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PEDIATRIC DENTISTRY/Copyright 1984 byThe American Academy of Pediatric DentistryVolume 6 Number 4 SCIENTIFIC

Parental acceptance of pediatric dentistry behaviormanagement techniques

Marilyn Goodwin Murphy, DDS, MSJ. Bernard Machen, DDS, MA, MS, Phd

Henry W. Fields, Jr., DDS, MS, MSD

AbstractThe purpose of this study was to assess the attitudes of

parents toward behavior management techniquesemployed in pediatric dentistry. Sixty-seven parentsviewed videotaped segments of actual treatment of three-to five-year-old children with whom the followingbehavior management techniques were used successfully:general anesthesia, Papoose Boarda, sedation, hand-over-mouth exercise (HOME), physical restraint by thedentist, physical restraint by the assistant, mouth prop,voice control, positive reinforcement, and tell-show-do.Each parent indicated the acceptability of each techniquefor treating their child. Mean ratings and rankings werecalculated for the behavior techniques, relationship of theapproval of techniques to demographic and historicalvariables was established, and the correlations among age,socioeconomic status, and the approval of other behaviormanagement techniques were calculated.

Both ratings and rankings indicated that the majorityof parents favored tell-show-do, positive reinforcement,voice control, and mouth props. Physical restraint by thedentist and assistant were viewed significantly morefavorably than sedation and HOME. The least acceptabletechniques were general anesthesia and Papoose Board.Parents with more than one child found the PapooseBoard significantly less acceptable than those with onechild. Parents who visted the dentist before they wereseven years old found voice control more acceptable.Parental age was not significantly related to approval of atechnique, and parental socioeconomic status wascorrelated negatively with approval of general anesthesia.

eling, 6 distraction, 7 desensitization, s and hypnosis9have been proposed as preventive and correctivetechniques for uncooperative behavior, but thesetechniques require additional timeand skill for suc-cessful implementation. Hand-over-mouth-exer-cise(HOME) 1 commonly is used to establishcommunication and obtain cooperation with highlydisruptive or defiant children. Physical restraint ap-pears to be indicated with extremely young, disrup-tive, or handicapped children, n When other techniquesfail or seem inappropriate, sedation or general anes-thesia may be indicated.12

While dentists continue to use these same man-agement strategies, societal attitudes toward dealingwith children have changed. 13 Health professionalsno longer can assume that parents are aware andapprove of even the most routine behavior manage-ment technique. In addition, the use and acceptanceof a technique by the profession does not assure itslegality as viewed by todays courts. 14 With the em-phasis on childrens rights, the attitude of parentstoward behavior management techniques constitutesanother important factor which must be consideredwhen selecting an approach for managing behavior.

The purpose of this study was to assess parentsattitudes toward 10 behavior management techniquesemployed by dentists treating young children.

Methodsand Materials

Although the majority of young children exhibitlittle disruptive behavior in the dental setting, 1 thereis a small percentage who exhibit behavior whichmakes dental treatment difficult. Dentists utilize nu-merous management techniques to obtain coopera-tive behavior. Tell-show-do, 2 expectation, 3 positivereinforcement, 4 and voice control s can be incorpo-rated easily into mildly disruptive situations. Mod-

The 67 subjects for this study included parents fromthe Durham, Raleigh, and Chapel Hill, North Caro-lina areas. The only requirement for participation wasthat they must be or have been parents, but therewas no limitation on socioeconomic status. All 67subjects volunteered and before participation wereinformed of the study content.

At the beginning of the study, data were collectedto calculate the Hollingshead index~5 as well as infor-

PEDIATRIC DENTISTRY: December 1984/Vol. 6 No. 4 193

mation pertaining to previous dental experiences ofthe parents. Frequently used behavior managementtechniques were selected and described to the par-ents in the following manner.

1. Tell-show-do (TSD): The dentist or assistant ex-plains to the child what is to be done using simpleterminology and repetition and then shows thechild what is to be done by demonstrating withinstruments on a model or the childs or dentistsfinger. Then the procedure is performed exactlyas described. Praise is used to reinforce coopera-tive behavior.

2. Voice control (VC): The attention of a disruptivechild is gained by changing the tone or increasingthe volume of the voice. Content of the conver-sation is less important than the abrupt or suddennature of the command.

3. Mouth props (MP): A device is placed in the childsmouth to eliminate closing when a child refusesor has difficulty maintaining an open mouth.

4. Positive reinforcelnent (PR): This technique rewardsthe child who portrays any behavior which is de-sirable. Rewards include compliments, praise,oraffectionate physical contact.

5. Hand-over-mouth-excercise (HOME): The disruptivechild is told that a hand is to be placed over thechilds mouth. When the hand is in place, the den-tist speaks directly into the childs ear and tells thechild that if the noise stops the hand will be re-moved. When the noise stops the hand is removedand the child is praised for cooperating. If the noiseresumes the hand again is placed on the mouthand the exercise repeated.

6. Physical restraint by the dentist (PRD): The dentistrestrains the child from movement by holding downthe childs hands or upper body, placing the childshead between the dentists arm and body, or po-sitioning the child firmly in the dental chair.

7. Physical restraint by the assistant (PRA): The assist-ant restrains the child from movement by holdingthe childs hands, stabilizing the head, and con-trolling leg movements.

8. Papoose Boardsa and Pedi-Wrapsb (PR): These are re-straining devices for limiting the disruptive childsmovement. The child is wrapped in these devicesand placed in a reclined dental chair.

9. Sedation (SED): Sometimes drugs are used to se-date a child who does not respond to other be-havior management techniques or is unable tocomprehend the dental procedures. Often, thesedrugs are administered orally.

10. General anesthesia (GA): The dentist performs thea Olympic Medical Corp., Seattle, WA.b Clark Associates, Worcester, MA.

dental treatment with the child anesthetized inthe operating room.

Participants viewed a videotape simulating whatmight happen in the operatory during treatment oftheir disruptive child. Each management techniqueportrayed in the videotape was consistent with theabove explanations. The validity of the videotapedbehavior management techniques was established byhaving a group of eight pediatric dentists on the fac-ulty at the University of North Carolina view andevaluate the tape for accuracy of presentation. Fivebehavior management techniques were retaped at therecommendation of this group. The order of presen-tation of the techniques was determined randomlyand a visual symbol of each technique was presentedin conjunction with the videotape.

A questionnaire allowed parents to rate the 10 be-havior management techniques in accordance withtheir willingness to have them used to gain the co-operation of their child. The questionnaire consistedof a single horizontal line running lengthwise acrossthe middle of a page. The right and left end pointsof the line were labeled most acceptable and leastacceptable, respectively. Each parent placed stickersfor each technique on the line to indicate the level ofacceptability of that technique relative to the scaleand to the other techniques. In order to simplify thetask, ties were permitted.

To establish reliability, a pilot group of 13 partici-pants was tested twice within a period of six weeks.Results were analyzed using the paired t-test, whichfocused on the differences between the responses forthe first or second test, and the signed rank test whichalso tested the difference and was appropriate for thesmall sample size.

In order to assess acceptability, the distance on theline from least to most acceptable was divided intoquarters and responses were scored by quartile andrank in quartile (0-9 in the first quartile, 10-19 in thesecond quartile, 20-29 in the third quartile, and 30-39in the fourth quartile). The 0-9 score represented theleast acceptable techniques and 30-39 the most ac-ceptable techniques. Thus, each of the techniques wasassigned a rating from 0 to 39. For example,the third-ranked technique in the first quartile was 2 (0, 1, 2).

To compare the levels of acceptability, the meanrating for each of the 10 behavior management tech-niques was determined. Variability among the meanswas investigated using asymptotic regression meth-odology as discussed by Koch et al. 16 A computerprogram was used to implement this methodologyfor multivariate categorical data. 17 Hypotheses statingsimilar distributions among techniques were testedusing a chi-square statistic. A general statistical modelincorporating the results of these tests proved to be

194 PARENTAL ACCEPTANCE OF BEHAVIOR MANAGEMENT: Murphy et al.

an adequate representation of the variability of themeans using the criterion of a goodness-of-fit test,which evaluates populations for distribution homo-geneity. By this method, similar techniques could bepaired or grouped and contrasted to other tech-niques.

Another framework of analysis was to developrankings for the behavior management techniques. Arank of 1 indicated that a technique was least ac-ceptable, while a rank of 10 indicated that a techniquewas most acceptable. If ranks tied, the average rankwas assigned to each technique. It was assumed thatthe resulting ranks were equivalent to what wouldhave been indicated if the parent had been asked torank instead of rate each technique. Mean ranks andstandard errors were calculated for each technique.This part of the analysis was undertaken in the man-ner outlined in Koch et al. 18 Again, hypotheses stabing similarities among techniques were tested. Inaddition, the Friedman statistic 19 was calculated fromthe ranks of the behavior management techniques.This test was directed at the hypothesis that eachpossible ranking of a technique is equally likely. Thealternative hypothesis was that some techniques tendto be ranked higher than each other.

Further analysis, using the chi-square statistic fo-cused on the relationships between demographic andhistorical data and the acceptability of five of the mostacceptable management techniques. Finally, the ac-ceptability of each management technique was cor-related with each other technique to determinesignificant relationships by a Pearson Product corre-lation.

Results

The results of the paired t-test were not significantat the p = 0.01 level and the signed rank test con-

TABLE 1. Rating Means and Standard Errors for 10 BehaviorManagement Techniques* (N = 67)

Technique Mean Standard ErrorPapoose Board~ 5.1 .97General anesthesia 5.4 1.12Sedation 11.8 1.46Hand-over-mouth-exercise 13.7 1.24Physical restraint, assistant 15.9 1.29Physical restraint, dentist 16.1 1.29Voice control 21.1 1.27Mouth prop 22.2 1.10Positive reinforcement 28.3 .78Tell-show-do 30.2 .60

* 0 = least acceptable / 39 = most acceptable; techniques that arenot significantly different in mean ratings are grouped.

TABLE 2. Ranked Means for 10 Behavior Management Tech-niques* (N = 67)

Technique Mean Standard ErrorPapoose Board 2.51 .189General anesthesia 2.96 .293Sedation 4.27 .306Hand-over-mouth-exercise 4.68 .232Physical restraint, dentist 5.22 .247Physical restraint, assistant 5.27 .289Mouth prop 6.47 .220Voice control 6.49 .253Positive reinforcement 8.18 .231Tell-show-do 8.97 .177

* 1 = least acceptable / l0 = most acceptable; techniques that arenot significantly different in mean ratings are grouped.

firmed that the responses for the first and secondtests were not significantly different.

Ninety-four per cent of the parents were female,with an average age of 34.3 years. Seven parents weresingle, 50 were married, and 10 were divorced. Fifty-three of the parents previously had taken their chil-dren to the dentist and 28 had watched their childrenreceive treatment in the dental operatory. As a whole,the parents themselves made a visit to the dentistevery 18 months. Their average age at their first den-tal visit was 9.1 years. The largest proportion of thesample was medium business, technical, or minorprofessionals with the remainder equally divided be-tween major professional and clerical workers. Thesample could be typified as upper middle class.

Table I shows the rating means and standard errorsfor the 10 behavior management techniques on the0-39 scale. Positive reinforcement and tell-show-dohad the most acceptable ratings of 28.3 and 30.2, re-spectively; general anesthesia and Papoose Board hadthe least acceptable ratings, 5.4 and 5.1.

Chi-square analysis revealed significant differencesbetween the mean ratings at the p < 0.01 level. Themodel and its goodness-of-fit statistic confirmed thatthe mean ratings were essentially the same for thefollowing pairs of techniques: general anesthesia andPapoose Board, sedation and HOME, physical re-straint by the assistant and physical restraint by thedentist, and mouth prop and voice control. Therewere significant differences between tell-show-do andpositive reinforcement.

The mean ranks and the standard errors for the 10behavior management techniques on the 1-10 scaleare presented in Table 2. Significant differences existbetween pairs of ranks at the p < 0.05 level. Themodel and its goodness-of-fit statistic verify that themean ranks for the following pairs were essentiallythe same; general anesthesia and Papoose Board,


TABLE 3. X2 Summary for Relationship Among Five Behavior Management Techniques and to Various Demographic andHistorical Variables

X~

N-ChildN-ChildN-ChildN-ChildN-Child

YPhysical restraint, assistantGeneral anesthesiaPapoose BoardVoice controlHand-over-mouth-exercise

X2 p-value/(ldf)0.72 .401.40 .236.10 .010.05 .480.57 .45

O-ChildO-ChildO-ChildO-ChildO-Child

Physical restraint, assistantGeneral anesthesiaPapoose BoardVoice controlHand-over-mouth-exercise

0.39 .530.11

.740.84

.361.90

.160.01

.93

Y-ChildY-ChildY-ChildY-ChildY-Child


3.70.05

0.02 .883.00 .080.004 .950.11 .74

Visit FreqVisit FreqVisit FreqVisit FreqVisit Freq


2.10 .141.40

.231.40

.230.95

.330.96 .33

Visit AgeVisit AgeVisit AgeVisit AgeVisit Age


0.45.50

0.09 .760.12 .766.10 .011.60 :20

W-DentW-DentW-DentW-DentW-Dent


0.07 .790.13

.720.16

.690.00 1.000.29 .59

Dental ExpDental ExpDental ExpDental ExpDental Exp


0.001 .970.14 .710.001 .970.26 .610.01 .93

* Classification SchemeAge = respondents age (35 and under/over 35)N-child = number of children of respondent (none or 1/more than 1)O-child = age of respondents oldest child (7 and under/over 7)Y-child = age of respondents youngest child (5 and under/over 5)Soc = respondents socioeconomic status (1-39/40-66)Visit Freq = frequency of respondents dental visits (annually add biannually/emergency)Visit Age = respondents age at first dental appointment (7 and under/over 7)W-Dent = whether or not respondent has watched his child receive dental treatment (yes/no)Dental Exp = respondents dental experience (minor/extensive)

sedation and HOME, physical restraint by the assist-ant and physical restraint by the dentist, and mouthprop and voice control. There were significant differ-ences between tell-show-do and positive reinforce-ment. The Friedman statistic value of 284.5 alsoconfirmed significant differences between meanrankings.

Two associations with significant chi-square statis-tics (p = 0.01) emerged in this analysis (Table Parents with more than one child found PapooseBoards less acceptable than parents with one child.A greater percentage of parents who first visited adentist at seven years of age or younger found voice

196 PARENTAL ACCEPTANCE OF BEHAVIOR MANAGEMENT: Murphy et al.

TABLE 4. Correlations Between the Acceptability of 10 Behavior Management Techniques, Parental Age,and Socioeconomic Status

AGE SES PRA PRD GA TSD PB MP VC SED HOME PRPRA - .25 - .14 1.0PRD -.29 -.15 .73"GA - ,08 - .58* - .02TSD - .13 .38 .09PB .09 -.22 ,24MP .11 .08 .29VC .12 .06 - .07SED .13 - .27 - .25HOME ,19 -,01 .19PR - .10 .45 - .06

1.0.15 1.0.14 -.17 1.0.12 .04 - .44 1.0.14 -.19 .01 .09 1.0,12 .27 .07 .20 .11

-.12 .39 -0.1 -.12 -.05,14 -.17 -.20 .45 .19

-.05 -.51" .56* -.14 -.06

1.0.07 1.0.53* - .18 1.0.04 - .23 - .07 1.0

* p-value -< 0.0001.

control more acceptable than parents whose first visitwas at eight years or older.

The correlations revealed there were no significantrelationships between the age of the parent and theapproval of a specific management technique (Table4). There was a significant negative correlation be-tween socioeconomic status and approval of generalanesthesia (Table 4). As ones socioeconomic statusincreases the approval of general anesthesia de-creases.

Four significant relationships emerged in this anal-ysis (Table 4). There was a significant positive rela-tionship between approval of physical restraint bythe dentist and physical restraint by the assistant.There was a significant negative relationship betweenapproval of general anesthesia and positive reinforce-ment. There was a positive relationship between pos-itive reinforcement and approval of tell-show-do.Finally, there was a positive relationship between ap-proval of HOME and approval of voice control. Dueto the reasonably large sample size, correlations werenot reported as significant if they were less than 0.50.Correlation coefficients of this magnitude would ac-count for approximately 25% of variability and couldhave clinical significance.

DiscussionThere have been no investigations of parental at-

titudes toward the use of behavior management tech-niques for the disruptive child dental patient. Thisstudy examined the relative acceptability of 10 be-havior management techniques. The mean ratings forthese techniques served as a method of quantifyingrelative acceptability. Since 20 on the 0-39 scale is thetheoretical midpoint, those with a mean rating greaterthan 20 are considered in the more acceptable range.Only four techniques have mean ratings on the moreacceptable side of the continuum. These included:voice control, mouth prop, positive reinforcement,and tell-show-do. The less acceptable techniques in-cluded: physical restraint by the dentist or assistant,

HOME, sedation, general anesthesia, and PapooseBoard. As expected, the least invasive or aggressivetechniques were most acceptable. Techniques em-ploying drugs (i.e., general anesthesia or sedation)were rated as least acceptable. Other authors haveemphasized the need to use these methods only as alast resort after all alternative management methodshave failed 3,4 -- parents seem to agree.

Following the asymptotic regression analysis, it waspossible to group techniques with similar levels ofapproval. The Papoose Board and general anesthesiawere viewed with equal disapproval. Sedation wasviewed distinctly more favorably than general anes-thesia and was grouped with HOME. It is evidentthat HOME was seen as similar in severity to a phar-macological technique, but separate from and lesspositively than physical restraint by the dentist andassistant.

Despite the fact that all mean ratings for physicalrestraining techniques were on the less acceptable sideof the continuum, the interval between Papoose Boardand physical restraint by a dentist or assistant wasstatistically significant. These types of restraint wereperceived differently.

The mean rankings developed for the behaviormanagement techniques were very similar in orderwhen compared to the mean ratings. The only dif-ferences were due to order changes between physicalrestraint by the assistant and physical restraint by thedentist, and voice control and mouth prop. Thesepairs of techniques were found to be statistically sim-ilar by both assessment methods. The differences thatwere present may reflect the fact that the 0-39 ratingscheme takes some measure of distance into account.

Although there was no statistically significant cor-relation between the parents age and the approvalof management techniques, there was a statisticallysignificant (r = .38) relationship between parentshigher socioeconomic status and reduced approval ofthe general anesthesia procedure. This relationshipmay be related to the fact that higher socioeconomic


status parents either understand or imagine the in-creased risk that is involved in the general anesthesiaprocedure or have encountered that risk and havemade the value judgment that is required. Also, thesesame persons are probably more unfamiliar with ad-vanced dental disease and the attendant pain.

Most of the statistically significant relationships thatemerged in this analysis are understandable; possiblymore interesting are those that did not emerge. Thoseparents who are most likely to approve physical re-straint by the assistant are more inclined to approvephysical restraint by the dentist (r ~ .73). These twotechniques have been ranked and rated similarly bythe parents throughout this investigation and havebeen paired closely in all analyses. On the other hand,approval of HOME and the approval of voice controlalso are related significantly (r = .53). These two pro-cedures have not been paired or adjacent to each otherin any of the analyses performed. In fact, physicalrestraint by the dentist and physical restraint by theassistant were intermediate between these tech-niques in all ratings. An obvious relationship be-tween these two teclhniques is not apparent. Finally,parents who approve of tell-show-do also approve ofpositive reinforcement (r = .56). These procedureswere consistently adjacent to each other in all rank-ings and ratings of approval and were the most ap-proved ratings. It should be noted that although theywere similarly rated they were statistically signifi-cantly different in their ratings at all points through-out the analysis. Parents seem to see these techniquesin the same light, but as distinctly different proce-dures.

Limitations of the StudyThe nature of this data is descriptive and any con-

clusions reached should be restricted to the actual testpopulation. An inability to use a scientific samplingscheme to obtain the test sample limits the degree towhich these subjects are representative of a generalpopulation.

Conclusions

1. The techniques used to determine parental atti-tudes appear to be reliable.

2. There is a difinite hierarchy of parental attitudesrelative to management techniques.

3. The least aggressive techniques are more accept-

able. Techniques employing drugs and restraintare less acceptable.

Dr. Murphy is in private practice in Macon, GA. Dr. Fields is anassociate professor, pedodontics and orthodontics, and Dr. Machenis an associate dean and professor, pedodontics, University of NorthCarolina, Chapel Hill, NC 27514. Reprint requests should be sentto Dr. Fields.

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3. Chambers DW: Managing the anxieties of young dental pa-tients. J Dent Child 27:363-74, 1970.

4. Wright GZ: Behavior Management in Dentistry for Children.Philadelphia; WB Saunders Co, 1975.

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13. Wright GZ: Patient management techniques in pedodonticspast, present and future, in Management of Children by HealthProfessionals: A Symposium, Healy A, Nowak AJ, eds. IowaCity, Iowa; University of Iowa, 1977 pp 10-14.

14. Sines J: Initial response of participants, in Management ofChildren by Health Professionals: A Symposium: Healy A,Nowak AJ eds. Iowa City, Iowa; University of Iowa, 1977 pp21-24.

15. Hollingshead AB: Four-Factor Index of Social Status. Stan-ford, California; Yale University, 1975 pp 1-24.

16. Koch GG, Landis JR, Freeman JL, Freeman DH, Lehnen RG:A general methodology for the analysis of experiments withrepeated measurement of categorical data. Biometrics 33:113-58, 1977.

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198 PARENTAL ACCEPTANCE OF BEHAVIOR MANAGEMENT: Murphy el al.

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