Parental Presence/Absence During the Treatment of a Pediatric Dental Patient

Julie Maniate DMD, FRCD(C), ABPD

November 7, 2010

Dental Fear
Handicapping complication, stress

1. Determine prevalence 2. Tools to diagnose presence & severity 3. Tools to measure treatment need & success of therapy1

Behavioural Rating Scale

Frankl Scale (1962)1
1. Definitely Negative: Child completely uncooperative,
crying, very difficult to make progress

2. Negative: Child uncooperative, very reluctant to

listen/respond to Qs, some progress possible

3. Positive: Child cooperative, somewhat reluctant/shy 4. Definitely Positive: Child completely cooperative and even
enjoys the experience

History
Focus: parent presence in operatory

18982:
parents be excluded

19583:
parent presence/absence did not affect patients response

History
19624:
age 41-49 mths: most negative behaviour when separated Age 50-66mths: no significant differences in behaviour

History
Focus: relationship b/w level of parental anxiety and patient behaviour 19835: 75% responding dentists restricted parents from operatory Dental schools: taught exclusion of parents

For Exclusion
1. Parent distracts

2. Parental anxiety 3. Uncomfortable for practitioner

For Exclusion
Psychological journals6-9
Parent-child separation issue Found:
presence of parent has favorable effect on children child feeling of security and improved coping behaviour

Conclusions contrast sharply with dental literature.

For Exclusion
Question:

Could the separation itself have caused the undesirable behavioural changes?

For Exclusion
197710:
Study of behavioural effect of parental presence & absence over series of appts N=98
2 groups: parent present or parent absent

Group category switched for 2nd appt Conclusion: no significant differences

For Exclusion
197811:
Study of behavioural effect of parental presence & absence over series of appts Allowed parent & child to choose group Conclusion: parent presence resulted in children being more relaxed

For Exclusion
198212:
Parent-child separation randomly assigned Conclusion: no significant difference

For Exclusion
199313:
No significant difference between patients separated from parents and those who remained for treatment Slight increased frequency of negative behaviour in separated group

For Inclusion
1. Studies show no significant difference in patient behaviour 2. Separation can increase stress 3. Parents concerns can be alleviated

4. Opportunity for parent to witness childs actual behaviour14

For Inclusion

Child

Dentist

Parent

For Inclusion
Association for the Care of Childrens Health (ACCH)15
Advocate/promote parental involvement in health care setting

Pediatric medical practice

Parents rarely excluded from observing & participating in care of child

For Inclusion
198916:
Surveyed pediatric dentists:
60%: parent welcome for initial exam 34%: allow parent during treatment visits

Increasing (slight) trend toward accepting and inviting parents to be present. Still no general consensus.

For Inclusion

Child

Dentist

Parent

Practitioner Attitude/Perception
Good behavioural management techniques essential Good rapport between dentist and child shown to influence success of treatment

Practitioner Attitude/Perception
2002 (Crossley & Joshi)17:
Survey: 245 pediatric dentists
Attitudes toward parental accompaniment Attitudes regarding parental expectations Attitudes toward use of different child mgmt techniques

Results/Conclusion
80% supported parental accompaniment Minority felt pressured by parental expectations 87% favoured tell-show-do method of beh. mgmt.

Parents Attitude/Perception
1998 (Peretz & Zadik)18:
Survey: 104 adults
Sociodemographic information Parent preference re. staying with child Willingness to assist dentist

Results/Conclusion:
No sociodemographic variable 70% expressed wish to be present in operatory 58% willing to assist dentist

Parental Presence/Absence (PPA) Technique

2009 (Kotsanos et al.)19:
Prospective study: 33 mths
440 children, ages 3 to 10 Frankl 1 or 2 behaviour--offered parental presence only if cooperative/parent stepped out until behaviour improved

Results/Conclusion:
93% responded to PPA technique by displaying positive behaviour as first visit progressed All children cooperated in subsequent appts

Summary
Parent:
be with children in operatory during dental treatment, assist when needed

Dentist:
develop strategies that include parent

Possible Strategies
1. 2. 3. 4. 5. 6.

Est. office policy that invites/encourages parent Train office staff Place an observation chair Learn to talk with both child & parent Discuss behaviour mgmt techniques with parents Establish rules of conduct for parent
silent observer

Conclusion

Including the parent in the operatory can be a very rewarding experience for the dentist who treats children, and can help build trust and understanding with the families of our children.20

References
1. 2. 3. Folyan MO, Kolawol KA. A critical appraisal of the use of tools for assessing dental fear in children. Afr J Oral H 2004; 1:54-63. Belcher D. Exclusion of parents form the operating room. Brit J Dent Sci 1898; 41:1117. Lewis TN, Law BB. Investigation of certain autonomic responses of children to a specific dental stress. JADA 1958; 57:769-777. Frankl S, Shiere F, Fogels H. Should the parent remain with the child in the dental operatory? J Dent Child, 2nd Quarter 1962;29:150-163. Glasrud PH. Dentists attitudes toward preschool patients. J Dent Res 1983; 62:234. Shirley M, Poyntz L. The influence of separation from the mother on childrens emotional responses. J Psychol 1941: 12:251-282. Arsenian JM. Young children in an insecure situation. J Abn & Soc Psychol 1943; 38: 225-229. Yarrow LJ. Separation from parents during early childhood. In Hoffmann ML and Hoffmann LW ed.: Review of child development research. Vol1, Russell Sage Foundation, New York 1964. Amorso D, Walters RH. Effects of anxiety and socially mediated anxiety reduction on pairedassociate learning. J Personal & Soc Psychol 1969; 11:388-396. Venham LL, Bengston D, Cipes M. Pre-school childs response to sequential dental visits. J. Dent Res 1977; 56:454-459. Venham LL Bengston D, Cipes M. Parents presence and the childs response to dental stress. J Dent Child 1978; 45:213-217.

4.
5. 6. 7. 8. 9. 10. 11.

References
12. Pfefferle JC, Machen JB, Fields HW, Posnick Wr. Child behavior in the dental setting relative to parental presence. Ped Dent 1982; 4:311-316. 13. Fenlon WL, Dobbs AR, Curzon MEJ. Parental presence during treatment of the child patient: A study with british parents. Brit Dnet J 1993; 174:23-28. 14. Weinstein P, Nathan JE. The challenge of fearful and phobic children. Dent Clin North Amer 1988; 32:667-692. 15. ACCH: Position Statement on Involvement of Parents and Families in Health Care Settings. Washington, DC, 1978. 16. Nathan JE. Management of the difficult child: A survey of pediatric dentists use of restraints, sedation and general anesthesia. J Dent Child 1989; 56:293-301. 17. Crossley ML, Joshi G. An investigation of paediatric dentists attitudes toward parental accompaniment and behavioural management techniques in the UK. Br Dent J 2002; 192:517521. 18. Peretz B, Zadik D. Attitudes of parents towards their presence in the operatory during dental treatments to their children. J Clin Pediatr Dent 1998; 23:27-30. 19. Kotsanos N, Coolidge T, Velonis D, Arapostathis KN. A form of parental presence/absence (PPA) technique for the child patient with dental behaviour management problems. Eur Arch Paediatr Dent 2009; 10:90-2. 20. Certo MA, Bernat JE. Parents in the operatory. NY State Dent J 1995; 61:34-38.