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First-Year Students’ Perceptions About Pediatric Dental Behavior Guidance Techniques: The Effect of Education

Key words: dental education, child behavior guidance, pediatric dentistry

Submitted for publication 01/16/08; accepted 04/17/08

	Abstract

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The purpose of this study was to evaluate the effect of a dental education component on dental students’ perceptions toward behavior guidance techniques in pediatric dentistry. A questionnaire was completed by seventy-three first-year dental students, before and after a course on human development and behavior guidance techniques in pediatric dentistry. The acceptability of behavior guidance techniques and situations in pediatric dentistry was scored with a visual analog scale before and after the course, compared, and evaluated in relation to demographic data. After the course, statistically significant increases (ANOVA) in the acceptability of aversive behavior guidance (voice control, hand over mouth, and immobilization), sedation, general anesthesia, and modeling were found. Statistically significant decreases (ANOVA) in acceptability were found in mentioning the possibility of pain during treatment and with a parent being in the clinic or talking with the child during treatment. Female or married students, those who had previously received dental treatment, or those who had a dentist in the family showed statistically significant changes that indicated more empathy toward the children. We conclude that undergraduate dental education may have a significant short-term influence on dental students’ perceptions of behavior guidance in pediatric dentistry.

For example, great emphasis is placed on the instruction of effective behavior guidance techniques in the pediatric dentistry predoctoral curriculum (e.g., voice control and passive/active immobilization). The American Academy of Pediatric Dentistry (AAPD) describes behavior guidance of children in the dental clinic as a continuum of interaction involving the dentist and dental team, the patient, and the parent with the goals of easing fear and anxiety, enabling the oral health team to perform quality treatment safely and efficiently, and nurturing a positive dental attitude in the child.² In the predoctoral pediatric dentistry curriculum, however, students’ adopted perceptions and attitudes towards behavior guidance are not often measured.

Given the role of dentists in practicing behavior guidance and explaining these techniques to a child’s caregiver, it would be useful to understand students’ perceptions concerning such techniques and assess how and to what extent those perceptions are modified through dental education. Previous studies described students’ perceptions of the acceptability of behavior guidance techniques including sedation, which is generally viewed as less acceptable than reinforcement techniques.^3,4 However, these studies did not evaluate the effect of the educational process on the students’ perceptions and whether those reflected reinforcement, reversal, or retention of their preconceived perceptions. While final grades may provide feedback on the students’ knowledge and understanding of material at the end of a course, they do not reflect the influence of the educational process on the students’ perceptions and, ultimately, their clinical philosophy.

The influence of the educational process on first-year students may help in understanding the perceptions of the general public and the parents of pediatric patients. Parental perceptions are important, considering that commonly used effective behavior guidance techniques are under scrutiny by the public, which plays a significant role in determining their acceptance and implementation. For example, the hand over mouth (HOM) behavior guidance technique was removed from the AAPD recommended techniques list during the General Assembly of the AAPD Annual Session in May 2006. The removal coincided with the trend of increasingly low acceptability ratings given by parents to aversive behavior guidance techniques.⁵ Changing perceptions of behavior guidance, including HOM, indicate a relationship between public perception and dental education topics—and that one may influence the other. Therefore, the reevaluation of behavior guidance techniques can begin with observations in the education of future dentists, whose opinions may reflect, to a certain degree, public perceptions of behavior guidance techniques.

The purpose of this study was threefold: to identify the perceptions of recently accepted first-year dental students towards behavior guidance techniques and behavior-related situations in pediatric dentistry; to evaluate the change in students’ perceptions due to an educational component; and to evaluate the influence of demographic factors and previous dental or medical experiences on the change in students’ perception.

	Method

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This study was approved by the Institutional Review Board at the University of Florida College of Dentistry (UFCD). First-year dental students were considered suitable for the purpose of the study as they are relatively uninformed about specific behavior guidance techniques in dentistry and since they receive during their first semester a fifty-five-hour course on psychological, systemic, and oral development. Sixteen hours of this course are devoted to behavioral issues, including pediatric behavior guidance. It was assumed that this course was likely their first educational encounter with behavior guidance techniques used in pediatric dentistry. The course curriculum included a comprehensive review of behavior guidance techniques and situations (see Table 1), observation in dental clinics, and interviews with dental clinicians; the latter two activities were in addition to the sixteen-hour behavioral component of the course. Students were taught verbally and visually during the course with videos of behavior guidance situations performed in the UFCD Pediatric Dentistry Clinics. Based on these experiences, groups of three students were required to produce a class presentation on a dental behavior topic or situation.⁶

The questionnaire introduction included a brief explanation of the goal of the study and directions for completion of the questionnaire. The first set of questions was designed to obtain demographic information, data related to previous dental and medical experiences, and experience taking care of children. These data were collected in order to evaluate the possible influence of these factors on the behavior responses. Visual analog scales (10 cm line) were used to collect student responses on the acceptability of behavior guidance techniques⁶ (Figure 1). Each technique was defined simply, in one line of text, and the students were asked to evaluate the described behavior guidance technique between "completely unacceptable" and "completely acceptable" on the visual analog scale. A second set of questions was used to evaluate the acceptability of clinical behavior scenarios from "never" to "always." Marked questionnaires were collected, and the distance from the left side of the scale was measured for each response. We then categorized the quantitative results into qualitative groups.

View larger version (4K): [in this window] [in a new window]   Figure 1. Sample of the segmented visual analog scale used to determine qualitative importance of shifts in perception

	Results

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From a total of eighty-two students, seventy-three returned completed questionnaires before and after the course. The demographic data on the participants are presented in Table 2. No statistically significant difference (t-test, p>.05) was found in age between male (n=40, mean=23.2 years, standard error[SE]=0.3) and female students (n=33, mean=23.0 years, SE=0.3). Of the participants who had previously received dental or medical treatments, the mean ratings of their experience were 20.7 (SE=2.6) and 28.0 (SE=2.4), indicating that the students mostly had "pleasant" experiences. The previous level of experience in taking care of children was 51.4 (SE=3.5), indicating a neutral experience level.

View larger version (26K): [in this window] [in a new window]   Figure 2. Graphical representation of the mean acceptability ratings given pre- and post-course

View larger version (35K): [in this window] [in a new window]   Figure 3. Graphical representation of the change in acceptability of behavior guidance techniques: positive values indicate increased acceptability

Aversive Behavior Guidance Techniques.
The magnitude and direction of significant changes between surveys show shifts in perceptions of aversive techniques. Pre-course results regarding the papoose board, for example, were classified to have 25 percent, 26 percent, 15 percent, 15 percent, and 19 percent of students rank acceptability as "completely acceptable," "acceptable," "neutral," "unacceptable," and "completely unacceptable," respectively. Corresponding post-course results were 66 percent, 26 percent, 5 percent, 1 percent, and 1 percent, respectively. Therefore, average papoose board perception shifted from "neutral" to "completely acceptable" on the visual analog scale (see Figure 1). By similar calculation, hand over mouth shifted from "completely unacceptable" to "neutral," while immobilization by staff or parent shifted from "neutral" to "acceptable." Perception of voice control did not shift qualitatively; it remained "acceptable."

Pharmacological Behavior Guidance Techniques.
Pharmacological techniques of behavior guidance also shifted significantly. Perception of sedation changed from "neutral" to "completely acceptable," and acceptability of general anesthesia improved from "neutral" to "acceptable." Use of nitrous oxide sedation was "acceptable" in the pre-course survey and increased in acceptability to "completely acceptable."

Desensitization Behavior Guidance Techniques.
While most of the shifts in perception in this category were not statistically significant, tell-show-do remained "completely acceptable," and modeling increased in acceptability, changing from "neutral" to "acceptable."

Other Categories.
Changes in acceptability towards several other categories were also seen. Acceptability of treatment without a parent in the room and not allowing a child to speak during treatment shifted from "unacceptable" to "neutral." Three of the behavior guidance techniques decreased in acceptability. The most significant of these was that of mentioning the possibility of pain, which decreased in acceptability from "acceptable" to "neutral." Treatment with parent present in clinic and parent-child communication during treatment also decreased from "acceptable" to "neutral."

	Discussion

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The visual analog scale allows for determination of relative change in perception. In this survey, such changes show the increase in acceptability of aversive techniques such as HOM. While the average perception may not have been completely swayed towards complete acceptability or unacceptability over the course of the semester, education was shown to change the perception of even the most initially unacceptable perceived behavior guidance technique (parent not present in clinic, HOM, etc.). In addition, the increase in acceptability of passive (papoose board) and active (human restraint) immobilization further indicates that undergraduate education can change the perception of even controversial behavior guidance techniques. It is interesting to note that while the use of the papoose board became "completely acceptable," HOM did not reach a level of "acceptable."

Educational Materials
It is interesting that the perception of the use of papoose boards became more acceptable than active immobilization. This may have been due to differences in educational methods: while the papoose board was demonstrated by a video of a child receiving safe treatment in a papoose board, active immobilization and other techniques were taught verbally and with pictures. It is unclear which of the educational components were most effective in changing student perceptions, though it is likely that the hands-on nature of clinical observation during the first semester had a significant impact.⁷ A recent study by Boynton et al.⁸ demonstrates the effectiveness of portable video-based instruction in teaching pediatric behavior guidance to dental students. A review of other studies shows the same potential benefit of a technology-based approach for patient education.⁹ Since there is an overlap between the educational components for first-year dental students and the public, effective methods in one learning environment may provide insight into the other.

Public Perceptions
Because this study involved only first-year dental students, the post-course results demonstrate the effectiveness of only that semester’s education by the behavior guidance course. The students’ initial perceptions could be compared, to a certain extent, to those of patients’ parents who also may have none to limited prior exposure to behavior guidance techniques. These perceptions may conflict with the implementation of behavior guidance techniques. For example, though a review of the literature by Wilson and Cody¹⁰ shows that the effectiveness of behavior guidance techniques has not been sufficiently clinically evaluated, techniques such as HOM have been removed from AAPD guidelines, which may lead clinicians to avoid its use. Thus, it is clear that increased public scrutiny may influence the implementation of behavior guidance techniques more than clinical efficacy.

Nevertheless, previous findings have demonstrated the positive change of parental perceptions due to education,¹¹ and others have shown the changes in technique perception over time.⁵ Further studies could demonstrate the potential for change in parental perceptions towards controversial techniques with similar, comprehensive emphasis on education as used with dental students. Such changes may result in fewer objections to effective techniques in the same way that students’ understanding led to increased acceptability of controversial behavior guidance techniques.

Limitations
Though this article provides compelling information, interpretation is limited to the short-term effects of one course on one class of students. Future studies should evaluate whether the attitudes reinforced in early courses on behavior guidance are maintained throughout the curriculum. In addition, while similarities have been drawn between first-year students and the general public, our findings may only partially reflect perceptions of the latter group, since first-year dental students have a characteristic age range, level of education, and exposure to health care settings that differ from that of the general population.

Recommendations
Empathy in a medical setting involves the health care provider’s appreciation of the patient’s emotions and the expression of that awareness to the patient. Empathy is believed to significantly influence patient satisfaction, adherence to medical recommendations, clinical outcomes, and professional satisfaction.¹² However, it has been found that the ability of medical students to empathize often declines as they progress through the curriculum;¹³ this trend is also applicable to the dental profession.¹⁴ Therefore, it is most important to provide an early opportunity in the dental curriculum to develop student understanding of behavior guidance in pediatric dentistry, which is based on an empathic approach towards the patient.

Although this goal can be achieved in our course as evidenced by the results, there are general shortcomings in the teaching of behavior guidance techniques. For example, despite the increased demand for providing students with education about sedation, as voiced by current practitioners and educators,¹⁵ there has not been a significant increased emphasis on sedation teaching in U.S. dental schools.¹⁶ Further, a survey by Adair et al.¹⁷ of behavior guidance taught in forty-eight predoctoral pediatric dentistry programs led those authors to conclude that time spent on behavior guidance in the overall predoctoral pediatric dentistry curriculum is not likely to change in most schools. Thus, it is important for educators to recognize that educational experiences and course content can influence the perceptions of their students. Educators must also design teaching and learning experiences that will allow continual reinforcement of the concept of empathy past a first semester course and throughout the entire dental curriculum.

Our study led us to conclude that first-year dental education has the potential to have a significant short-term influence on dental students’ perceptions of behavior guidance in pediatric dentistry. This change should be further emphasized during the education process leading to an empathic approach after graduation.

	APPENDIX: DEN 5210: Student Attitudes Toward Pediatric Dental Behavior Management and Situations

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Introduction
Dear students,

The goal of this study is to evaluate your knowledge of behavioral management techniques and dental clinic situations involving children before and after this course.

Your genuine responses are most significant for the evaluation and enhancement of this course, 5210, and the general education of Pediatric Dentistry at the University of Florida. Therefore, your genuine responses and cooperation are greatly appreciated.

This questionnaire will be given to you once before and once after the behavioral management section of course DEN 5210.

Identifiable data are not collected; your responses are anonymous. However, for comparison of your responses before and after this course, we request that you provide a nickname (a word and a number that you can remember; for example: nick213). Please make a note of your nickname to be able to use it again the second time that you respond to the questionnaire.

For many questions, a visual analyzing scale is utilized. Please indicate the degree of your response by drawing a line on the scale. The following is an example between "completely acceptable" and "completely unacceptable":

The use of laser cleaning machines is:

Thank you for your genuine responses and cooperation,

Dr. Jason Sotto

Amir Azari

Dr. Joseph Riley

Dr. Enrique Bimstein

Demographic Data
Nickname __________ (please make a note of your nickname to be able to use it again)

Age (in years) ________

Please circle the appropriate answers to the following questions:

Gender: M F Do you have older siblings? Yes No Do you have younger siblings? Yes No Are you married? Yes No Are you a parent? Yes No Have you received any restorative dental treatment (e.g., fillings)? Yes No     If so, was the restorative dental treatment extensive? Yes No Do you have a family member who is a dentist? Yes No Have you worked in a dental clinic? Yes No Have you visited a dental clinic to observe treatment(s)? Yes No Have you received dental treatment (e.g., exam, cleaning)? Yes No Have you received medical treatment? Yes No

For the next 3 questions, please rate your answer on the scale below each question.

If you have been a dental patient, how unpleasant was (were) your dental experience(s)?

If you have been a medical patient, how unpleasant was (were) your medical experience(s)?

How much experience have you had taking care of children other than your own?

Ratings of Pediatric Behavior Management and Clinical Techniques
Please rate the following behavior management techniques on the scale below each question.

1. The dentist tells his/her patient what is to be done. The procedure is slowly demonstrated. The dental procedure is then performed by the dentist as described.
   
   

   

   
   
2. The dentist does not allow the child to speak since he/she may interfere with the treatment.
   
   

   

   
   
3. The dentist modifies voice volume (raises his voice significantly), tone, or pace to direct the child’s behavior.
   
   

   

   
   
4. The dentist places his/her hand over the mouth of a hysterical or out-of-control child to achieve silence.
   
   

   

   
   
5. The dentist administers nitrous oxide/oxygen inhalation.
   
   

   

   
   
6. The dentist encourages the child not to be a coward.
   
   

   

   
   
7. The child is immobilized by the dentist, the dental staff, and/or a parent; he/she is held firmly in place.
   
   

   

   
   
8. The child is immobilized with the aid of Velcro straps attached to a board, holding his/her hands and feet.
   
   

   

   
   
9. Talking to the child and playing videos or music to attract the child’s focus of attention.
   
   

   

   
   
10. The dentist praises the child when he/she does something he/she is asked to do.
    
    

    

    
    
11. The dentist stimulates the child’s imagination with sensory appeal to distract him/her from the treatment.
    
    

    

    
    
12. The dentist tells the child that he/she should be aware that dentistry may involve pain.
    
    

    

    
    
13. The dentist explains exactly what is going on during the dental treatment to the child.
    
    

    

    
    
14. The dentist sedates the child with drugs.
    
    

    

    
    
15. The child is treated under general anesthesia in a hospital to avoid awareness of the dental experience.
    
    

    

    
    
16. The child is promised a toy if he/she cooperates with the dentist.
    
    

    

    
    
17. The use of euphemisms (an expression intended to be less offensive than the word it replaces) to describe dental procedures.
    
    

    

    
    

	Author Information

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Dr. Sotto is a Resident in the Pediatric Dentistry Department, College of Dentistry; Mr. Azari is a Student of Microbiology and Cell Science, College of Agricultural and Life Sciences; Dr. Riley is Associate Professor, Community Dentistry and Behavioral Science Department, College of Dentistry; and Dr. Bimstein is Professor, Pediatric Dentistry Department, College of Dentistry—all at the University of Florida. Direct correspondence and requests for reprints to Dr. Enrique Bimstein, Pediatric Dentistry Department, College of Dentistry, University of Florida, P.O. Box 100426, Gainesville, FL 32610-0426; 352-392-4131 phone; 352-392-8195 fax; ebimstein{at}dental.ufl.edu.

	REFERENCES

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2. AAPD reference manual: guideline on behavior guidance for the pediatric dental patient. Pediatr Dent 2006–07;28(7):97–105.
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11. Lawrence SM, McTigue DJ, Wilson S, Odom JG, Waggoner WF, Fields HW Jr. Parental attitudes toward behavior management techniques used in pediatric dentistry. Pediatr Dent 1991; 13(3):151–5.[Medline]
12. Stepien KA, Baernstein A. Educating for empathy. J Gen Intern Med 2006; 21(5):524–30.[Medline]
13. Benbassat J, Baurmal R. What is empathy, and how can it be promoted during clinical clerkships. Acad Med 2004; 79(9):832–9.[Medline]
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15. Dionne R, Gordon SM, McCullagh L, Phero JC. Assessing the need for anesthesia and sedation in the general population. J Am Dent Assoc 1998; 129(2):167–73.[Abstract/Free Full Text]
16. Boynes SG, Lemak AL, Close JM. General dentists’ evaluation of anesthesia sedation education in U.S. dental schools. J Dent Educ 2006; 70(12):1289–93.[Abstract/Free Full Text]
17. Adair SM, Rockman RA, Schafer TE, Waller JL. Survey of behavior management teaching in predoctoral pediatric dentistry programs. Pediatr Dent 2004; 26(2):143–50.[Medline]

This article has been cited by other articles:

				E. Bimstein, A. F. Azari, J. J. Sotto, and J. L. Riley III Students' Perceptions About Pediatric Dental Behavior Guidance in an Undergraduate Four-Year Dental Curriculum J Dent Educ., December 1, 2009; 73(12): 1366 - 1371. [Abstract] [Full Text] [PDF]

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