Behavior Management Techniques Employed by Nigerian Dentists for their Child Patients

DESCRITORES Comportamento l; Relações den ti sta-paciente. st-pa Objec ti ve: To determine the di ﬀ erent behavior management techniques employed by den ti sts in Nigeria for their child pa ti ents. Method: One hundred and ﬁ ft y ques ti onnaires were hand delivered to den ti sts in di ﬀ erent loca ti ons in Nigeria. Informa ti on required include respondent’s bio data, years post gradua ti on, behavior management techniques employed, and reasons for choice of technique. Results: A total of 128 (85.3%) were returned completed, comprising 53.2% females and 46.8% males, in age groups, < 30 years (25%), 30-39 years (48.4%), 40-49 years (19.5%) and 50 years and above (7.1%). Thirty ﬁ ve (27.3%) prac ti ced in health centers, 88 (68.8%) in teaching hospitals and 5 (3.9%) in private hospitals. Majority (98.4%) a tt ended to child pa ti ents and 29.6% rated their pa ti ents as uncoopera ti ve.


Oredugba and Sanu -Behavior Management Techniques Employed by Denti sts
Children and young adults, and indeed all pati ents, exhibit some form of anxiety or fear when about to receive dental care. However, eff ecti ve behavior management techniques can help alleviate the pati ent's fear or anxiety, an integral part of any dental practi ce that incorporates the care of children.
Many factors have been proposed as contributory to children's anxiety about dental procedures. These include the dental clinic environment, equipments, past dental treatment experience and the atti tude of dental staff . In order to achieve the cooperati on of the potenti ally cooperati ve child during dental treatment, it is necessary to att empt to modify or infl uence the child's behavior patt ern 1 . Therefore various behavior management strategies are being practi ced to address these causati ve factors. These include verbal and nonverbal communicati on, tell-show-do (TSD), distracti on, presence or absence of parents in the surgery, modeling, audio visual aids, positi ve reinforcement, physical restraint, hand over mouth exercise (HOME), sedati on and general anesthesia. Behavior management methods in pediatric denti stry were either directed to maintain the communicati on process or intended to exti nguish inappropriate behavior 2 . The use of many of these procedures has been highly controversial in the literature. As expected, the use of these methods depends on the practi cing denti st's preference and experience, locati on of practi ce and acceptability by the child and parent. The study of denti sts' management strategies and manner of use can contribute to the behavior of children in receiving care 3 , identi fying the educati onal needs of the practi ti oner 4 , formulati ng causal models of the determinants of denti sts' behavioral management choices 5 .
Reports on the use of many of these strategies by denti sts in many parts of the world abound in the literature. This study was carried out to determine the behavior management techniques employed by denti sts in Nigeria to aid their child pati ents to cope with dental treatment and to suggest ways in improving behavioral management strategies used in the dental clinic setti ngs.
One hundred and fi ft y questi onnaires were hand delivered to denti sts in diff erent locati ons in Nigeria. Informati on required in the questi onnaire include respondent's biodata, years post graduati on, behavior management techniques employed, and reasons for choice of technique, self rati ng of skill, rati ng of undergraduate training, rati ng of atti tude to diffi cult pati ents, reacti on to pati ent's behavior and rati ng of available faciliti es in respondent's practi ce setti ng. Respondents were grouped into age groups <30, 30-39, 40-49 and 50 years and above.
Data collected were analyzed using Epi info version 6 health stati sti cal soft ware. Descripti ve stati sti cs, chi square and t-test were used to compare respondents' age groups, gender and type of BMT at p<0.05 level of signifi cance.
Sixty (46.9%) rated their undergraduate training in behavior management as 'adequate', with signifi cantly higher proporti on of younger denti sts responding 'adequate' training (p=0.01) ( Table 4). One hundred and fi ft een (91.3%) respondents would try to manage their child pati ent's behavior and this is signifi cantly so among the younger age groups and recent graduates (p=0.04 and 0.03 respecti vely) ( Table 5). Majority (64.3%) rated their skill at managing diffi cult behavior as 'fair', irrespecti ve of gender, age group and number of years post graduati on ( Table 6).

Age of child Convenience of denti s Availability of faciliti es
Acceptability to parent

DISCUSSION
The majority of respondents who parti cipated in this study att ended to children in their practi ces. There are less than 20 qualifi ed practi cing pediatric denti sts in Nigeria (Nigerian Associati on of Paediatric Denti stry, NAPD, unpublished data, 2008), therefore most general denti sts would also att end to child pati ents. Most of the respondents rated most of the child pati ents they had att ended to as cooperati ve irrespecti ve of gender and age group. Usually, with the basic BMT, almost all child pati ents will be able to receive dental care in the regular dental clinic setti ng. Studies have correlated child dental anxiety and age and reported that most are able to cope with dental situati ons at age 6-7 years 6,7 . It was also reported that as many as 60% of anxious children can be treated by careful treatment planning and the use of behavioral management 8 .
While more females rated their atti tude as tolerant of diffi cult behavior, age group and number of years post graduati on did not infl uence atti tude of respondents in this study. Previous studies have shown female denti sts to be more empathic of fearful child pati ents than the males 4 . However, younger denti sts in this study would prefer to try and manage diffi cult behaviour than refer to another denti st compared with older denti sts, irrespecti ve of gender. This fi nding is similar to that of other authors which reported that younger groups of denti sts tended to be more frequent users of behavioral strategies indicati ng changing educati onal background 4 . It was reported that changes in the undergraduate course play a role in shaping behavioral practi ces.
In this study many of the respondents rated their skill at managing diffi cult behavior as fair. In Nigeria, behavior management of child pati ents occupy a whole series of lectures which is widely taught in the undergraduate curriculum in pedodonti cs. Improvement in teaching and exposure to advanced behavior management techniques will improve practi ti oner's skill and confi dence to manage diffi cult behavior.
The most widely used BMT among respondents in this study was "Tell-show-do", practi ced by more than 70%, while the least practi ced was Hand-overmouth exercise (HOME) and general anesthesia. This fi nding is similar to that reported on pediatric denti sts in the United Kingdom 9,10 . It was reported that very few pediatric denti sts endorse or use HOME and restraint as techniques for the control of non-cooperati ve children. The use of restraint was seen as appropriate only for use on certain populati ons such as those with physical and mental disabiliti es and the elderly 9 . It was observed from this study that none of the respondents used audiovisual aids to manage diffi cult behavior. This may be due to non availability of audiovisual faciliti es in most clinics. Two types of model are recognized -live and symbolic models. In live modeling, the child watches sibling, parent or peer receive treatment, while in symbolic modeling, the model is a puppet or video which is shown undergoing treatment 11 . Both live and symbolic models may be useful to encourage the child to adopt acti vely the coping strategies and non anxious behavior exhibited by the models 12 . The effi cacy of the diff erent modeling interventi ons is infl uenced by the previous dental treatment experiences of the child 13 . The choice of technique by the denti st will therefore depend on the individual child, the procedure to be carried out and clinic situati on.
The age of the pati ent had the greatest infl uence on the choice of BMT of respondents in this study. Only 18.8% considered the parents' acceptability of their choice of technique However, the decision about the treatment the pati ent will undergo is not up to the denti st alone 14 . It is essenti al to reach a consensus with the child's family and clarify the advantages, disadvantages and possible risks to the pati ent before the procedure 15,16 .
Some authors have reported that majority of parents favored TSD, positi ve reinforcement, voice control and mouth props over physical restraint, sedati on and HOME with the least acceptable methods being general anesthesia and papoose board 17 . Some other parents did not view papoose board and HOME as justi fi able in the management of their children 18 . In Saudi Arabia, parental separati on, physical restraint, HOME and voice control were least acceptable by parents 1 . As expected, the most acceptable techniques are those which expose the pati ent to less risk. Establishing a dialogue with the parents is the fi rst step towards a good relati onship between the health care professional and the pati ent and family 15 . Dental fear and anxiety contribute to diffi cult behavior and may prevent a child from receiving care or completi ng a dental procedure. This may negati vely aff ect a child's oral health related quality of life, social and emoti onal well being 19 . Provision of bett er faciliti es and support staff may increase the use of more advanced techniques which will make dental treatment more acceptable to child pati ents. So also is good psychological understanding and care for child pati ents, eff ecti ve BMT and an empathic atti tude and atmosphere which would form the basis for successful dental treatment for all child pati ents 20 .

CONCLUSION ACKNOWLEDGEMENT
It is concluded that most respondents in this study favored TSD, positi ve reinforcement, modeling and desensiti zati on over restraint, HOME, sedati on and general anesthesia. The age of the pati ent was also a major factor in the choice of technique.