, convenience, previous experience and cost all influence parental acceptability. iii

5 Dedication This document is dedicated to all of those who have helped in my education. iv

6 Acknowledgments I d like to express my sincerest gratitude to my advisor, Dr. Dennis McTigue, and my committee members, Dr. Sarat Thikkurissy and Dr. Henry Fields. This thesis would not have been possible without the guidance and support. v

7 Vita 2002 Hempfield Area Senior High School 2006 B.S. Business Management, Case Western Reserve University DMD, University of Pennsylvania 2010 to present...pediatric Dentistry Resident, Nationwide Children s Hospital, The Ohio State University Fields of Study Major Field: Dentistry vi

8 Table of Contents Abstract ii Dedication... iii Acknowledgments.. iv Vita..v Table of Contents vi List of Tables. vii List of Figures... viii Introduction..1 Materials and Method.. 6 Results 11 Discussion.. 15 Conclusions 23 References.. 24 Appendix A: Tables and Figures vii

9 List of Tables Table 1. Order of Randomizations 26 Table 2. Demographic Variables.. 27 Table 3. Techniques ranked by Acceptability using VAS scale Table 4. VAS ratings differing between CH and PVT groups. 30 Table 5. Mean VAS ratings for child in pain/treatment urgent 31 Table 6. Mean VAS ratings for multiple appointments 32 Table 7. Mean acceptability for monetary GA variables.. 33 Table 8. Mean acceptability for monetary Sedation variables.. 34 Table 9. Mean acceptability for techniques with/without previous experience 35 Table 10. Techniques ranked by Acceptability in 4 similar studies. 36 viii

10 List of Figures Figure 1. Mean VAS rating by technique for entire group ix

11 Introduction Pediatric dentists provide oral health care and treat dental diseases in infants, children, adolescents and persons with special health care needs. Safe and effective treatment often requires management of the child s behavior. 1 Uncooperative or disruptive behavior can interfere with quality of care, increase the length of treatment time and increase risk of injury to the child. 2 As many as 22% of children seen by pediatric dentists reportedly present management difficulty. 3 The challenge of treating children who are unable or unwilling to cooperate has led to the development of a variety of behavior management techniques. According to the American Academy of Pediatric Dentistry (AAPD), the main goals of behavior management are to: 1. Establish communication with the child and parent 2. Alleviate the child s fear and anxiety 3. Deliver safe, quality dental care 4. Build a trusting relationship between the dentist, child and parent 5. Promote the child s positive attitude toward oral healthcare A continuum of both non-pharmacological and pharmacological behavior guidance techniques may be used depending on the individual patient, the procedure and the 1

12 dentist. 1 Since every child is different, pediatric dentists have a wide range of approaches to help a child complete needed dental treatment. A pediatric dentist recommends behavior guidance methods for the child based upon their health history, special health care needs, dental needs, type of treatment required, the consequences of no treatment, their emotional and intellectual development, the parents preferences and dentist s preferences and skills. The AAPD Clinical Guideline on Behavior Management defines the techniques currently used in the management of children in contemporary pediatric dentistry. It outlines the objectives, indications, and contraindications for each of the techniques approved by the AAPD, as documented in the dental literature and reflective of professional standards. The guideline has divided the techniques into two categories: Basic behavior guidance and Advanced behavior guidance. The basic behavior guidance includes communication and communicative guidance, tell-show-do, voice control, nonverbal communication, positive reinforcement, distraction, parental presence/absence, nitrous oxide/oxygen inhalation. Less cooperative children can be managed by more advanced behavior guidance techniques, which include protective stabilization (active and passive restraint), sedation and general anesthesia. 1 One aspect of behavior management research aims to gain an understanding of parental perceptions regarding behavior guidance techniques and determine factors that may affect their attitudes towards the various techniques. 4 Societal and professional views of behavior management and parenting styles have changed tremendously over the past years. 2,5 Studies show societal changes toward increased parental participation 2

13 during the child s dental experience. 6,7 As a result, the selection of the behavior management techniques to be used is no longer made largely by the dentist but, rather, with the active involvement and consent of the parents. 6,8 Therefore, effective communication with parents is crucial and presents the opportunity to carefully work together and select the best treatment methods to make the child s visit as safe, effective and comfortable as possible. Behavior management techniques are not all equally accepted by parents. 9 Several studies of parental acceptance of behavior guidance techniques used in pediatric dentistry show differing views of parental attitudes. In 1984, Murphy et al noted that tell-show-do and positive reinforcement were rated as the most parentally acceptable and the Papoose Board (Olympic Medical Group, Seattle, WA) and general anesthesia were the least acceptable. 9 Fields et al found that the type of dental treatment influences parental acceptance of the behavior management technique; however, the Papoose Board and hand-over-mouth were unacceptable to the majority of parents irrespective of the dental procedure. 10 A study by Lawrence et al reported that informed parents, those provided with an explanation of the behavior management technique, were significantly more accepting of the techniques than parents provided with no explanation. 11 Eaton et al found that parents are most accepting of tell-show-do and nitrous oxide and least accepting of the passive restraint (the Papoose Board) and hand-over-mouth. The study also showed there has been an increase in acceptance of advanced pharmacological techniques, sedation and general anesthesia, over time. 4 Although treatment provided may alter parental approval of behavior management techniques, these studies taken 3

14 together over time show that the hierarchy of acceptability of the techniques has changed in some regards decreasing approval of the physical management of behavior and increasing approval of pharmacological management. Several studies have also investigated the influence of other variables on parental acceptance of behavior management techniques. Variables such as the family s socioeconomic status have been found to influence parental acceptance of behavior guidance techniques. 8 Differences in parental acceptance of behavior management techniques of parents of disabled and nondisabled children have also been studied. 12 This study showed that ratings did not differ significantly between the two groups. Wilson et al examined the effect of rating the techniques while in a group setting or individually and found no significant differences. 13 Previous parental experience with a particular behavior management technique can also affect their acceptance. Studies by Frankel, Peretz and Zadik, and ElBadrawy and Riekman report that parents are more accepting of a technique once they have had personal experience with their own child While many factors have been studied, including type and urgency of treatment, no study has examined the effect of cost on parental acceptance of behavior management techniques. Parental attitudes are constantly changing as society evolves so it is important to regularly reassess their beliefs and update our understanding of their attitudes toward behavior management techniques. At the AAPD s 2004 behavior management conference there was little controversy or discussion regarding the appropriateness of basic behavior guidance techniques as they are the safest and least aggressive. 17 Since the acceptability of the basic behavior guidance techniques has been relatively stable over 4

15 time, the present study will focus on the advanced behavior guidance techniques: active restraint, passive restraint, oral premedication (sedation) and general anesthesia. The purpose of the present study is first, to reexamine parental attitudes toward advanced behavior guidance techniques and second, determine how factors such as pain, amount of treatment and cost influence parental acceptability. 5

16 Materials and Methods This IRB-approved study was conducted at a children s hospital dental clinic (CH) and a suburban private practice (PVT) in Columbus, Ohio. All behavior guidance definitions were based on the current AAPD Clinical Guidelines on Behavior. 1 Parents were asked to view videotapes of the advanced behavior management techniques and to rate their acceptance of each. All techniques were presented and rated as separate entities although it is not uncommon to use some of the techniques simultaneously. Two convenience samples were selected: 1) fifty-five parents bringing children for routine outpatient dental care at CH and 2) fifty parents accompanying children for routine outpatient dental care at PVT. Inclusion criteria were: parent 18 years of age or older and willingness to participate. Due to the fact that the videos were in English, only parents literate in written and spoken English were enrolled. Parents presenting for sedation, general anesthesia or emergency visits were excluded from the study. Subjects completed a demographic questionnaire form prior to viewing the videotape presentation. The demographic information obtained included: age, sex, level of education, occupation, household income, ethnicity, and type of insurance. Parents were also asked about previous experience with the use of advanced behavior management techniques for any of their children. Lastly, their current anxiety/stress level was established using the Spielberger State-Trait Anxiety Inventory (STAI) prior to watching 6

17 the videotape. This inventory uses 6 statements (3 relating to the presence of anxiety and 3 relating to the absence of anxiety) to evaluate the respondent s anxiety at that moment in time. A score ranging from 6-24 is possible, with a high score reflecting greater anxiety. The STAI is one of the most frequently used measures of anxiety in research. 18 Subjects willing to participate were taken to a private room that was equipped with a table, chair and laptop computer. Informed consent was obtained and each parent was given thorough oral and written instructions for completing the survey form. Validity of the questionnaire was tested in a pilot study with 15 parents to insure clarity of the questions. Each subject was then given time to complete the demographic form and anxiety test prior to watching the videotape. The study coordinator then started the videotape and left the room. The original videotape was produced by Lawrence et al in 1991 and consisted of vignettes of actual treatment appointments using accepted behavior guidance techniques at that time. 11 Those video vignettes were validated by several subsequent studies. 8,13 An edited version of that videotape was used in the present study. The edited version eliminated all vignettes of the basic behavior management techniques (tell-show-do, nitrous oxide sedation, voice control) and hand-over-mouth. The videotape used in this study consisted of an introduction by a dentist and vignettes demonstrating the four advanced behavior management techniques: passive restraint, active restraint, oral premedication (sedation) and general anesthesia. The order of the behavior management vignettes in the video was varied to determine if the sequence of presentation affected parents acceptability ratings. Four separate 7

18 videotape presentations (or randomizations) with varying sequence of the four techniques presented were produced to control for an order effect (Table 1). Each subject was randomly assigned to one of the four randomizations. Prior to the demonstration of each technique in the video, the dentist who introduced the study on the tape explained the purpose and application of the technique. At the end of the demonstration, the name of each technique was shown against a black background while the dentist asked How acceptable is this technique? A few seconds later, the videotape stopped and the screen read please rate the acceptability of the technique on your paper now; when finished click on the screen to continue. This allowed the participant to answer all questions pertaining to that specific technique before continuing. The survey form was consistent with the order in which the techniques were demonstrated in that specific randomization. Parents were asked to determine the acceptability using a 100mm horizontal anchored visual analogue scale (VAS). The left end of the scale read completely acceptable and the right end of the scale read completely unacceptable. The subjects were asked to place a vertical line on the scale reflective of their personal opinion of acceptability. Previous studies have found the VAS instrument used in this study to be reliable in measuring parental acceptance of behavior management techniques. 9,11 The acceptability rating was determined by measuring the distance from the left end mark on the VAS scale to the mark made by the parent. All measurements were rounded to the nearest millimeter. In instances where subjects circled the left end mark or completely acceptable, the response was counted as 0mm. In instances where subjects circled the 8

19 right end mark or completely unacceptable, the response was counted as 100mm. The study coordinator, using the same measurement tool, completed all measurements. To establish measurement error, 15 VAS responses were measured twice. Upon completing the questions on that page, the subject clicked on the screen to continue to the next technique. This process continued until all techniques were demonstrated on the video and all pertaining questions had been answered. At the conclusion of the videotape, the author returned to room to collect the survey form. The videotape was 6 minutes long and the study, on average, took 8-10 minutes to complete. For all four techniques parents were asked to evaluate the following using the VAS scale: (1) acceptability of the technique; (2) acceptability of the technique if their child was in pain, had a swollen face, and treatment was urgent and (3) acceptability of using the technique at multiple appointments, if their child had several cavities. For general anesthesia it was stated that all treatment would be completed at one appointment. To establish reliability, parents were also asked to rate acceptability of the technique using a categorical value (yes or no), as well. Further, for oral premedication and general anesthesia, parents were asked to evaluate the acceptability of the technique relative to cost per appointment. They were asked to evaluate the acceptability of oral premedication (sedation): (1) if the cost was completely covered by insurance ($0 out of pocket); (2) if the cost was $100/visit out of pocket; (3) if the cost was $200/visit out of pocket and (4) if the cost was $400/visit out of pocket. For general anesthesia parents evaluated acceptability: (1) if the cost was completely covered by insurance ($0 out of 9

20 pocket); (2) if the cost was $1000 out of pocket; (3) if the cost was $2500 out of pocket; (4) if the cost was $5000 out of pocket. To compare the levels of acceptability, the mean rating and standard deviations for each of the advanced behavior management techniques was determined for the entire group, the CH group and the PVT group. VAS measurements were analyzed using a Wilcoxon two-sample test and paired t-tests. The Wilcoxon two-sample test focused on differences between the CH and PVT groups. The paired t-tests looked for differences within individuals in a given group. Further analysis, using the Chi-squared test and Fisher s exact test analyzed categorical variables and focused on the relationships between demographics and acceptability of each behavior management technique. Mixed effects linear regression with a random intercept for each respondent was used to analyze differences between the CH and PVT groups when statistically significant differences in demographic variables existed between the groups. 10

21 Results The results reported are from 105 parents who agreed to participate in the study, 55 from CH and 50 from PVT. The combined CH and PVT groups had the following characteristics. The parents ranged in age from years, with a mean age of (±8.39) years. Eighty-five were female and 20 were male. The majority had high school and bachelor s degrees. Fifty-seven (54.2%) reported earning less than $50,000 annually and 48 (45.7%) earned in excess of $50,000 annually. Twenty-seven (25.7%) of the parents were black, 71 (67.6%) were white, and the remainder being other ethnicities. Fifty-two (49.5%) parents reported having public insurance, 56 (53.3%) having private insurance, and 4(3.8%) having no insurance. Demographic variables for each group are noted in Table 2. Three demographic variables significantly differed between the CH and PVT groups: income, insurance, and race. The PVT group had more parents with incomes >$50,000, had more parents who identified themselves as white, non-hispanic, and had more parents who had private insurance than did parents in the CH group. The mean STAI score for parents in this study was 9.76 (±3.97) with no significant difference in anxiety between the CH and PVT groups. No statistically significant relationship was found between STAI score and acceptability ratings for any of the techniques in any group. 11

22 The mean VAS ratings and standard deviations for the 4 advanced behavior management techniques for the entire group, CH group, and PVT group are shown in Table 3. The paired t-tests indicated that there were significant differences (p<0.05) among the different behavior management techniques within each group. All techniques were judged, on average, to be in the acceptable range (<50mm) and acceptability ratings for passive restraint were significantly less acceptable than all other techniques. For the entire group, oral sedation was rated as the most acceptable technique, followed (in order of decreasing acceptance) by general anesthesia, active restraint and passive restraint. There was no significant difference in the mean VAS rating between oral sedation, general anesthesia and active restraint. The results for the entire group are shown graphically in Figure 1. The rankings of parental acceptability of the techniques using the categorical variables (yes or no) were the same as the rankings using the VAS for the entire group. However, several respondents (<6%) were inconsistent having a mean VAS rating that signified unacceptable but then having a categorical rating that signified acceptable and vice versa. The mean VAS ratings for 4 variables: acceptability of GA (ga_acceptmm), acceptability of GA when treatment is urgent and child is in pain (ga_pain), acceptability of GA if treatment is completed in 1 appointment (ga_1appt) and acceptability of GA if there is $0/visit out of pocket cost (ga_$0) were significantly more acceptable (p<0.05) to parents in the CH group compared to parents in the PVT group. The mean VAS ratings and standard deviations are summarized in table 4. 12

23 Parents with private insurance found oral premedication (sedation) as more acceptable than active restraint or passive restraint. Parents making >$50,000 found active restraint as more acceptable than general anesthesia. Although race varied between the groups, according to the mixed effects linear regression, it was not a strong definer of acceptability. Each parent was assigned to one of four videotape presentations (or randomizations) with varying sequence of management technique vignettes. The order in which the vignettes were presented affected the ratings of 5 variables: STAI score, acceptability of active restraint if treatment requires 4 appointments (active_4appt), acceptability of passive restraint (passive_acceptmm), acceptability of passive restraint when treatment is urgent and child is in pain (passive_pain) and acceptability of passive restraint if treatment requires 4 appointments (passive_4appt). Parents watching randomization #2 were significantly (p<0.05) more anxious than parents watching randomization #1. Parents watching randomization #3 were significantly more accepting (p<0.05) of the following than were parents watching randomizations #1 and #4: active_4appt, passive_acceptmm, passive_pain and passive_4appt. If the child was in pain and treatment was urgent, acceptability for all techniques increased except for active restraint in the entire group, CH group and PVT group (Table 5). If the child required multiple appointments (4 appointments with passive or active restraint, 2 appointments with sedation), the acceptability for all techniques decreased in the entire group, CH group and PVT group. If all treatment could be completed in 1 13

24 appointment under general anesthesia, acceptability for all techniques increased in the entire group, CH group and PVT group (Table 6). Additionally, as out of pocket expenses increased for GA and Sedation, acceptability of these techniques decreased (Tables 7 & 8). Income, race or type of insurance did not significantly affect acceptability ratings between the different willingness to pay variables for either GA or Sedation. Mean VAS values between all variables for willingness to pay for GA (GA $0, GA $1000, GA $2500, GA $5000) were significantly different (p<0.0001) for the entire group, CH group and PVT group. Mean VAS values between all variables for willingness to pay for Sedation (Sedation $0, Sedation $100, Sedation $200, Sedation $400) were significantly different (p<0.0001) for the entire group, CH group and PVT group. Overall, parents ratings for paying $0 out of pocket per visit for GA was in the acceptable range (<50mm) and paying $1000, $2500, or $5000 out of pocket per visit for GA was in the unacceptable range (>50mm). For sedation, results showed parents rated paying $0, $100, or $200 out of pocket per visit for sedation in the acceptable range (<50mm) and paying $400 out of pocket per visit for sedation in the unacceptable range (>50mm). For the entire group, parents with previous experience of a particular technique rated that particular technique as more acceptable (Table 9). The mean VAS ratings for previous experience versus no previous experience were statistically different (P<0.05) only for general anesthesia and oral premedication (sedation). 14

25 Discussion In the past several decades, the hierarchy of acceptability of the techniques has changed in some regards decreasing approval of the physical management of behavior and increasing approval of pharmacological management, namely oral premedication (sedation) and general anesthesia. Table 10 lists the techniques in order of acceptability for the present study in addition to listing the rankings from 3 previous studies by Murphy, et al., Lawrence, et al. and Eaton et al. 4,9,11 It is interesting to note that the acceptability of some techniques has changed, while the acceptability of other techniques has remained more constant over time. In examining the results, oral premedication (sedation) and general anesthesia were ranked towards the lowest in 1984 and However, acceptability for both pharmacologic methods increased to midrange in In the present study, both oral premedication (sedation) and general anesthesia were ranked higher than both active restraint and passive restraint. It is interesting to speculate on the possible rationales for changing patterns. Changing attitudes toward acceptability of behavior management techniques may be attributed to changes in parenting styles over the past years. A recent study reported parents are more overprotective and less likely to set limits on children s behavior. 19 As a result, there may be a shift towards more pharmacologic management of behavior. Additionally, due to Associated Medical Cost laws there is increased coverage of general 15

26 anesthesia for dental procedures by third party payers. 20 Associated Medical Cost laws require that medical plans pay for hospitalization and related medical expenses, such as the administration of general anesthesia, when dental treatment is best performed in the hospital. Since 1995, at least 32 states have adopted laws or regulations requiring this type of coverage for particular patients. 20 Furthermore, there has been a significant increase in the number of outpatient surgical centers and outpatient surgeries, due to simpler and safer procedures; thereby, increasing parental accessibility and familiarity with outpatient general anesthesia. 21 In modern-day America, direct drug advertising in the mass media, the increased use of the internet for information and the trend of medical television shows may have increased exposure and awareness of both general anesthesia and oral premedication (sedation). Changes in medications, with increased safety profiles and efficacy, used for oral premedication (sedation) over the years may also contribute to the rising acceptability. Overall, parents may perceive oral premedication (sedation) and general anesthesia to be less risky, more cost-effective, more comfortable for their child and convenient than in the past; thus, leading to a rise in their acceptability. Our results suggest that the healthcare delivery system (private practice versus hospital setting) affects parental acceptability ratings. Parents in PVT rated active restraint as more acceptable than parents in the CH group. This could be due to the dynamics of private practice same dentist and assistant at each visit making both the parent and child more comfortable due to familiarity. In the CH group, a different dentist and assistant may see the patient at every visit, making it harder for the parent and child 16

27 to develop a trusting relationship. Furthermore, general anesthesia was rated as significantly more acceptable at CH compared to PVT. This could be due in large part to cost effectiveness and patient/parent convenience. A higher percentage of parents at CH had public insurance, which may cover more of the cost for treatment under general anesthesia as compared to private insurance. Additionally, since mean annual income was lower at CH parents may prefer general anesthesia due to cost effectiveness because all dental treatment can be completed at one appointment thereby decreasing costs and increasing convenience related to time off work, time off school, and transportation. Lastly, CH has facilities for general anesthesia whereas parents from private practice need to assess geographic distance and accessibility to an ambulatory surgery center or hospital. Previous studies examining parental attitudes toward behavior management techniques have used the VAS and the same clinical vignettes to measure acceptance of behavior management techniques; however, none have examined the effect of order by varying the sequence of the management technique vignettes. 8,11,13 This is important since the relative position of the vignette in the video/questionnaire may uniquely influence the way in which a respondent reacts. This phenomenon is referred to as order effect. To counterbalance or washout the order effect, four different randomizations were created and a relatively equal number of parents in both the CH and PVT group were randomly assigned to each randomization. In examining the results, when passive restraint was shown last (randomizations 1 & 4), it was much less acceptable than when it was shown first (randomization 3). Parents watching passive restraint last may have 17

28 subconsciously compared it to the previous management techniques and felt in comparison to other techniques that passive restraint was much less acceptable. On the other hand, parents watching passive restraint first were not influenced by other management techniques and therefore may not have rated it as unacceptable as parents watching passive restraint last. Previous studies using a VAS have arbitrarily considered a mean rating of less than 50mm to signify a technique is acceptable since it is the midpoint on a 100mm VAS scale. Using this criterion, all techniques evaluated in this study had mean VAS ratings in the acceptable range. To assess intra-subject reliability, subjects were asked to rate acceptability of the behavior management technique using both a categorical scale (yes or no) and a continuous scale (VAS). Less than 6% of participants recorded VAS ratings for behavior guidance techniques that were inconsistent with their categorical ratings. This could be due to several different reasons. First, the break-point was arbitrarily determined and for some subjects the break-point may not have been at the 50mm mark. Second, subjects may have confused which side of the line represented acceptable and which side represented unacceptable. In this study, the mean ratings for all techniques were associated with large standard deviations, representing substantial variability in parental perceptions of behavior management techniques. The mean ratings for oral premedication (sedation), general anesthesia and active restraint were all statistically similar. Passive restraint was ranked as the least acceptable technique and had a mean VAS rating (44.42mm) that was significantly different from all other techniques. It was the closest to being in the 18

29 unacceptable range (>50mm). Passive restraint (Papoose Board) was also ranked as the least acceptable technique in the 1984 Murphy et al study and in the 1998 Scott and Garcia-Godoy study which examined parental acceptance of behavior management in Hispanic parents. 9,22 It was ranked as the second to least most acceptable technique in the 2003 Eaton et al. study. 4 However, studies by Frankel and Peretz and Zadik found parents to approve of the Papoose Board once the technique had been used with their child. 14,15 The current study showed that those with previous exposure to passive restraint responded that the technique is more acceptable than those without previous experience; however, this difference was not statistically significant. It is evident that great variability in parental attitudes toward passive restraint exists, thereby making it crucial to thoroughly explain indications, risks, benefits and possible alternatives to parents and to obtain informed consent prior to utilizing the technique. There have been no previous studies on the effect of cost on parental acceptability of behavior management techniques in dentistry. We evaluated acceptability of oral premedication (sedation) and general anesthesia based on varying out of pocket expenses. The term out of pocket expense was used to eliminate any differences between individuals due to varying insurances. Values for expenses were based on average expenses for those procedures. It is not surprising that as cost per visit of oral premedication or general anesthesia increases, the acceptability for that technique decreased. Parents found paying up to $200 per visit for oral premedication to be in the acceptable range; however, paying $400 per visit was in the unacceptable range. Interestingly, paying even $1000 out of pocket for general anesthesia was in the 19

30 unacceptable range. The economy can impact a parents willingness to pay for dental treatment. The results suggest that although parents may find these techniques acceptable, a cost versus benefit analysis must be done and their use may be limited due to financial implications. The STAI was used to measure an effect of anxiety on parental acceptance of management techniques. No statistically significant relationships appeared between anxiety level and acceptability. This is interesting to note as parents current anxiety level does not influence his/her rating of a particular technique. The study by Lawrence et al. did find, however, that as parents current stress level increased, acceptability decreased. 11 Additionally, parents watching randomization 2 were significantly more anxious than parents watching randomization 1. All parents completed the STAI prior to watching the videotape and the reason for this difference is unknown. Parents rated each technique as more acceptable if they had previous experience with that particular technique. For general anesthesia and oral premedication (sedation) acceptability ratings for those with previous experience were statistically more acceptable than for those with no previous experience. For passive restraint and active restraint acceptability ratings for those with previous experience were not statistically different than for those with no previous experience. Previous exposure to a particular technique is an important confounding variable and can increase acceptability ratings. Past studies by El Badrawy and Riekman, Frankel, and Peretz and Zadik all suggest that parents tend to approve of behavior management techniques once the technique has been used with their child. 14,15,16 20

31 Results from this study indicated that the acceptability of all of the techniques, except active restraint, increased as the dental procedure increased in urgency, due to facial swelling and pain. This is consistent with the study by Fields et al. that reports that parents are more approving of a technique as treatment becomes urgent and the child is experiencing discomfort. 10 Parents are more likely to ignore a problem if it is not urgent and are more willing to accept aggressive techniques if treatment is urgent. If a child required multiple appointments using passive restraint, active restraint or oral premedication (sedation), acceptability decreased. The use of passive restraint for 4 appointments was rated in the unacceptable range (>50). Parents may perceive the use of passive restraint multiple times for dental treatment as potentially traumatizing to their child. Additionally, returning for dental treatment 4 different times may be associated with other costs such as transportation and time off work. As a result of these findings, it is evident that parental acceptability of the techniques can vary depending on the given circumstance (emergency, amount of decay) and procedure. The study had several limitations. Only English speaking individuals were included thus eliminating a significant percentage of the population at CH. Additionally, some parents may have misinterpreted the VAS scale reversing the anchor points for positive and negative. The addition of graphical images such as smiley/frowny faces to supplement the words anchoring the VAS scale could be helpful. Another limitation related to the choices offered to determine the effect of cost on parental acceptance. Future studies should include either an open-ended question to evaluate willingness to pay or more intervals/values to evaluate the effect of cost on parental acceptance of 21

32 management techniques. Furthermore, future studies may want to assess mother s dental anxiety and how this affects acceptability. 22

33 Conclusions 1. Advanced pharmacologic techniques (oral premedication and general anesthesia) were rated as the most acceptable behavior guidance techniques. 2. Passive restraint was rated as the least acceptable technique. 3. The acceptability of oral premedication and general anesthesia is related to the cost: as cost increases, acceptability decreases. a) Parents found paying up to $200 per visit out of pocket for oral premedication (sedation) to be in the acceptable range; however, they found paying $400 per visit out of pocket to be in the unacceptable range. b) Parents found paying $1000 out of pocket or general anesthesia to be in the unacceptable range. 4. The sequence in which the techniques are viewed does affect acceptability ratings. 5. The acceptability of different behavior management techniques is related to urgency of treatment and amount of treatment necessary. 6. Previous parental experience with a particular technique increases acceptability of that technique. 23

34 References 1. American Academy of Pediatric Dentistry. Guideline on Behavior Guidance for the Pediatric Dental Patient. Pediatr Dent 2011;36: Kuhn BR, Allen KD. Expanding child behavior management technology in pediatric dentistry: a behavioral science perspective. Pediatr Dent 1994;16: Allen KD, Stanley, RT, McPherson K. Evaluation of behavior management technology dissemination in pediatric dentistry. Pediatr Dent 1990;12: Eaton JJ, McTigue DJ, Fields HW Jr, Beck M. Attitudes of contemporary parents toward behavior management techniques in pediatric dentistry. Pediatr Dent 2005;27: Long N. The changing nature of parenting in America. Pediatr Dent 2004;26: Hagan PP, Hagan JP, Fields HW, Machen JB. The legal status of informed consent for behavior management techniques in pediatric dentistry. Pediatr Dent 1984;6: Pinkham JR. An analysis of the phenomenon of increased parental participation during the child s dental experience. ASDC J Dent Child 1991;58: Havelka C, McTigue D, Wilson S, Odom J. The influence of social status and prior explanation on parental attitudes toward behavior management techniques. Pediatr Dent 1992;14: Murphy MG, Fields HW, Machen JB. Parental acceptance of pediatric dentistry behavior management techniques. Pediatr Dent 1984;6: Fields HW, Machen JB, Murphy MG. Acceptability of various behavior management techniques relative to types of dental treatment. Pediatr Dent 1984;6: Lawrence SM, McTigue DJ, Wilson SW, Odom JG, Waggoner WF, Fields HW. Parental attitudes toward behavior management techniques used in pediatric dentistry. Pediat Dent 1991;13:

35 12. Brandes DA, Wilson S, Preisch JW, Casamassimo PS. A comparison of opinions from parents of disabled and non-disabled children on behavior management techniques used in dentistry. Special Care in Dent 1995;15: Wilson S, Antalis D, McTigue DJ. Group effect on parental rating of acceptability of behavior management techniques used in pediatric dentistry. Pediatr Dent 1991;13: Frankel RI. The Papoose Board and mothers attitudes following its use. Pediatr Dent 1991;13: Peretz B and Zadik D. Parents attitudes toward behavior management techniques during dental treatment. Pediatr Dent 1999;21: ElBadrawy HE and Riekman GA. A survey of parental attitudes toward sedation of their child. Pediatr Dent 1986; 8: Adair SM. Behavior Management Conference Panel I Report- Rationale for Behavior Management Techniques in Pediatric Dentistry. Pediatr Dent 2004;26: Marteau TM, Bekker H. The development of a six-item short-form of the state scale of the Spielberger State-Trait Anxiety Inventory (STAI). Br J of Clinical Psych 1992;31: Casamassimo PS, Wilson S, Gross L. Effects of changing US parenting styles on dental practice: perceptions of diplomats of the American Board of Pediatric Dentistry. Pediatr Dent 2002;24: American Dental Association. Department of State Government Affairs. Associated Medical Cost laws; David G, Neuman M. The changing geography of outpatient procedures. Leonard David Institute of Health Economics 2011;16: Scott S, Garcia-Godoy F: Attitudes of Hispanic parents toward behavior management techniques. J Dent Child 1998;65:

36 Appendix A: Tables and Figures Table 1: Order of Randomizations 26

37 Table 2: Demographic Variables 27

38 Table 3: Techniques ranked by Acceptability using VAS scale *Vertical lines (I) indicate mean values that were not significantly different between techniques (paired t-tests) 28

39 Figure 1: Mean VAS (±SD) rating by technique for entire group *Vertical line (I) indicates mean values that were not statistically different between techniques (paired t-tests) 29

40 Table 4: VAS ratings differing between CH and PVT groups 30

41 Table 5: Mean VAS ratings for child in pain/treatment urgent *Vertical line (I) indicates mean values that were statistically different (paired t-tests) between overall acceptability of technique and acceptability if treatment is urgent 31

42 Table 6: Mean VAS ratings for multiple appointments *Vertical line (I) indicates mean values that were statistically different (paired t-tests) between overall acceptability of technique and acceptability if treatment requires certain number of appointments 32

43 Table 7: Mean acceptability for monetary GA variables 33

44 Table 8: Mean acceptability for monetary Sedation variables 34

45 Table 9: Mean acceptability for techniques with/without previous experience 35

46 Table 10: Techniques ranked by Acceptability in 4 similar studies *Vertical lines (I) indicate mean values that were not significantly different between techniques (ANOVA and Tukey test) **Vertical lines (I) indicate mean values that were not significantly different between techniques (Wilcoxon two-sample test) 36