CLINICAL AND MATERIALS SCIENCES
Children's Response to Sequential Dental Visits L. VENHAM, D. BENGSTON, and M. CIPES
University of Connecticut Health Center, Farmington, Connecticut 06032, USA Behavioral, self-report, and physiological measures were used to study the response of young children to their initial series of dental visits. Their negative response increased from the examination visit through the third treatment visit, then decreased during the fourth treatment visit and the polish visit. Initially, dental experience appeared to sensitize the child to dental procedures. Experience may also allow the child to accurately distinguish between stressful and nonstressful procedures. The effect of sequential dental visits on the young child's response to the dental situation has received limited study. Frankl et a1l studied the cooperative behavior of children 3 to 5 years old durino a dental exam visit and one subsequent dental treatment visit. They concluded that cooperative behavior increased on the second visit. Oppenheim and Frankl2 found no change in cooperative behavior during an exam visit followed by a dental treatment visit. Koenigsberg and Johnson3'4 studied the cooperative behavior of 3- to 7-year-old children during a dental exam and two subsequent dental treatment visits. They did not find a significant difference in the frequency of uncooperative behavior over the three visits. In contrast, Venham5 reported a significant increase in anxiety and a significant decrease in cooperative behavior on the second of two dental treatment visits for children 3 to 8 years old. This "visit" effect was particularly strong in younger children 3 to 5 years of age. Howitt and Stricker6 measured the heart rate of 8 to 14 year olds during a series of dental visits. They reported the highest heart rate during treatment visits, significantly lower heart rate during the exam visit and the lowest heart rate during the This research was supported by Grant No. R23-DE03891 35-009 from the National Institute of Dental Research. Received for publication June 9, 1975. Accepted for publication August 5, 1976.
454
six-month recall exam visit. A comparison of individual treatment visits was not reported. They concluded that the child's arousal level was reduced as he gained experience with the dental environment and procedures. The purpose of the present study was to examine the response of young children to their initial series of dental visits. A combination of meastsres was used to provide a comprehensive assessment of the child's response and to allow a comparison of the results with previous studies which have used either physiological or behavioral rneasures.
Materials and Methods Twenty-nine preschool children 2 to 5 years old (x = 4 years), with no previous dental experience, were studied. The racial distribution was 11 white and 18 black children, with an equal division between boys and girls. The socioeconomic level of the population was lower middle class.7 Each child had six dental visits: an examination visit, four visits involving restorative treatment, and a final visit to polish the restorations, clean the teeth, and apply topical fluoride. The chiJd's response to each visit was assessed using a combination of four measures: heart rate, ratings of clinical anxiety and cooperative behavior and the picture test. The picture test is a projective self-report measure of anxiety consisting of eight items (page 455). The child was asked to choose the little boy in each picture who feels the most like he feels. The child's score represented the number of times the more anxious member of each pair was chosen. Therefore, the scores may range from 0 to 8. Development of the picture test and reliability and validity data have been reported 8 Ratings of clinical anxiety and cooperative behavior were made by three judges independently viewing the video tapes of the visits.
Vol. 56 No. 5
CHILD'S DENTAL VISITS
5
8
FIG 1.-Picture test.
455
456
VENHAM, BENGSTON,
&
J Dent Res May 1977
CIPES
TABLE 1
CLINICAL ANXIETY RATING SCALE
Relaxed, smiling, willing and able to converse. 1. Uneasy, concerned. During stressful procedure may protest briefly and quietly to indicate discomfort. Hands remain down or partially raised to signal discomfort. Child willing and able to interpret experience as requested. Tense facial expression, may have tears in eyes. 2. Child appears scared. Tone of voice, questions and anwers reflect anxiety. During stressful procedure, verbal protest, quietly crying, hands tense and raised, but not interfering. Child interprets situation with reasonable accuracy and continues to work to cope with anxiety. 3. Shows reluctance to enter situation, difficulty in correctly assessing situational threat. Pronounced verbal protest, crying. Protest out of proportion to threat. Copes with situation with great reluctance. 4. Anxiety interferes with ability to assess situation. General crying not related to treatment. More prominent body movement. Child can be reached through verbal communication and eventually with reluctance and great effort he begins the work of coping with threat. 5. Child out of contact with the reality of the threat. General loud crying, unable to listen to verbal communication, makes no effort to cope with threat, actively involved in escape behavior, physical restraint required. 0.
Since six-point rating scales were used, the ranged from 0 to 5 (Tables 1 and 2) Each judge received several hours of training prior to this study to become familiar with the rating scales used. Correlations between judges' ratings in this study ranged from 0.78 to 0.98. In order to avoid bias, the principal investigator who also provided the dental treatment did not serve as a judge. Development of the rating scales has been reported.5 Heart rate was recorded using a photoscores
electric sensor clipped to the child s finger. Heart rate is a measure of physiological arousal rather than a specific measure of anxiety. The assumption is that an increase in arousal during the dental visit may be attributed to the stress of the dental procedure and therefore is one index of the patient's response to the dental stimuli.
Each visit was divided into three periods corresponding to specific dental procedures. Values were obtained for heart rate, clinical
TABLE 2 COOPERATIVE BEHAVIORAL RATING SCALE
0. Total cooperation, best possible working conditions, no crying or physical protest. 1. Mild, soft verbal protest or quiet crying as a signal of discomfort, but does not obstruct progress. Appropriate behavior for procedure, i.e., slight start at injection, "ow," during drilling if hurting, etc. 2. Protest more prominent and vigorous. Both crying and hand signals. Protest more distracting and troublesome. However, child still complies with requests to cooperate. 3. Protest presents real problem to dentist. Complies with demands reluctantly, requiring extra effort by dentist. 4. Protest disrupts procedure, requires that all of the dentist's attention be directed toward the child's behavior. Compliance eventually achieved after considerable effort by dentist, but without physical restraint. 5. General protest, no compliance or cooperation. Physical restraint is re-
quired.
Vol. 56 No. 5
CHILD'S DENTAL VISITS
457
TABLE 3 ANALYSIS OF VARIANCE FOR PICTURE TEST SCORES Source
df
Subjects Visits
24
422.105
5
44.167 1.512 33.717 .321 3.150
Linear Quadratic Cubic Quartic
1 1 1 1 1
Quintic VXS (Error)
Mean SD
SS
MS
17.588 8.833 1.512 33.717 .312 3.150 5.467 11.556
5.467 1386.660
120
F
1.522
P
NS
NS NS 2.918
Exam
T1
T2
T3
T4
Polish
2.84 1.95
2.68
2.20 2.08
2.52 2.20
2.68 2.27
2.96 2.62
2.03
P > .01.
anxiety, and cooperative behavior during each period. These three values were averaged to produce an average value for the visit. The three periods during the examination and polish visits were the mirror and explorer examination, the prophylaxis, and the application of topical fluoride. Treatment visits were divided into the mirror and explorer examination, the administration of local anesthesia, and the cavity preparation using the dental handpieces. The picture test was administered only once, at the beginning of each visit. When the child arrived for the dental visit, the assistant seated him/her in the dental chair and attached the finger clip. While the physiological equipment was adjusted and a baseline value established, the assistant administered the picture test and obtained an oral hygiene index. At this point, the dentist entered the treatment
room. The first procedure performed by the dentist at each visit was a mirror and explorer examination. The dental procedures that followed depended upon the type of visit. The initial visit included a mirror and explorer examination, prophylaxis, topical fluoride application and radiographs. Needed dental treatinent was provided at subsequent visits following the quadrant approach, using local anesthesia and the rubber dam. The polish visit consisted of a mirror and explorer examination, polishing of restorations, prophylaxis, and topical fluoride application. All dental procedures were performed by the principal author. An analysis of variance for repeated measures was used to test for significant differences in the children's response to the six dental visits. When a significant visit effect was found, a trend analysis was used to establish the best
TABLE 4 ANALYSIS OF VARIANCE FOR CLINICAL ANXIETY RATINGS df
Source
Subjects Visits Linear Quadratic Cubic Quartic Quintic VXS (Error) Mean SD
SS
28 5 1 1 1 1 1 140
MS
80.040 134.32 .9005 128.8185 2.1650 1.6500 .7855 395.40
2.8586 26.865 .9005 128.8185 2.1650 1.6500 .7855 2.8243
F
1.012 9.512 45.611
Exam
T 1
T2
T3
T4
.5117 .8955
1.0914 1.020
1.4145 1.2406
1.4134 .8572
1.3217 1.073
P
NS .01 NS .01 NS NS NS Polish
.5055 .6448
458
VENHAM, BENGSTON, & CIPES
J Dent
Res
May 1977
TABLE 5 ANALYSIS OF VARIANCE FOR COOPERATIVE BEHAVIOR SCORES Source
df
Subjects
28 5 1 1 1 1 1 140
Visits Linear Quadratic Cubic Quartic Quintic VXS (Error) Mean SD
SS
MS
64.7882 109.6175 .0020 103.5410 1.7465 3.2010 1.1265 390.8169
2.3139 21.9235 0020 103.5410 1.7465 3.2010 1.1265 2.7915
Exam
TI
T2
T3
.2931 .7936
.8262 .9744
1.0693 1.2825
1.0228 .7715
model to fit the pattern of change over the six visits. This procedure consisted of a division of the sum of squares for the significant visit effect into a linear, quadratic, cubic, quartic, and quintic component. Each was tested for significance.
F
P
.8289 8.063
NS .01 NS .01 NS NS NS
37.092
Polish
T4
.9934 1.0057
increasingly positive
over
.1955 .5242
the fifth and sixth
v.isits.
Discussion
The only previous study designed to examine the effects of a series of dental visits was reported by Howitt and Stricker6 who concluded that the child's arousal level was reduced as he gained experience in the dental situation. In contrast with the present research, Howitt and Stricker studied older children with previous dental experience. They did not include a polish visit and did not examine individual treatment visits. Tne results of the present study indicate the effect of experience is complex. The selfreport data collected at the beginning of each
Results The results of the analysis of variance for repeated measures are presented in Tables 3-6. No significant differences were found on the picture test. Significant differences were found over the six visits for anxiety, cooperating behavior, and heart rate (P > .01). An examination of the means in each case indicated the response of children became increasingly negative over the first four visits and then became
'LE 6 ANALYSIS OF VARIANCE FOR HEART RATE Source
Subjects Visits Linear Quadratic Cubic Quartic Quintic VXS (Error) Mean SD
df
SS
26 5 1 1 1 1 1 130
14783.5 9887.96 1734.17 7525.96 499.17 9.57 119.09 61778.2
MS
568.598 1977.591 1734.17 7525.96 499.17 9.57 119.09 475.217
F
P
1.197 4.161 3.649 15.837
NS .01 NS .01 NS NS NS
Exam
T1
T2
T3
T4
Polish
87.55 10.88
91.73 12.85
94.82 14.36
98.01 13.63
95.71 12.73
90.52 14.36
Vol. 56 No(. 5
CHILD'S DENTAL VISITS
visit reflected the child's general feeling toward the dental visit. The results of the picture test suggest that children's feelings toward the dental situation were not significantly changed during the series of visits. The other three measures were collected during the dental visits reflecting the child's response to experiences during the visits. The increasingly negative response observed during the examination and first three treatment visits sug;,ests that t.he dental experience sensitized the children to specific dental procedures. The improvement in their response during the last two X isits suggests the experience gained during the preceding visits eventually helped the child to recognize the nonthreatening aspects of the visits and to cope with stressful dental procedures. Dental experience may allow the child to more accurately anticipate and respond to specific stressful dental procedures. Analysis of children's response to specific dental procedures which are repeated during a sequence of visits is needed to further study this problem. Consistently high values for SD were obtained on all four dependent measures (Tables 3-6) wvhich indicate Considerable intersubject -variability in response to dental stress. A wide range in coping behavior and tolerance for dental stress was also observed clinically. Further research is needed to study the factors which are associated with children's wide variations in response to dental stress.
Conclusions The results of this study indicate the preschool child's response to sequential dental visits is complex. Experience initially sensitized him to stressful treatment procedures.
459
With continued experience, the child's response improved, indicating desensitization to dental stress. Experience may also reduce the general amount of negative response by allowing the child to accurately distinguish between stressful and nonstressful procedures. Further research is needed to examine the variability among children in response to dental stress and the effects of age and experience. References 1. FRANKL, S.; SHIERE, F.; and FOGELS, H.:
Should the Parent Remain with the Child in the Dental Operatory, J Dent Child 29: 150-163, 1962. 2. OPPENHEIM, M.N., and FRANKL, S.: A Behavioral Analysis of the Preschool Child when Introduced to Dentistry by the Dentist or Hygienist, J Dent Child 38:317-325, 1971. 3. KOENIGSBERG, S., and JOHNSON, R.: Child Behavior During Sequential Dental Visits, JADA 85:128-132, 1972. 4. KOENIGSBERG, S., and JOHNSON, R.: Child Behavior During Three Dental Visits, J Dent Child 42:197-200, 1975. 5. VENHAM, L.: The Effect of the Parent's Presence on the Anxiety and Behavior of Children Receiving Dental Treatment, unpublished dissertation, Ohio State University. 6. HOWITT, J.W., and STRICKER, G.: Sequential Changes in Response to Dental Procedures, J Dent Res 49:1074-1077, 1970. 7. HOLLINGSHEAD, A.: Two Factor Index of Social Position, New Haven: A. B. Hollingshead, 1957. 8. VENHAM, L.: The Development of a SelfReport Measure of Anxiety for Young Children. Manuscript submitted for publication. Available from author.