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Patient Education and Counseling 85 (2011) 413

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Patient Education and Counseling


journal homepage: www.elsevier.com/locate/pateducou

Review

Systematic review of the effect of dental staff behaviour on child dental patient anxiety and behaviour
Yuefang Zhou a,*, Elaine Cameron b, Gillian Forbes a, Gerry Humphris a
a b

Bute Medical School, University of St Andrews, UK Birmingham Childrens Hospital NHS Foundation Trust, UK

A R T I C L E I N F O

A B S T R A C T

Article history: Received 19 April 2010 Received in revised form 6 July 2010 Accepted 3 August 2010 Keywords: Dentist Children Behaviour Dental anxiety

Objectives: To review the literature, of the past 30 years, on the effects of dental staff behaviour on the anxiety and behaviour of child dental patients; especially to determine staff behaviours that reduce anxiety and encourage cooperation of children. Methods: A systematic literature review was conducted using PubMed, Web of Science, The Cochrane Library, PsycINFO, Embase and CINAHL. Results: Initial search returned 31 publications of which 11 fullled the criteria for review. Among seven studies that measured anxiety, four used validated measures. Five observational studies coded behaviour using Weinstein et al.s (1982) coding scheme [1]. An empathic working style and appropriate level of physical contact accompanied by verbal reassurance was found to reduce fear-related behaviours in children. Findings regarding positive reinforcement and dentists experience increasing cooperative behaviour were inconsistent. Conclusions: Measures for anxiety and behaviour varied across studies. Relationships between certain dental staff behaviours and child anxiety/behaviour were reported. However, limited work was identied and research using improved sampling, measurement and statistical approach is required. Practice implications: Understanding what routine clinical behaviour of dental staff affects childrens dental anxiety/behaviour will inform investigators of how children comply and help staff be aware the signicance of their daily behaviour on treatment success. 2010 Elsevier Ireland Ltd. All rights reserved.

1. Introduction It is widely accepted in the area of paediatric dentistry that childrens dental fear and anxiety (DFA) and dental behavioural management problems (DBMP) often create barriers to successful treatment [2]. A recent review [3] referred to DFA as strong negative feelings associated with dental treatment and DBMP as a collective term for uncooperative and disruptive behaviours in a dental situation. The review suggested that DFA and DBMP each affects approximately 9% of the child and adolescent population although the relationship between DFA and DBMP is not always consistent [47]. There is considerable interest in how to reduce child dental anxiety. Dentists are generally discouraged from using sedative drugs to achieve compliance in dentally anxious children [8];

* Corresponding author at: School of Medicine, University of St Andrews, North Haugh, St Andrews, Fife, KY16 9TF, Scotland, UK. Tel.: +44 1334 463564; fax: +44 1334 467470. E-mail address: yz10@st-andrews.ac.uk (Y. Zhou). 0738-3991/$ see front matter 2010 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.pec.2010.08.002

hence research has explored potential risk factors for development of DFA/DBMP. The origins of DFA/DBMP are likely to be multifactorial [3], including general fear, negative dental experience, temperament and parental dental anxiety [9]. Research has emphasized the investigation of acceptability [10], effectiveness [11] and attitude [12] towards different behavioural management techniques with regard to types and outcomes of treatment. Paediatric dentists in the UK generally favour less restraining methods of behavioural management, such as voice control and dentists spending time with children in the waiting room prior to treatment [13]. The tell-show-do method is favoured although dentists frequently resort to general clinical rather than formal behavioural management techniques to gain childrens cooperation. Understanding dentists dental practice behaviour is vital for investigators to learn how children may accept treatment without formal intervention. Little attention has been directed at examining the effects of dental staff behaviour that occur during routine clinical practice on anxiety and behaviour of the dental child patient. It is, therefore, important to examine the relevant literature of how children react to clinical behaviour without special formal intervention. In addition, a knowledge of those

Y. Zhou et al. / Patient Education and Counseling 85 (2011) 413

dentists routine behaviours that reduce child anxiety and disruptive behaviour can construct new complex interventions [14] to ultimately enhance treatment outcomes. Accordingly, the aim of this review was to examine the recent literature on the effects of dental staff behaviour and experience on the anxiety and behaviour of child dental patients. Specic objectives were to (a) identify the literature in this area over the past 30 years; (b) report publication patterns, quantity and quality of studies especially including measurement issues and analytic techniques; (c) determine specic staff behaviours that reduce anxiety and encourage cooperative behaviours of children.

2. Methods 2.1. Search strategy A systematic review was conducted between April and May 2008 using the terms shown in Table 1. Six electronic databases were searched: PubMed, Web of Science, The Cochrane Library, PsycINFO, Embase and CINAHL. To ensure completeness, functional search characters were used to search for word variations, for example, behavi*r returned results that included both behaviour and the American spelling behavior. Similarly, dent* was used to obtain results containing dentist, dentists and dental. A database of the rst search results was created into which subsequent database search results were entered and duplicate entries removed. An updated search took place in January 2010 within the six databases and was followed by hand search in Google Scholar. 2.2. Inclusion criteria
Table 1 Databases and terms used for literature search. Database PubMed Search Terms Dentist AND child AND behaviour Dentist AND child AND dental anxiety Paediatric dentistry AND dentistpatient relations Paediatric dentistry AND behaviour Dentistpatient relations AND child Dental assistants AND child AND behaviour Dental assistants AND paediatric dentistry Dental assistants AND dentistpatient relations Child AND behaviour AND dental anxiety Dental auxiliaries AND child AND behaviour Dental auxiliaries AND paediatric dentistry Dental hygienists AND paediatric dentistry Dental hygienists AND child AND behaviour Dentist* child* behavi$r* P*diatric dent* behavi$r* Child* dent* anxiety behavi$r* Dentistry AND child behaviour (MeSH terms) Dentistpatient relations (MeSH terms) Child behaviour AND dental anxiety (MeSH terms) Dentist* child* behavi*r P*diatric dent* behavi*r Child* dent* anxiety behavi*r Dentist child behavi*r Child dental anxiety behavi*r P*diatric dentist behavi*r Dentist child behaviour Dentist child behavior Child dental anxiety behaviour Child dental anxiety behavior Dentist child behaviour Dentist child behavior Child dental anxiety behaviour Child dental anxiety behavior Dentistpatient relations child behaviour Dentistpatient relations child behavior

 Abstract was available in English.  A substantial proportion (>50%) of children were aged 312 years. These are the approximate ages when the majority of problem behaviours during treatment occur. Furthermore, children beyond this age range might experience different causes of treatment anxiety (e.g., orthodontics) and associated management (e.g., habituation of dental environment from regular attendance to attend to orthodontic appliance and orthodontists). Thus, their behaviour in response to that of the dentist would have been signicantly different to our group of interest and were excluded from the review.  Children undergoing a dental check-up or treatment which did not involve any type of sedative or behaviour-altering medication.  Observed or manipulated behaviour of a dental professional (including dentists, dental assistants and dental hygienists).  Dental staff behaviour associated to the behaviour and/or anxiety level of child patients during a dental procedure.  Studies published from 1980 onwards. 2.3. Exclusion criteria  Standard behaviour management technique or package (e.g., tell-show-do).  Complex intervention that involved several components. 2.4. Procedure Initial selection was based on the titles and abstracts of the studies obtained. Whenever fulllment of these criteria was not clear from the abstract, a full text of the study was obtained for verication. Two of the authors iteratively applied inclusion and exclusion criteria, resolving disagreements through discussion with the remaining authors. Study authors were not contacted for additional information. 2.5. Data extraction categories Full text copies of the nal studies for review were obtained. Data were then extracted from the articles as follows:        Year of publication Journal title Country where study was conducted Main study objectives Context: type of dental procedure and number of sessions observed Child characteristics: age, previous dental experience, expected level of anxiety or expected behaviours prior to treatment Dental staff characteristics: professional status (e.g., paediatric dentist, dental assistant) and level of experience in treating dentally anxious children Child outcome measures: levels of anxiety and behaviour during and/or after treatment Dental staff outcome measures: staff behaviour or reports on behavioural intervention (not complex intervention) during a dental procedure Main analysis techniques Key study ndings

Web of Science

The Cochrane Library

 

PsycINFO

Embase

 

CINAHL

3. Results The data extraction results from the studies reviewed, according to the categories described in Section 2, are presented in Tables 2 and 3.

Table 2 Overview of the studies included in the review. Ref. [1] USA OB Aim Effect of dentists behaviour on fearrelated behaviour in children Analysis Lag sequential Context Injection; 1 dentist treat 2 children for 2 or 2+ sessions per child; private practice Child No/age 50; 35 years Staff No 25 volunteer practitioners (22 GP & 3 pedodontists) Child measurea Dentist report on expected child behaviour; child treatment behaviour video recorded & coded (movement, verbal behaviour & comfort) Child treatment behaviour video recorded & classied using the modied Flanders system (MFS) (talk-response, movement-response, talk-initiated, movementinitiated & cooperative ongoing treatment) Assistant report on expected child behaviour; child treatment behaviour video recorded & coded using Weinstein et al. (1982) coding scheme Staff measureb Dentist self-report on condence & experience; dentist behaviour video recorded & coded (guidance, empathy, physical contact & verbalization) Dentist behaviour video recorded & classied using MFS (accept feelings, ask questions, praise/encourage, give information, give direction, criticize & cooperative ongoing treatment) Assistant self-report on condence & experience; assistant behaviour video recorded & coded using Weinstein et al. (1982) coding scheme Key ndings Direction#* reinforcement# patting/ stroking# explanations! reassurances! coercion" coaxing" putdowns" stopping treatment" ** (p 0.05) Dentists empathic style signicantly positively correlated to cooperative behaviour in patients (p 0.05) Y. Zhou et al. / Patient Education and Counseling 85 (2011) 413

[19] USA OB

Relationship between empathic dentists behaviour and childrens cooperation

Correlation tests (Spearmans rho)

Rotations in the oral paediatric clinic; middle 2 h of a 4-h clinic

18,440 observations no. not reported; 512 years

100 male Caucasian; 3rd & 4th yr dental students

[20] USA OB

Effects of dental assistants behaviour on childrens behaviour

Lag sequential

Injection; 1 team treat 2 children for 2 or 2+ sessions per child

50, 35 years

30 dental assistants

[22] USA OB

Intra-dentist behavioural variability & its relationship with occurrence of fearrelated behaviour of children

t-test & ANOVA

Children need treatment requiring 2 or 2+ operative sessions

36, 35 years

25 volunteer practitioners (22 GP & 3 pedodontists)

[21] the Netherlands OB

Effects of dentists behaviour on anxious behaviour of child patients

Lag sequential (autocorrelations)

2 treatment sessions: 1st prophylactic, 2nd preparation and restoration of a cavity under local anaesthesia (only 2nd for analysis)

24, 512 years (12 high & 12 low anxious)

6 dentists (3 experienced)

Child treatment behaviour video recorded & classied as fear vs. nonfear-related behaviour (derived from Weinstein et al., 1982 & pre-school observation scale of anxiety); real time coding Anxiety prior to treatment assessed; child behaviour during treatment video recorded & coded (Weinstein et al., 1982 coding scheme modied)

Dentist behaviour video recorded & coded in real time; duration of each behaviour calculated & compared to 2nd session with the same child

Dentist behaviour video recorded & coded (Weinstein et al., 1982 coding scheme modied): guidance (direction), guidance (feedback), empathy, physical contact & verbalization

[23] the Netherlands OB

Child behaviour during treatment in relation to childs dental fear and dentist experience

Log linear, x2 (chi square) & ANOVA

Simple amalgam restoration; 2 treatment sessions: 1st prophylactic, 2nd curative

24, 512 years (12 high & 12 low anxious)

6 dentists (3 experienced)

Anxiety level prior to treatment assessed on a 5point Likert scale; child behaviour during treatment video recorded & coded (Weinstein et al., 1982 coding scheme modied)

Dentist behaviour video recorded & coded (Weinstein et al., 1982 coding scheme modied)

Reinforcement# questioning for feelings# chatting to dentist# dental-orientated communication to dentist/child# patting! reassurances " holding" restraining " (p 0.05) No signicant difference in dentist behaviour between the group of 10% children with the most fear behaviours and the group of 10% with the least fear behaviours (p > 0.05) 22 signicant effects without autocorrelations (22 increased and 7 decreased fearful behaviours in children); only 2 signicant effects with autocorrelations: working contact decreased & no physical contact increased fearful behaviours in children (p 0.05) Children treated by more experienced dentists showed more fear-related behaviours (p 0.05); experienced dentists were more communicative and worked faster

[15] Israel OB (audio)

Effects of dentists communication strategies on childrens anxiety, cooperation, treatment success & mood

Correlation tests (Pearsons r) & ttest

75% invasive & 25% non-invasive procedures

24 (14 boys); 312 years, 2 age group: 35.5 & 5.512

4 dentists (3 females), 2nd-yr residents in paediatric dentistry

Child self-report on an analogue anxiety scale before treatment; observer graded cooperation on a modied Frankls cooperation scale (MFCS) at start, middle and end of treatment; dentist evaluated treatment success; observer evaluated child mood at the end Child self-report on pre- & post-dental treatment anxiety (CFSS-DS-SF); treatment behaviour observed & most dominant ones video recorded & assessed using Venham clinical rating scale (VCRS)

Conversation audio recorded, transcribed & analyzed (unit = sentence); sentences divided into permissive, empathic, personal & common approaches; frequency of each approach computed

[7] Nigeria OB

Effect of dentists experience on childrens behaviour during treatment & effect of dentists behaviour on childrens anxiety after treatment

Correlation tests (Pearsons r), x2 & t-test

Attendance at dental clinic for 1st time care; analysis of one treatment session: examination, scale, polish or tooth extraction

69 (39 boys); 813 years

7 dentists (4 experienced)

Dentist behaviours observed & most dominant ones video recorded & coded using Weinstein et al. (1982) coding scheme

[18] USA EX

Effects of 4 different reinforcement conditions on childrens behaviour, fear & subsequent cooperation (positive reinforcement (PR), punishment, PR+punishment, neutral)

ANOVA, Duncans Multiple Range test & correlation test (Pearsons r)

3 restorative sessions at 1-week intervals

42 (26 boys); 412 years

4 dentists, trained in all 4 management conditions to 86% accuracy

[16] USA EX

Effects of dentists voice control on childrens disruptive and affective behaviour (loud & normal voice)

x2, ANOVA &


ANCOVA

Cavity restoration; university paediatric clinic

40 (23 boys); 3.5-7 years

3 paediatric dentists (2 males)

Expected anxiety: child self-report on CFSSDS + SAM & parent completed maternal anxiety questionnaire; anxiety after treatment: self-report on SAM & dentist/observer rated fearfulness; expected behaviour: parent completed behaviour problem checklist + child development questionnaire & observer rated BPRS; treatment behaviour video recorded & rated (BPRS); dentist observer rated cooperativeness after treatment Pre-treatment: child selfreport on anxiety/feeling (CFSS-DS & SAM); behaviour video recorded & scored (BPRS); dentist rated child fear and cooperation; posttreatment: child selfreport on feelings (SAM)

Use of 4 management conditions during restorative sessions 1&2; other sessions neutral for comparison (initial exam. neutral, restoration 1 & 2 assigned conditions, 3rd treatment session neutral, 6-month followup neutral)

Factors reduced anxiety and increased cooperation: empathic approach, giving sensory information and reasons, giving specic instructions, persuasion, control and assertiveness; positive reinforcement had little impact on childs behaviour (p < 0.05 for sensory & p < 0.001 for all others) Dentists behaviour did not signicantly affect the anxiety level of the child, nor did it affect the childs anxiety-related behaviour; however, the anxiety level of the children decreased signicantly (p < 0.02) after treatment when experienced dentists managed the children compared to inexperienced dentists Punishment resulted in most un-cooperation and highest self-reported fear in children; most susceptible to effects of punishment: older than 7.5 years, with previous dental experience and initially low in fear; criticism led to uncooperativeness (p < 0.05)

Y. Zhou et al. / Patient Education and Counseling 85 (2011) 413

Normal tone vs loud tone; all saw at least one subject each condition; normal or a loud/sudden/rm verbal command delivered to stop childrens disruptive behaviour

Loud voice treatment reduced disruptive behaviour of children during treatment without increasing negative emotional effects (p < 0.004)

8 Touched children (710 years) displayed less dgeting behaviours than no-touch children (p < 0.05); children were touched reported greater pleasure (p < 0.06) and less dominance (p < 0.10) than children not touched after treatment

Y. Zhou et al. / Patient Education and Counseling 85 (2011) 413 OB, observational study; EX, experimental study. a Includes child characteristics (previous dental experience, expected anxiety and behaviour prior to treatment) and outcome measures (level of anxiety and behaviour during and/or after treatment). b Includes dental staff characteristics (professional status and level of experience in treating anxious children with fear-related behaviours) and outcome measures (observed/reported behaviour or reported behavioural intervention). * Increase ("), decrease (#) and ineffectual (!) in fear-related behaviour of children. ** p-Value at the end applies to all ndings unless specied.

3.1. Study characteristics A review of the abstracts and titles returned by the initial search yielded 31 studies for consideration, of which 11 fullled the review criteria. Reasons for exclusion included: inability to obtain the full English text (n = 5), child participants outside specied age range (n = 1), use of nitrous oxide during treatment (n = 1) and the implementation of assessment measures beyond the scope of this review (n = 13). Eight studies reviewed were observational, recording only naturally occurring behaviour of the clinician including one study that audio recorded dentistchild conversation. The other three studies were experimental, that is, some aspects of the clinicians behaviour were manipulated and comparisons tested between experimental and control groups. The constructs manipulated in these studies were non-procedural touch, voice control and the use of positive and negative reinforcement. These simple intervention studies only involved one independent variable with two to four conditions in comparison to a complex intervention where a larger number of independent variables are included. Years of publication ranged from 1982 to 2004, with the majority of the 11 studies conducted prior to 1991 (n = 8). The studies were performed in the USA (n = 7), the Netherlands (n = 2), Israel (n = 1) and Nigeria (n = 1). The most common dental procedure reported was cavity preparation and restoration (n = 4); others included dental examination, tooth extraction or simply requiring an injection. A total of 397 children were observed across 10 of the studies (range 2469 per study). One paper ignored sample size. The number of participating dental staff (total N = 207) in the 11 studies ranged from 2 to 100 (Mean = 19, SD = 28.5). Of these, 67 were dentists in general practice, 15 worked in paediatric dentistry, 100 were dental students and 25 were dental assistants. The results of the review are described under the following seven sections. 3.2. Effects of staff behaviour on child anxiety Five studies [7,1518] reported effects of dental staff behaviour on child dental fear and anxiety. Sarnat et al. [15] audio recorded dentistchild conversation during treatment. Prior to treatment, children reported their level of anxiety. Frequencies of different communication strategies (permissive, personal and empathic) adopted by dentists were counted, which were then correlated with childrens cooperation, fear and mood at the end of treatment. They identied that an empathic communication approach focusing on the childs feelings and physicians attentiveness (e.g., I care how you feel.) and giving clear and specic instructions reduced anxiety and brought about better mood in children. Greenbaum et al. [17] found that children who were reassuringly patted by dentists on their upper arm or shoulder reported greater satisfaction and less dominance after treatment than children who did not receive any reassuring touch. Touch was accompanied by verbal explanation and reassurance. Children reported their dental fear on the dental fear scale (DFS) and their feelings about being at the dentists on the self-assessment mannequin (SAM). At the end of the treatment, children were reassessed using SAM. In 1990, Greenbaum et al. [16] found that a rm and loud voice stopped childrens disruptive behaviour without increasing negative emotional effects. Similar to Greenbaum et al. [17], childrens anxiety level was assessed before and after treatment. Melamed et al. [18] in 1983 found that punishment (verbal statements of criticism for non-compliance) resulted in the highest self-reported fear in children. Again, the difference in childrens anxiety level before and after treatment was measured.

Key ndings Staff measureb Child measurea Staff No Child No/age Analysis Table 2 (Continued ) Aim Ref. Context

[17] USA EX

Effects of dentists reassuring touch on childrens fear & behaviour (touch & not touch)

ANOVA

Paediatric dental clinic: routine dental examination, prophylaxis or uoride treatment

38 (20 boys); 3.5 10 years

2 dentists (1 male)

Child self-report on dental fear: DFS (trait index before treatment); SAM (pre- & post-treatment); behaviour video recorded & rated by observer using BPRS

Touch = pat child on upper arm/shoulder for about 2 s on 2 occasions during examination, plus verbal explanation & assurance; not touch = only verbal explanation & assurance without physical contact

Y. Zhou et al. / Patient Education and Counseling 85 (2011) 413 Table 3 Review results on child/dentist measures. [1] Child Previous dental experience Expected anxiety level Expected behaviour prior to treatment Anxiety during treatment Anxiety after treatment Behaviour during treatment Behaviour after treatment Staff Level of experience Behaviour during treatment Behavioural intervention U U [19] U [20] U U [22] U [21] U? U [23] U U U? U NA [15] U U U [7] U U U U? U NA [18] [16] U? U U? U U U [17] U U U

U U U U U U

U U NA

U NA

U U NA

U NA

U NA

U NA

NA U

NA U

NA U

U = measured and ndings reported; = neither measured nor reported; U? = measured only, ndings not reported; NA = not applicable.

Only one study included in this review [7] reported no signicant correlations between dentist behaviour and childrens anxiety level. Children reported their anxiety level on a short form of the dental subscale of the childrens fear survey schedule (CFSSDS-SF) before and after treatment. 3.3. Effects of staff behaviour on child behaviour The majority (n = 10) of the 11 publications examined the effects of dental staff behaviour on fear-related behaviour of a child dental patient during a dental procedure; two studies specically investigated the effects of staff behaviour on behaviour of children after treatment [16,18]. In general, dental staff behaviours that were found to help reduce fear-related behaviours and encourage childrens cooperation were: giving clear and specic instructions, an empathic communication style and appropriate level of working contact, including verbal reassurance. Restraining and punishment-oriented behaviours were most likely to result in fearful behaviour. Specically, staff behaviours associated with cooperative behaviours in children included: giving clear direction [1], giving specic instruction [15], giving sensory information and reasons [15], an empathic approach [15,19], questioning for feelings [20], chatting to the dentist and dental-oriented communication to dentistchild (in the case of dental assistants) [20] and persuasion [15]. Dentists who showed a good level of control and sense of assertiveness [15] encouraged childrens cooperation. Furthermore, a loud rm voice [16], an appropriate level of working contact [21] and a reassuring touch accompanied by verbal explanation of ongoing procedure and verbal reassurance [17] reduced childrens fearful behaviour. Dental staff behaviours associated with fear-related behaviours in children included coercion, coaxing, putdowns, stopping treatment [1] and holding and restraining [20]. Verbal statements of criticism led to uncooperativeness [18]. Importantly, giving explanations was ineffective in reducing fearful behaviour in children [1]. Inconsistent ndings were obtained for the effect of positive reinforcement in preventing disruptive behaviours. It was effective in reducing fearful behaviours in some studies [1,20], whereas Sarnat et al. [15] found that it had very little impact on childrens behaviour. Other inconsistent ndings were reported for touch-related behaviours (e.g., patting, stroking only) and verbal reassurance only. Patting helped to reduce fearful behaviour in Weinstein et al.s rst study [1], but ineffective in Weinstein et al.s second study [20]. Staff verbal reassurance induced fearful behaviours in children in one study [20] that was not conrmed in another report [1]. Nevertheless, it was evident that children were more likely to

cooperate when an appropriate level of physical touch was combined with verbal reassurance [17]. Two studies reported that dentist behaviour did not affect childrens anxiety-related behaviour [7,22]. Getz et al. [22] found no signicant difference in dentist behaviour between the group of 10% children with the most fearful behaviour and the group of 10% children with the least fearful behaviour. In 2004, Folayan et al. [7] conducted a study with 69 children of 813 years old in Nigeria and found that dentists behaviour and childrens fear-related behaviour were unrelated. 3.4. Effects of dental staff experience on child anxiety and behaviour Two studies assessed dentists level of professional experience but did not relate this to child anxiety and/or behaviour during and/or after treatment [1,20]. Another two studies [7,23] examined specically the association of dental staff experience and child anxiety and/or behaviour during and/or after treatment. In 1987, Prins et al. [23] found that experienced dentists, compared to their less experienced counterparts, were more communicative, worked faster and the children treated showed more fear-related behaviours. The authors explained that, as experienced dentists were more communicative, they might have elicited more expressions of fear through their behaviours. It cannot be concluded, however, that children treated by experienced dentists also subjectively felt more fearful than those treated by inexperienced dentists. In 2004, Folayan et al. [7] reported some positive effect of dental staff experience on child anxiety. They found that the anxiety level of children decreased signicantly after treatment when experienced dentists managed children compared to inexperienced dentists. It is worth noting that the denition for an experienced dentist was different in the last two studies [7,23]. In Prins et al.s [23] study, an experienced dentist was dened as had a working experience of several years with mainly high-anxious children; whereas in Folayan et al.s [7] study, an experienced dentist was dened as had more than six consecutive months exposure (in the management of child dental patients). 3.5. Measures of child behaviour Table 4 presents measures of childrens fearful behaviour before, during and/or after a dental procedure. All 11 studies measured child behaviour during a dental procedure as an outcome variable and two studies also specically examined child fearful behaviour after treatment. Three studies [1,18,20] reported child expected behaviour prior to treatment, two of which were for screening purposes [1,20]. The third study [18] correlated initial disruptive behaviour with amount of disruptiveness during

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Y. Zhou et al. / Patient Education and Counseling 85 (2011) 413

Table 4 Measures of child fearful behaviour before/during/after a dental procedure and staff behaviour during a dental procedure. Ref. [1] Age 35 Child Before: dentist reportquestionnaire During: video recorded & codedWeinstein et al. (1982) coding scheme During: video recorded & classiedthe modied Flanders system (MFS) Before: dental assistant reportquestionnaire During: video recorded & coded in real timeWeinstein et al. (1982) coding scheme During: video recorded & coded in real timecoding scheme derived from the Weinstein et al. (1982) coding scheme During: video recorded & codedWeinstein et al. (1982) coding scheme modied During: video recorded & codedWeinstein et al. (1982) coding scheme modied During: audio recorded & observer gradedmodied Frankls cooperation scale (MFCS) During: video recorded & codedVenham clinical rating scale (VCRS) Before: observer ratedbehavioural prole rating scale (BPRS) Parent reportbehavioural problem checklist Parent reportchild development questionnaire During: video recorded & observer rated (BPRS) After: dentistobserver rated cooperativeness on a 10-point scale During: video recorded & observer scored (BPRS) After: dentist rated cooperativeness on a 7-point scale During: video recorded & observer scored (BPRS) Staff Video recorded & codedWeinstein et al. (1982) coding scheme Video recorded & classiedMFS Video recorded & coded in real timeWeinstein et al. (1982) coding scheme Video recorded & duration and category of behaviour measured and compared Video recorded & codedWeinstein et al. (1982) coding scheme modied Video recorded & codedWeinstein et al. (1982) coding scheme modied Audio recorded & frequency of communication approaches counted/compared Video recorded & codedWeinstein et al. (1982) coding scheme Behavioural intervention reported Inter-coder reliability r = 0.850.94 (child)

[19] [20]

NA 35

r > 0.85 (both intra & inter) (child & staff) Adequatereferred to study [1]

[22]

35

Referred to study [1]

[21] [23] [15]

512 512 312

Not reported (neither child nor staff) K = 0.91 (child & staff) Not reported (MFCS)

[7] [18]

812 412

Not reported (VCRS) Not reported (BPRS)

[16]

3.57

Behavioural intervention reported

[17]

3.510

Behavioural intervention reported

r = 0.840.94 (BPRS) r = 0.72 (staff verbal content) r = 0.880.92 (BPRS)

treatment. All 11 studies video recorded child behaviour except one [15] in which dentistchild conversation was audio recorded. Many of the studies (n = 5) [1,2023] used Weinstein et al.s [1] coding scheme to code child behaviour. Reports on inter-coder reliability of this coding scheme varied considerably, from providing Cohens Kappa and Pearsons r values to limited information being provided (see Table 4 for details). The coding scheme divided childrens behaviour into three categories: movement and physical positioning, verbal behaviour and comfort. Under each category, there were a number of subbehaviours that can be grouped into fear and non-fear behaviours. For example, fear-related behaviours included minor and problem movement (in the movement and physical positioning category), crying (in the verbal behaviour category) and discomfort (in the comfort category). Two studies [20,22] coded child behaviour in real time and two studies [21,23] modied Weinstein et al.s [1] coding scheme, mainly by clarifying specic dentist behaviours. Three studies [1618] used the Melamed behaviour prole rating scale (BPRS [24]) to measure the incidence of childrens disruptive behaviour during a dental procedure. Recorded video tapes were scored by one or two independent raters using BPRS. Inter-rater reliability was reported by two studies: r = 0.840.94 for Greenbaum et al.s study [16] and r = 0.88 to 0.92 for Greenbaum et al.s second study [17]. Melamed et al. [18] did not report inter-rater reliability results. Stave [19] used the modied Flanders system [25] to classify childrens behaviour, which were divided into four categories: patient talk-response, patient movement-response, patient talk-initiated and patient movement-initiated. Cooperative ongoing treatment was common to both children and dentists. Both intra- and inter-coder reliabilities were reported as above 0.85. Folayan et al. [7] used the Venham clinical anxiety rating scale (VCARS [26]) to assess child behaviour. Inter-rater reliability was not reported. Child behaviour after treatment was also assessed in two studies [16,18]. In Melamed et al.s study [18], both the dentist and an observer rated child cooperativeness on a 10-point scale; in

Greenbaum et al.s study [16], only the dentist rated child cooperativeness on a 7-point scale. Neither of these two studies reported details of the scales. In Sarnat et al.s study [15], an outsider observer graded childrens verbal behaviours during treatment on audio recorded transcripts using a modied Frankls cooperation scale (MFCS [27]). Inter-rater reliability and the specic modication to Frankls scale [28] were not reported. Three studies [1,18,20] measured and reported childrens expected disruptive behaviour prior to treatment. In Weinstein et al.s [1,20] studies, dentists or dental assistants completed a questionnaire concerning childrens expected behaviour, which was not explicitly related back to the child outcome variables (anxiety and/or behaviour during/after treatment). Melamed et al. [18] measured childrens disruptive behaviour prior to treatment from both observer (BPRS) and parent (behavioural problem checklist and child development questionnaire). Inter-correlations between these three scales were absent. The authors did, however, link childrens initial degree of disruptive behaviours (BPRS) to disruptiveness during treatment sessions. 3.6. Measures of staff behaviour Measurement instruments for dental staff behaviour are presented in Table 4. Seven studies video recorded staff behaviour, one study audio recorded dentistchild conversation and three studies reported details of behavioural interventions. Five of the seven studies with video recording methods used Weinstein et al.s [1] coding scheme to code dentist behaviour. Dentist behaviours were categorized in this coding scheme into four groups: guidance, empathy, physical contact and verbalization. The other two studies [21,23] modied the coding scheme by splitting the guidance category into two: direction and feedback. Folayan et al. [7] grouped a number of behaviours into the four categories according to the Weinstein et al.s [1] coding scheme. Using the modied Flanders system (MFS), Stave [19] classied dentists behaviours according to six categories: accepts feelings, asks questions,

Y. Zhou et al. / Patient Education and Counseling 85 (2011) 413 Table 5 Measures of child dental fear and anxiety. Ref. [21] Age 512 Scale Unspecied 5-point Likert scale, 1 (not anxious) to 5 (extremely anxious) (scale referred to elsewhere) Unspecied 5-point Likert scale, 1 (not anxious) to 5 (extremely anxious) Unspecied analogue scale, not afraid (1), in the middle (2), very afraid (3) Observer evaluated childs mood at the end CFSS-DS-SF (8 items), 5-point Likert scale with 1 (not anxious) to 5 (extremely anxious) CFSS-DS (modied, 15 items) Self-assessment mannequin rating scale (SAM) Unspecied 10-point scale for fearfulness CFSS-DS (15 items) SAM Unspecied 7-point scale for fear Dental fear scale (DFS), 15 items derived from CFSS-DS SAM Before/after treatment Before Cut off score Referred to elsewhere 45 Administered to whom Unspecied Reliability/validity

11

[23]

512

Before

Unspecied

[15]

312

Before After Before & after Before Before & after After Before Before & after After Before Before & after

NA

Child self-report Observer Child self-report Self-report Self-report Dentist & observer Self-report Self-report Dentist Self-report Self-report

Not reportedgeneral details referred to elsewhere Comparable to other more sophisticated means Not reported

[7] [18]

812 412

19 NA

Not reported Not reported

[16]

3.57

NA

[17]

3.510

NA

Referred to elsewhere (CFSS); varied (SAM) referred to elsewhere r = 0.86 (test-retest for DFS); validity (DFS) elsewhere; validity (SAM) elsewhere

praises or encourages, gives information, gives direction and criticizes. The nal category, cooperative ongoing treatment, was related to both dentists and children. The study in which dentist child conversation was audio recorded [15] calculated the frequency of each of the dentists communication strategies and correlated these with child anxiety, behaviour and treatment success. The three studies [1618] with experimental designs reported details of dentists behavioural interventions. Greenbaum et al. [16] examined the punishing-reinforcing quality of the dentists verbal contents by two independent raters on a 7-point bipolar scale from extremely reinforcing (3) to extremely punishing (+3). Inter-rater reliability was reported as r = 0.72. 3.7. Measures of child dental fear and anxiety Seven studies included in this review reported using either recognized or self-developed scales to measure child dental fear and anxiety. Table 5 presents details of the scales adopted by the studies. Apart from three studies adopting the most widely-known scale, the dental subscale of the childrens fear survey schedule (CFSS [29]; CFSS-DS [30]), the use of the self-assessment mannequin rating scale (SAM [31]) (n = 3) or unspecied scales (n = 4) was another feature of the studies reviewed. The SAM scale measures affect in children in three dimensions of emotion: arousal, pleasure and dominance. Childrens fear was characterized as high arousal, low pleasure and low dominance. The unspecied scales were usually developed as a 5, 7 or 10-point Likert-type scale, rated either by the child, the dentist or an observer. Reports on reliability and validity of these unspecied scales were poor. 3.8. Data analysis approaches The majority of the studies included in this review adopted traditional analysis methods, such as analysis of variance (ANOVA), correlation tests (Pearsons r and Spearmans rho) or Students ttests (see Table 2 for details). Three studies included in this review [1,20,21] implemented lag sequential analyses to evaluate whether childrens behaviours (especially fear-related behaviours) were determined by preceding dental clinicians behaviours. Both child and dental staff behaviour were video recorded and coded using Weinstein et al.s [1] coding scheme in all three studies. In Weinstein et al.s [1] study, the conditional probability of a childs

response behaviour (i.e., the probability that a childs behaviour will occur given the presence of another behaviour occurred simultaneously or previously) was calculated for six preceding time lags in a criterion behaviour (i.e., a dentist inuencing behaviour prior to a child behaviour). The authors argued that a criterion behaviour would lose its inuence on a response behaviour after some time; it was thus reasonable to consider only probabilities of lag 0 to lag 7 in the analyses. Similar analysis techniques were followed with dental assistants in another study [20], this time with only three lags being considered. Horst et al. [21] also implemented similar lag sequential analyses using two lags. This study, however, took an advanced step in that also it controlled for the childs own preceding behaviours. As childrens behaviours were strongly correlated with their own preceding behaviour, lag sequential analyses were conducted when controlling the effects of childrens own behaviour. Once autocorrelations were controlled, the number of dentists behaviours that were signicantly correlated to child behaviour, reduced from 22 to 2. The authors of this study challenged the ndings of the previous lag sequential analysis studies that did not control for the effects of childrens own antecedent behaviours on their present ones. 4. Discussion and conclusion 4.1. Discussion 4.1.1. Study characteristics The ndings from this systematic review suggest that over the past 30 years in paediatric dentistry there have been a limited number of studies (n = 11) that investigated the effects of dental staff behaviour on anxiety and/or behaviour of a child dental patient. The review results have also shown that the majority of studies (n = 7) were conducted in the USA over a 10-year period between 1982 and 1993. Furthermore, no studies in this eld were found in the UK over the last 30 years. Considering the limited number of studies drawn from restricted areas and an extensive time period, the review suggests that we have much to learn in this eld. There is an urgent need for researchers to investigate further how dental health professionals inuence child anxiety and behaviour during and after treatment. The child sample size of the majority (n = 10) of the studies included in the review was between 24 and 50, while the sample

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Y. Zhou et al. / Patient Education and Counseling 85 (2011) 413

size for dental staff varied from 2 to 100. Furthermore, three of the USA and the two Netherlands studies used the same participants though with different foci of investigation indicating nonindependence. None of the studies justied their sample size. In addition, participant recruitment procedures varied considerably. Future researchers in this eld should consider representative sampling, justication of sample size to test associations with sufcient power and recruitment standardization. 4.1.2. Effects of staff behaviour on child anxiety/behaviour Findings conrmed that there were relationships between dental staff behaviour that occurred in a routine clinical practice and the anxiety and/or behaviour of child dental patients. Generally, those staff behaviours that reduced child anxiety, that is, an empathic communication style and appropriate level of physical contact accompanied by verbal explanation and reassurance, were also those that could bring about cooperative behaviours in children. Some staff behaviours (e.g., punishment) that were found to raise child fear also induced uncooperativeness. One important nding was that verbal explanation and instruction only, or physical working contact only, was not the most effective methods when communicating with children of about 312 years old. A rm and loud voice used by a dentist during treatment deterred childrens disruptive behaviour without increasing any negative emotional effect. This technique is obviously useful for inattentive children; however, selective rather than universal use is recommended. Furthermore, there is some evidence that the voice control technique is not acceptable to all parents [10] or clinicians [32]. Future investigation is required with this approach on children of various ages and behavioural or emotional difculties. One study [17] revealed that the emphasis on single elements of staff behaviour may be partially misplaced. An alternative or supplementary approach should explore the effects of combinations of behaviours that may be advantageous to improving child cooperation. Analytical techniques that enable the pairing of discrete codes by chaining or collapsing two coincident codes would enable such a development. An interesting possibility is raised of detecting combined behavioural repertoires, and labelled as strategies to assist the receipt of treatment procedures in children. Staff behaviours associated with cooperation in children did not necessarily reduce childrens anxiety. In future studies, it is worth investigating whether those staff behaviours that impact on child behaviour will also have an effect on child anxiety in the same direction. This will have practical implications for dental health professionals to help them work effectively with young children without jeopardizing their psychological emotions. It will also be useful for researchers to understand the relationship between emotion and behaviour in general and child dental anxiety and dental behavioural management problems in particular. Positive reinforcement inconsistently reduced fear-related behaviours. The two studies that found positive reinforcement to be effective in reducing childrens fearful behaviours were conducted in the USA with 35-year-olds in the 1980s with lag sequential analyses implemented on video recorded and coded data. Little impact of positive reinforcement on child behaviour was found in the Israeli study with 312-year-olds in 2000 using audio recording methods. It is not clear whether child age, country or time of study and/or analysis methods had any inuence on the ndings. It is important to note that dental staff behaviour and childrens anxiety and behaviour might vary considerably among different dental treatments. As the studies reviewed contained several types of dental treatments, caution is warranted to conclude that childrens anxiety and/or behaviour were inuenced by certain staff behaviours. Childrens anxiety and/or behaviour might be affected by a combination of staff behaviour and the nature of treatments. As none of the studies reviewed examined the effects

of staff behaviour on child anxiety and/or behaviour when controlling the effects of the treatment types, future researchers should explore this issue further. 4.1.3. Effects of staff experience on child anxiety and behaviour Two ndings were reported 17 years apart regarding the effects of staff experience on child anxiety and/or behaviour. Experienced dentists elicited more fear-related behaviours in children during dental treatment, while in the longer term, childrens anxiety level decreased when experienced dentists managed them. The denition for the level of staff experience was different in these two studies. The ndings were inconsistent, but not contradictory. In future studies, it is worth considering both short-term and longterm effects of dental staff experience on child anxiety. The level of dental staff experience should be clearly explained. Future research should explore the extent that the experience of dentists contributes to fear-related behaviours in children. 4.1.4. Measures of behaviour and anxiety Measurement instruments used to assess behaviour and anxiety varied. Assessment of behaviour should emphasize the reporting of coder reliabilities. Scale modications require detailed specication. For child dental fear and anxiety measurement, psychometrics for the study sample are recommended. 4.1.5. Analysis approaches The majority of the studies reviewed adopted traditional analysis methods of the data obtained from rating or grading on scales. A reasonable number of studies implemented the lag sequential analysis technique to identify patterns of behaviour of both children and dental staff. The adoption of autocorrelation in the lag sequential analysis was a further advance as the occurrence of certain child behaviour was not only inuenced by staff behaviour but also by the childs own previous behaviour. No study took into account the clustering effect of individual staff and their possible inuence on the group of children they treated. The effect may be relevant when more than one staff member is recruited into the study. Attempts to control for clustering should be incorporated into sequential analysis, such as multilevel modelling, to take account of some participant-specic variables [33]. 4.2. Conclusion The literature search, although restricted to publications in English, revealed a neglected eld of study. The intensive investigation into the routine clinical repertoire of individual elements of staff behaviour is to be commended. The review conrmed the existence of a relationship between certain dental staff behaviours and child anxiety and/or behaviour in a dental setting. Further systematic work is required to identify those behaviours that have consistent effects on child cooperation. A focus not only on single behavioural elements but also on small combinations of staff behaviours may prove to be fruitful. In addition research is needed to develop consistency in the assessment of child anxiety and also sophisticated and valid behavioural codes. Researchers are encouraged to utilize some of the newly developing statistical methodologies that have become available recently [34,35] to uncover some of the hidden associations that are believed to exist between the subtle interaction of dental personnel and the children they wish to serve. 4.3. Practice implications Understanding whether and how some routine clinical behaviour of dental staff affects childrens dental anxiety and cooperation is essential for investigators to learn how children may comply

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in a dental setting. In addition, identifying daily dental staff behaviours that have consistent effects on childrens cooperation enhances the chances of treatment success and reduces the likelihood of raising anxiety in children attending for dental procedures. Conict of interest statement The authors have no conict of interest that could inappropriately inuence or be perceived to inuence this manuscript. Acknowledgements The authors wish to acknowledge the support of the Childsmile evaluation programme as part of the Scottish governments initiative to improve childrens oral health. We also wish to thank Professor Martin Fischer for his critical reading during the preparation of the manuscript as well as to the two reviewers for their close attention to our article and helpful comments. References
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