Restraint in paediatric dentistry: a qualitative study to explore perspectives among public, non-specialist dentists in Norway

A Randomized Cross-over Trial of Behavior Guidance Techniques on Children with Special Needs during Dental Treatment: The Caregivers' Perceived Mannerisms

Aim

To compare caregivers' acceptance, consent, and concern toward utilization of a combination of basic behavior guidance technique (CBBGT) and Papoose Board (PB) for their special needs children and to evaluate the impact of PB usage on the caregiver's attitude and the association between their education level, monthly household income, and previous dental experience.

Materials and Methods

This cross-over study incorporated 90 special needs children who were recruited to receive dental treatment with two ways of behavior guidance exposures consecutively in the order of A-B/B-A design. Exposure A is CBBGT (distraction, tell-show-do, and positive reinforcement), while Exposure B is PB. The dental procedures were either dental prophylaxis or restoration with a handpiece. Caregivers need to answer a paper-based questionnaire before and after exposure. The Wilcoxon sign rank test and logistic regression were utilized in order to establish the comparability, impacts, and association.

Result

About 88 caregivers of special needs children aged between 2 and 15 years completed the sequence. Overall, 98.9% of the children presented with neurodevelopmental disorders. Twenty-seven caregivers were significantly concerned when the combination of basic BGT was applied to their children, and 14 caregivers felt the same for PB. However, the Wilcoxon sign rank test revealed insignificant caregiver scores on acceptance and consent for both methods but significantly improved attitudes towards the use of PB after observing the placement of their children.

Conclusion

The studied caregiver demonstrated equivalent acceptance, consent, and concern toward the use of PB and a combination of basic BGT with improved attitudes after comprehensive explanation and real-time observation of PB usage during their children's dental treatment.

Non-pharmacological Behavior Management Techniques in Pediatric Dentistry: A Bibliometric Analysis

As an emerging trend, non-pharmacological behavior management has gained immense research interest. By utilizing a bibliometric approach, this investigation aims to review the state of the non-pharmacological behavior management techniques research in pediatric dentistry. A Scopus search was done on non-pharmacological behavior management in pediatric dentistry, including literature from 1900 to 2022, using "Cited Reference Search" on 4/2/2022. After being screened, the articles were ranked according to the number of citations they had, and the publication year, authorship, contributing institutions, countries, article topic, study design, H index, and keywords were extracted. Out of the 1431 articles found during the literature search, the top 50 cited articles were used for analysis. The citation counts of the 50 selected articles varied from 163 to one, and their highest publications were in the years 2017 and 2019 (n = 7). Most studies were published in the United Kingdom (n = 10). The studies done in Australia and USA have the highest mean citation with the most significant contributions from the Department of Dental Medicine, Children's Hospital, Regional Medical Center, USA. The systematic review was the most frequent study design (n = 19). Among 110 unique keywords, dental anxiety (n = 11) was the most frequently used. This bibliometric analysis offers valuable details on the top 50 publications cited between 2006 and 2022. Although these methods have been employed for many years, only recently have they been the subject of significant scientific publications. It is hoped that this study will enable aspiring and seasoned researchers to envision and create potential future scenarios for interdisciplinary research collaborations on the use of non-pharmacological behavior management techniques in pediatric dentistry.

Necessity and relevance of qualitative research in pediatric dentistry. A literature review

Objectives

This review aims to understand the essence and relevance of qualitative research in pediatric dentistry and summarizes the most important information needed for a pediatric dentist before conducting a qualitative study.

Methods

An electronic search was conducted on studies published from December 2019 until December 2021 using PubMed, Scopus, and King Abdulaziz University Digital library. Several keywords were used to identify the studies for this review.

Results

Thirty-three studies involving qualitative methods in pediatric dentistry have been conducted on parents and dentists. Qualitative studies in pediatric dentistry are used to explore the perceptions of mothers and their children and to understand their behavior in different areas related to pediatric dentistry. Barriers to conducting qualitative studies with children include credibility, the influence of others on children's opinions, and differences that influence children's behavior while conducting the study.

Conclusion

Qualitative methods in pediatric dentistry have been conducted on parents and dentists; however, little is known about the credibility and trustworthiness of conducting qualitative research with children. Future studies are needed to investigate effective interview techniques with children and more research should be conducted to evaluate the credibility and trustfulness of using children as a source to collect data in qualitative research.

A Randomised Crossover Trial of Behaviour Guidance Techniques on Children with Special Health Care Needs during Dental Treatment: The Physiological Variations

Passive immobilisation is regarded as able to potentially cause physical distress and intense anxiety manifestations. The study aims to investigate the physiological variations of children with special health care needs while using a Papoose board and a combination of basic behaviour guidance during dental treatment. This is a randomised crossover trial involving 90 children with special health care needs receiving standard dental care with two methods of behaviour guidance sequentially. Exposure A is a combination of tell-show-do, distraction, and positive reinforcement, while exposure B is passive immobilisation with a Papoose board. The subject child’s blood pressure, heart rate, and oxygen saturation level were measured at four different times during dental treatment. In total, 74 children’s physiological data were successfully collected with a mean age of 9.85 years (SD = 2.71). Further, 64.9% of the children were diagnosed with autism spectrum disorder, 12.2% with attention deficit hyperactivity disorder, 9.5% with intellectual disability, 8.1% with Down syndrome, 2.2% with global developmental delay, and 1.1% with dyslexia and cerebral palsy, respectively. The measurement of children’s blood pressure, heart rate, and oxygen saturation level with the application of a Papoose board or a combination of the basic behaviour guidance revealed no significant changes (p > 0.05). The use of a Papoose board is safe and has no discernible influence on the child’s physiological responses.

Held still or pressured to receive dental treatment: self-reported histories of children and adolescents treated by non-specialist dentists in Hordaland, Norway

Aim

This study aimed to estimate the prevalence of a self-reported history of restraint in children and adolescents when receiving dental care by non-specialist dentists and to assess differences in dental fear and anxiety (DFA), intra-oral injection fear, and trust in dentists between patients with and without a self-reported history of restraint.

Methods

An electronic cross-sectional survey was distributed to all 9 years old (n = 6686) and 17 years old (n = 6327) in the Public Dental Service in Hordaland County, Norway, in 2019. For statistical evaluation, we generated descriptive statistics and Mann–Whitney U tests.

Results

The response rate ranged between 43.5 and 59.9% for the different questions. The prevalence of a self-reported history of being held still against one’s will during dental treatment and pressured to undergo dental treatment against one’s will was 3.6% and 5.1%, respectively. In general, these patients reported higher DFA, and higher intra-oral injection fear compared with those without such histories of restraint. Patients who had reported being held still against their will during dental treatment had significantly higher distrust in dentists than those who did not report restraint (p < 0.001).

Conclusion

To feel pressured to receive dental treatment and to be held still against one’s will overlap with the concepts of psychological and physical restraint. Patients with a self-reported history of restraint recorded significant differences in DFA, intra-oral injection fear, and trust in dentists compared to those who did not report restraint. Future studies should explore the role that restraint may play in relation to a patient’s DFA, intra-oral injection fear, and trust in dentists.

Patient-self-reported history of restraint among 17-year-olds: a retrospective study of records by non-specialist dentists in the public dental service in Hordaland, Norway

PURPOSE

The primary purposes were to examine dental records of Norwegian adolescents' with and without self-reported history of restraint for information about oral health (DMFT), total scheduled time in the Public Dental Service (PDS) (dental appointments, cancelled and missed appointments), and reluctant behaviour and/or dental fear and anxiety (DFA). Another purpose was to explore their dental records for information recorded by the dentist concerning the use of restraint.

METHODS

Data on patient-self-reported history of restraint and DFA were collected in a population-based cross-sectional survey of 17-year-olds in the PDS in Hordaland, Norway, 2019. Patients were divided into two groups: self-reported restraint group (N1 = 26) and self-reported non-restraint group (N2 = 200). Data on oral health and dental treatment, total scheduled time of the PDS, reluctant behaviour or DFA, and information on the use of restraint were extracted from the dental records written by non-specialist dentists using a pre-set protocol covering the period from 2002 to 2019.

RESULTS

A total of 206 dental records were analysed. Adolescents with self-reported history of restraint (n1 = 18) had higher DMFT and greater descriptions of reluctant behaviour and/or DFA, and total scheduled time compared with the self-reported non-restraint group (n2 = 188). The use of restraint was recorded in the dental records of one patient from the self-reported restraint group and in two patients from the self-reported non-restraint group.

CONCLUSIONS

The adolescents with self-reported history of restraint had higher DMFT, higher scheduled time attending the PDS, and had more descriptions of reluctant behaviour and/or signs of DFA compared with the self-reported non-restraint group. The patient records contained limited information concerning restraint, and there were significant discrepancies between patient-self-reported history of restraint and the recording of restraint by the dentist in the patients' records.

Physical Constraint in Pediatric Dentistry: The Lived Experience of Parents

Background:

The use of physical constraint in pediatric dentistry is highly controversial. Papoose boards in particular, which envelop and immobilize children during treatment procedures, have been described as barbaric devices even though their goal is to protect the patient. In this debate, the voice of parents is important but still missing in the scientific literature.

Aim:

To understand how parents or caregivers experienced physical constraint and the use of the papoose board on their children during regular dental treatment.

Design:

We conducted qualitative research rooted in interpretive phenomenology. Accordingly, we performed in-depth individual interviews with a purposive sample of 7 parents or caregivers. The interviews took place in Montréal, Canada, after the children had been treated with a papoose board for nonemergency dental treatments. The discussions were audio recorded, transcribed, and thematically analyzed.

Results:

Two perspectives emerged among participants. Some explained that the papoose board calmed their children, helped the dentist to complete the procedures, and made their experience less stressful. For others, the papoose board was a horrible and traumatizing experience, leading to feelings of guilt toward their children. They expressed anger toward the dentists for not allowing them enough time to decide and for imposing use of the device.

Conclusion

Our study raises serious ethical concerns about this practice. We believe that using a papoose board should remain an extraordinary measure and, more generally, that dental professionals should reflect on the place of children and their families in clinical encounters.

Knowledge Transfer Statement:

The findings of this study should encourage policy makers, dental professionals and ethicists to consider the following points: 1) the traumatizing experiences described by parents raise serious ethical concerns about the use of papoose boards; 2) the dental profession should reflect on the place of children and their families in the clinical encounter and grapple with the importance of consent and how to ensure consent in encounters involving children and their parents.

Sedation versus protective stabilization for dental treatment of children with caries and challenging behavior at the dentist (CHOOSE): a study protocol for a non-randomized clinical trial

BACKGROUND

There is a lack of evidence on the effectiveness of moderate sedation in pediatric dentistry, compared to protective stabilization, which remains routinely used in Brazil despite moral questions. This prospective non-randomized clinical trial's objective is to evaluate the effectiveness of moderate sedation, compared to the protective stabilization, in the dental care of children with dental behavior management problems.

METHODS

Participants will be 152 children under seven years of age with early childhood caries (ECC) who need specialized dental treatment due to a history of challenging behavior during dental care. The interventions to be compared are moderate sedation with oral administration of ketamine and midazolam and protective stabilization. The primary endpoint will be the child's behavior during treatment assessed using the Ohio State University Behavioral Rating Scale (OSUBRS). The secondary outcomes are (A) child's - behavior according to the visual analogue scale, anxiety, pain, and physiological stress; (B) parent's - satisfaction and anxiety; (C) family and child - impact on oral health-related quality of life (OHRQoL); (D) dentist's - satisfaction and stress; (E) procedure - adverse events of the intervention and dental treatment longevity. A cost-effectiveness analysis will be performed from the perspective of the Brazilian Unified Health System (SUS).

DISCUSSION

Considering the primary outcome, this study hypothesis is that sedated children have better behavior during dental treatment than children whose behavior was managed by protective stabilization without sedation. Additionally, at the end of 12 months, we expect to identify participants' reported outcomes and objective measures related to dental behavior in early childhood. Trial registration Clinicaltrials.gov registration NCT04119180 on October 8th, 2019. https://clinicaltrials.gov/ct2/show/NCT04119180.