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Background: The decision to include or exclude parent presence in the dental operatory during a child’s visit has long been a controversial issue in pediatric dentistry. The intent of this paper was to explore the contemporary views of pediatric dentists and parents with respect to the rationale for which including or excluding parents has impact on children’s behavior and response to dental treatment. Methods: A printed mailed randomized survey of 1000 nationwide pediatric dentists was distributed. A second survey of parents was requested from offices which both included and excluded parents from the operatory to ascertain their opinions of how they anticipated their children would react and whether or not their inclusion in the dental operatory would impact favorably or not on their child’s acceptance of care. Results: In contrast to previous decades increasing interest and willingness of pediatric dentists to permit parent presence was found significant for children 30 months of age or older. Regardless of whether parents were permitted to be present in various offices, interest to be present among parents was found to be significantly increased for examinations and treatment. Where parent presence was permissible significant differences (p<0.001) were found between parents from pediatric dental practices that routinely allowed parents to be present compared to both dentists and parents from practices in which parents were excluded. Conclusions: For pre-school children, children lacking in cooperative potential, and those with a history of fearful or unpleasant previous experience, arbitrary exclusion of parents from the dental operatory appears increasingly perceived as unproductive and unwarranted. Trends appear to emerge in the direction of increasing willingness of pediatric dentists to permit parent presence for examination and treatment visits.
Keywords: Parent presence; Behavior guidance; Childhood dental anxiety
Two surveys were developed for distribution. This project received institutional review board approval from Northwestern University Medical Center, Chicago. One thousand surveys were mailed to pediatric dentists, both diplomats and nondiplomates on a nationwide basis. 665 participants responded, representing 32 states.
A second survey of parent attitudes was distributed through the private practice settings of the authors as well as several offices in which parents were not welcome in the operatory. It was known that each of the authors’ settings readily permit and encourage parents to be present during examinations and treatment. Parents were unaware, however, of such bias when asked to respond to the survey. It was also not known if parent presence or the opportunity to be present was a factor in their selecting the particular dental office for care for their child. Three hundred thirty five parent surveys were returned from offices which excluded their presence and 150 surveys from parents from offices in which their presence was welcomed.
1000 were sent to pediatric dentists across the United States and 500 surveys were given to parents from both practices in which parents were permitted as well as excluded from the operatory. 665 surveys were returned from dentists (66.5% response rate). Thirty two states were represented in this survey, separated into three regions with data analysis presented in Table 1.
Three hundred and thirty five surveys were returned from parents that attended offices that did not allow them back and 150 surveys were returned from parents in which their presence was permitted.
The majority of dentists surveyed stated that they would Region 1 Region 2 Region 3 NY, CT, PA, MA, NJ, DC, MD, KY, NC, FL, TN, SC, MS, VA, GA, AL MO, MI, IN, IA, IL, OH, MN, LA, OK, AR, TX CA, CO, WA, AZ, OR Region 1 = Eastern Region 2 = Middle Region 3 = West Table 1: Regional distribution of states surveyed.
Page 54 allow parents back for children < 18 months (85%), and 18-25 months (79%) and 24-30 months (63%). For children between 30-60 months, no significant differences were found in regard to preference for having the parent in the operatory. 53% of the dentists did feel that parents were helpful in the operatory when treating difficult 5-9 year old children and 40% felt that having parents present was a hindrance for the dentist (Table 2).
Regional analysis showed that dentists in region 2 (Midwest and Central U.S.) felt that parents were either neutral in helping with the child or were a hindrance when compared to dentists from regions 1 and 3 that generally felt parent presence was helpful (p<0.05). When parents were asked how their child would respond to the dental visit, 62% of those from offices that allowed them back said their child would react favorably. 23% said their child would be reluctant, 7% thought they would be timid, and 7% thought they would be uncooperative. In contrast, only 23% of the parents from offices in which they were excluded felt their child would respond favorably. Nineteen per cent said their child would be reluctant, 21% timid, and 37% uncooperative (p<0.001, Table 3). These differences, however, are most likely due to the fact that the median age of those patients attending offices which allowed parents presence was 79 months in comparison to offices which exclude parents of only 33.5 months (p<0.05).
Both dentists and parents were asked questions regarding their preference for parental presence during various dental procedures (Table 4). In general, dentists responded favorably to allowing parents during initial exam, recall, restorative, and extractions (76%, 66%, 51%, and 50%, respectively (p<0.05). However, no statistically different differences were found for procedures using nitrous oxide or other sedative agents. In general it was found that 44% of the dentists allowed parents and 29% did not routinely allow parents to be present (Table 4). Regional comparisons were made regarding dentists’ preferences for having parents present for certain procedures. These data showed that for all situations, dentists from region 2 were much less inclined to have parents present compared to regions 1 and 3 (p< 0.05). The same questions were asked of parents from offices that either allowed or refused their presence. Table 5 presents the results of this analysis. Eighty six percent of the parents from offices that allowed parents responded they would like to be present during the initial exam. Similarly, 79% said this for the recall, 84% for restorations, 87% for extractions, and 87% for sedation. Alternatively, only 44% of the parents from offices that do not permit parents stated they would like to be present for recall exams. For restorative, extractions, and sedation, 54%, 51%, and 54% respectively said they would like to be present (p<0.001). Table 6 shows a composite of the results from both dentists and parents in regard to their preference for being present. As might be expected, parents from dental offices where parents are allowed responded yes significantly more than either dentists or parents from practices that do not allow them (p< 0.001).
Parental Presence and Communication between Dentist, Child and Parent Overall, (Table 7) 52% of the dentists agreed that par ents generally expect to be present, 70% felt parent presence helps with parent rapport, 62% said it helped facilitate treatment acceptance, and 57% felt it was appreciated by the child. Nevertheless, only 34% stated they thought parent presence helped with the rapport of the child. When regional comparisons were made, overall those dentists from region 2 felt that under no circumstances was parental presence a positive experience. In contrast, 85% of those parents surveyed from offices that allowed AGE (MOS) HELPFUL N(%)
N(%)
N(%) NR N(%) <18 546(85)* 53(8) 34(5) 12(2) 18-24 509(79)* 76(12) 47(7) 13(2) 24-30** 408(63)* 124(19) 100(16) 13(2) 30-36** 301(47) 172(27) 158(24) 14(2) 36-48** 187(29) 191(31) 248(38) 19(3) 48-60** 149(23) 183(28) 291(45) 22(3)
**=Statistical significance at p<0.001 using ANOVA on ranks when comparisons were made among age groups *=Statistical significance at p<0.001 using ANOVA on ranks when comparisons were made for individual age groups Table 2: Dentists’ attitudes towards parental presence and age of the child.
Age* (mos) Response to Dental Visit Med 25% 75% Favorably N(%)
N(%)
N(%)
N(%)
Not Allowed 150 33.5 26 41 35(23) 29(19) 31(21)** 55(37)** **=Statistical significance at p<0.001 using Mann-Whitney Rank Sum Test *=Age is represented in months (mos) with the median age (Med), 25 percentile and 75 percentile Table 3: Parents’ perception on how their children will react to their dental visit.
N(%) NO N(%)
N(%) NR N(%)
IN GENERAL** 284(44) 185(29) 118(18) 58(9) **=Significant differences were found at p<0.05 using ANOVA on Ranks when procedure types were compared *=Significant difference were found at p<0.05 using ANOVA on Ranks when responses for individual procedures were compared Table 4: Dentists’ responses on allowing parental presence in the dental operatory during various procedures.
N(%) Not Allow N(%)
N(%) Not Allow N(%)
N(%) Not Allow N(%)
N(%) Not Allow N(%)
N(%) Not Allow N(%) Yes 290(86)* 112(75)* 263(79)* 66(44) 289(84)* 81(54) 292(87)* 76(51) 293(87) 81(54) No 13(4) 35(23) 26(8) 74(49) 22(7) 59(39) 16(5) 64(43) 15(5) 59(39)
NR 2(0.6) 0 4(1) 0 1(0.3) 0 1(0.3) 0 2(0.6) 0 **=Using Mann-Whitney rank sum test, statistical differences were found at p<0.001 between perceptions of parents survey in dental offices that allow them back vs. those parents from dental offices that do not allow them back. *=using ANOVA on ranks, statistical differences were found at p<0.01 in individual parental groups regarding preference for being present during certain procedures NR=Non responders Table 5: Parents’ perceptions on presence in the dental operatory during various procedures.
Med 25% 75% Med 25% 75% Med 25% 75% Med 25% 75% Med 25% 75% Dentist Yes Yes Yes Yes Yes No Yes Yes Some Yes Yes Some Yes Yes No Parents Not Allowed Back Yes Yes No No* Yes No Yes Yes No Yes Yes No Yes Yes No Parents Allowed Back Yes Yes Yes Yes Yes Yes Yes* Yes Yes Yes* Yes Yes Yes* Yes Yes Some= sometimes; *=Kruskal Wallis ANOVA on Ranks, p<0.001
Table 6. Perceived expectations of parental presence during different dental procedures as viewed by dentists and parents that are allowed in the dental operatory and those that are not.
their presence, stated they thought the child preferred having them back and 62% believed their child did not behave better when they were excluded (Table 8). Similarly, only 51% agreed that the dentist should decide if they should be present or not (Table 8). Alternatively, only 64% of the parents from offices that exclude all parents thought that their child preferred them there and 34%stated their child behaved better with them in the operatory. Along with this, 71% said that the dentist should decide whether or not they should be present.
Dentists were asked regarding their views on paren- Page 56 tal presence and the quality of care, productivity, appointment length, recognition of behavior management skills, parental observation of different treatments, and general enjoyment when parents were present (Table 9). Sixty nine percent agreed that their behavior management skills were more appreciated (p< 0.05) and 55% felt that parents should not observe all interac tions between the child and dentist (p<0.05). In general dentists thought that neither their quality of care, productivity or visit length were affected by a parent being present.
When asked if it was important for the dentist to allow them back, 87% of the parents surveyed from offices that allow parent presence responded yes in contrast to only 23% of those parents from offices that do not allow their presence (p< 0.001, Table 10). Similarly, 69% of the parents where they are permit ted, selected the office because of this ability, compared to 1% of the parents from those offices where their presence is prohibited (p< 0.001). An interesting finding was that 49% of the parents that took their children to offices, in which they were allowed back, had had a negative dental experience. This compared to 87% of the parents from offices that did not allow parents back who had not had a bad dental experience (p<0.05).
When confronting young, timid, and apprehensive children during their initial dental experiences adoption of a proto- SA/A N(%) N N(%)
N(%) NR N(%)
Generally expect to be present 338(52)** 91(14) 210(32) 6(1) Parental presence helps rapport with child 219(34) 144(22) 278(43) 4(1) Parental presence helps rapport with parent 453(70)** 94(15) 96(15) 2(0.3) Parental presence facilitates treatment acceptance 401(62)** 116(18) 125(19) 3(0.5) Parental presence appreciated by parents 506(78)** 85(13) 42(6) 12(2) Parental presence appreciated by child 367(57)** 178(28) 84(9) 16(2) SA/A=Strongly agree/agree; N=Neutral; SD/D=Strongly disagree/disagree **=Statistical significance at p<0.001; ANOVA on rank was used as the data points were ranked using a Likert type scale Table 7: Dentists perceptions on parental presence associated with communication between dentist, child and parent.
Better With Us Not There Other DDS Have Not Allowed Us Allow N(%) Not Allow** N(%)
N(%) Not Allow N(%)
N(%) Not Allow N(%)
N(%) Not Allow N(%) Yes 172(51)* 106(71)* 284(85)* 96(64)* 51(15) 48(32) 83(25) 4(3) No 98(29) 20(13) 23(7) 19(13) 298(62)* 51(34) 113(34) 14(9)
NR 11(3) 0 3(1) 0 5(1) 0 98(29) 0 **=Statistically significant difference at p<0.05 using Mann-Whitney Rank Sum Test between perceptions of parents surveyed in dental offices that allow them back vs. those parents from dental offices that do not allow them back *=using ANOVA on Ranks, statistical differences were found at p<0.05 in individual groups regarding parental presence and child behavior, presence and dentists’ decision making Table 8: Parents’ perceptions on child behavior, preference and dentists’ decision making regarding their presence. col which mandates separation of parent from child before sufficient coping behaviors have developed may questionably be expected to facilitate patient communication and acceptance of care. However, given variation in experience, training, and disposition of clinicians, it is not surprising that disparity among pediatric dentists perceptions regarding the merit or detriment to parent presence continues to exist, although to a lesser extent than in previous decades.
Parent presence or absence, is not an issue when deal ing with cooperative, non-apprehensive children. Children whose cooperative potential readily permits exposure to novel situations, even potentially noxious stimuli, and/or strangers are not the subject of this debate.
Age alone may not be a factor or criterion upon which to base decisions whether or not a parent should be included. Where an assessment is made that the child possesses a disposition (regardless of age) that readily permits entrance into the dental situation without fear or trepidation seems among the most pertinent of variables upon which to set office policy regarding parent presence. 1,29 While many children readily encounter their first and subsequent dental experiences with minimal or no anxiety, such responses and the capacity to cope with dental treatment is by no means universal. Regardless of age, there are those young or older who lack an ability to accurately appraise the limit of threat imposed by dental stimuli either during their initial exposures, or secondary to a previous unpleasant experience. Apprehension and a lack of successful coping experience contribute to a child’s maladaptive response when confronting novel situations and result in a distortion of their perceptual and cognitive interpretations. Anxious children require lengthier pe- SA/A N(%) N N(%)
N(%) NR N(%) Quality of care increases 233(36) 130(20) 272(42) 10(2) Productivity inhibited 281(44) 145(22) 214(33) 5(1) Visit prolonged 304(47) 147(23) 190(30) 4(1) Behavior management skills appreciated more 445(69)** 113(17) 82(12) 5(1) I enjoy parental presence 218(34) 172(27) 250(39) 5(1) Parents shouldn’t observe all interactions 497(55)** 142(22) 143(22) 5(1) SA/A= strongly agree/agree; N=neutral, SD/D=strongly disagree/disagree **=ANOVA on Ranks; statistical significance at p<0.05. Data points were ranked using a Likert type scale Table 9: Dentists’ perceptions on parental presence and quality of care, productivity and behavior management.
We Selected this Office Because Allow us Back Child Had Prev Bad Experience Child Had Prev Bad Medical Experience Parent Had Prev Bad Experience Allow** N(%) Not Allow N(%)
N(%) Not Allow N(%)
N(%) Not Allow N(%)
N(%) Not Allow N(%)
N(%) Not Allow N(%) Yes 291(87)* 35(23) 232(69)* 1(1) 58(17) 36(24) 64(19) 13(9) 163(49) 19(13) No 9(3) 44(29) 33(10) 138(92) 263(79)* 112(75)* 254(76)* 136(90)* 158(47) 131(87)* Neutral 32(10) 71(47) 55(16) 11(7) 3(1) 2(1) 3(1) 1(1) 8(2) 0 NR 3(1) 0 15(4) 0 11(3) 0 14(4) 0 6(2) 0 **Statistical significance at p<0.05 using Mann-Whitney Rank Sum Test were found between parents surveyed in dental offices that allow them back vs. those parents from dental offices that do not allow them back.
*Using ANOVA on Ranks, statistical differences were found at p<0.001 in individual parental groups regarding importance of presence in operatory and past medical/ dental experiences NR=Non responders Table 10: Parents’ perceptions on importance of presence in operatory and past medical/dental experiences. Page 57 riods in which to develop coping skills.
Alternatively, there is virtually no disagreement among pediatric dentists that there indeed exists reasons and appropriate indications to exclude some parents from the operatory. Parents generally have the best intentions when visiting the dental office with their child. No one has motive to derail a positive experi ence for their child. There are some parents, however, whose entry characteristics, biases, personal experiences and anxieties preclude them from responding favorably to advice and counseling as to how they may most benefit their child. Unfavorable body language, facial expressions, verbal inquiries and conjec ture of pain and discomfort compromise one’s best efforts to establish rapport with the child. These parents can be particularly challenging despite even the most subtle (or not so subtle), sympathetic and conciliatory gestures to identify how their presence can be optimized. Alternatively, assessment of children who behave in one manner which contradicts cooperation and would otherwise not occur if a parent was excluded is at best judgmental and difficult to either predict or explain. Nevertheless, this intuitive assumption and integral component of clinician judgment plays a significant role for those who mandate or request parent exclusion. This is elaborated below.
In addition to parental factors which impact on whether or not to include parents in the operatory, the style of the dentist no doubt plays a role. There are some who, simply put, are uncomfortable with a parent present. Their training, experience, personal disposition, preference and comfort level make inclu sion of parents a distraction and source of irritation.
Alternately, to deny there are instances in which some children simply will misbehave or manifest non-coping behaviors as a show for their parent, which might not otherwise manifest, supports the contention of practitioners who choose either an arbitrary manner to exclude parents, or, based on specific cues they receive from the child, have legitimate reasons to exclude or ask a parent to leave the operatory.
In some offices, space designs do not readily permit additional chairside presence of a parent. For such individuals, referral of the parent insisting to be present is a viable option. These factors appear as reasonable justification for identifying an office policy of exclusion.
For others, however, the rationale for arbitrary parent exclusion may not be credible or valid. Some indicate they believe child rapport cannot be established with a parent present. Some contend parent presence inhibits their productivity and slows the dental team from achieving their treatment objectives in timely fashion. The data obtained in this study do not support this contention.
More contemporary arguments to the contrary appear to prevail. For the introduction of children below the age of reason, children whose cooperative potential can at best be described as volatile, and those who report unpleasant prior medical or dental experiences, parent presence, in almost every instance, may be believed to facilitate establishment of a rapport as well as productivity.
First, parent child-separation for those lacking in cooperative potential can more often than not be expected to initiate a negative child response simply on entry. From a practice management perspective there can be little benefit derived when a behavior management problem is precipitated before a problem need occur. Having a known and friendly person present to assure the child of the safety of a new environment might be sufficient to allow the child to adapt over the next several minutes, more effortlessly and less traumatically to the dental operatory. Allowing the parent to maintain physical contact with their child allows time, before the examination is initiated, to establish a dialogue with both parent and child. Such opportunity offers dentist, parent, and patient opportunity to become acquainted, explore relevant concerns, such as medical history, child developmental and behavioral issues, and specific parental concerns and queries. Opportunity for observation of the physical attach ment of parent and child, the child’s relative responsiveness to his/her new environment, can only facilitate the clinician’s judgment as to how to best determine the modality to pursue. Opportunity to elicit valuable insight from the parent, inclusive of securing informed consent at this early moment, may be lost when a parent is not included in the operatory. The impact of such is magnified when circumstances deteriorate in which the parent is excluded at the outset and behavioral resistance is encountered by separation, only later to require the dentist explain what took place, and why the child is or became upset, and the measures taken to address the situation. In addition to avoiding such occurrences by having the parent present might also enhance rather than inhibit productivity.
Secondly, it might be hypothesized that for some who arbitrarily exclude all parents, there is in reality, an underlying reluctance to have parents witness how a child, (“out of control” or responding negatively at the outset) is spoken to or physically managed by the dentist or the dental team. In every instance conceivable, it would be the hope and expectation that such is not representative of what occurs in the dental office. Literature, media, and alleged anecdotal reports of misbehavior have been reported. Inappropriate application of obsolete and discouraged aversive techniques of behavior management have appeared. It suffices to say that nothing is said or done to a child, regardless of the severity or potentially harmful nature of the child behavior, should occur without the parent’s presence and consent. Reports of the application of physical restraints without parent presence or consent raise serious and legitimate public concerns. Parent presence without exception, offers opportunity to ensure that consent is (or is not) granted on an ongoing basis.
Thirdly, this report explored the relative frequency with which parents are permitted to be present during treatment, inclusive of when sedation techniques are employed. During such visits, the dentist is obligated to follow specific and expected guidelines to assure patient safety. As per the survey, 75% prefer to exclude parents from such visits, in large part due to the complexity of care and the extent to which interruptions are less likely to facilitate efficient and safe care.
With or without parent presence, it is not uncommon that some young children may be refractory to any and all conventional communication strategies during initial contacts. Under these circumstances, the dentist faces a dilemma. If the origin of the child’s non-compliance is initiated or exacerbated by parent exclusion and the dentist is determined to proceed without the benefit of the parent, what options and techniques become available to elicit cooperation? How does one establish communication lines when behaviors are so resistant? The extremely skillful communicator may eventually succeed in taming such behaviors and successfully manipulate a disruptive child’s responses. Those less skilled, some out of frustration, may give way to aversive methods and deploy physical methods to redirect non-compliant behaviors. Without parental consent, this has potential to create additional problems, practical or legal, if the parent and dentist are not in agreement with how to address the misbehavior.
Alternately, where parent presence is permitted, opportunity exists for parent and dentist to witness the behavioral management challenge ahead, engage in a productive dialogue to optimally establish a mutually accepted plan how to proceed. After having exhausted all reasonable verbal attempts to secure the child’s attention and elicit desirable behavior, the dentist may consider a technique which makes use of the parent’s presence as a reward and positive reinforcement. This technique31,32,36 first involves explanation to the parent on how he/she wishes to use the parent’s presence to shape their child’s behavior. Failing to acknowledge the parent as an expert on their child’s disposition and capabilities may serve to compromise development of a favorable rapport at the outset.
While this may be time-consuming, energies to describe the technique has the potential to rapidly re-direct a child’s lack of cooperative ability to one of compliance and acceptance. At the very least, a reticent parent may be inclined to become a strong advocate and referral source for the dentist’s expertise and compassionate management skills. Comments frequently expressed afterwards by parents indicate an appreciation for the tact, calm demeanor, and patience of the dentist who shows no alarm to initial displays of their child’s negative behavior, and for their systematic and soft-spoken approach.
In some instances, mention of Mommy being asked to leave the treatment area is sufficient to induce acceptable child behavior; other times, the sight of the parent getting up to leave will induce a change in behavior for the better. Sometimes, the parent may have to leave the area, return, leave and return several times before the child realizes he/she will have to mind the dentist if he/she wants the parent to stay. In almost all instances, behavior can be expected to improve after two to three trials of having the parent enter or leave. If this continues 2-3 times to no avail, the dentist and parent may wish to reassess the situation. Recalcitrant children may require a non-mainstream modality if urgent treatment needs are identified. Regardless, all efforts are expended to give the child a choice and that their feelings are being considered meaningful. In this manner, the child has some control, but similarly, the options given remain acceptable to the dentist. At this juncture, opportunity for parent and dentist to collectively review future exploits can remain healthy and intact.
1. There appears to be general agreement among pediatric dentists that there are legitimate reasons to include and exclude parents from the dental operatory.
2. Regardless of whether parents are permitted by office policies of pediatric dentists, there is a tendency of parents to prefer to be present for examinations and in many cases for various forms of treatment, particularly for children who are below the age of reason, manifest non-coping and apprehensive behaviors, or have a history of unpleasant previous medical or dental experiences. 3. General belief appears among dentists that parent presence is not a hindrance to establishment of a favorable child rapport, improved patient cooperation, and office productivity.
4. Arbitrary parent exclusion denies an opportunity for the dentist to make use of the parent’s presence as a positive reinforcement tool to re-direct initial or uncooperative child behaviors. Those who mandate parent exclusion from the outset for all children may wish to re-assess their office policies when encountering initial negative and non-coping behaviors.
While not universal, pediatric dentists report more parents expressing a desire to be present and that parents believe their presence will be helpful to their children. The majority of pediatric dentist’s today report that neither quality of care, productivity, nor visit length was adversely affected by a parent’s presence. The opportunity for a parent to be present to witness their child’s behavior brings numerous possible advantages. If parent presence is indeed important to the child, their selective presence can be used as positive reinforcement to replace disruptive behaviors with desirable ones. Mandatory parent exclusion serves to remove this potentially useful and effective technique from a clinician’s conventional behavior shaping arsenal. Lastly, additional potential benefits to parent presence, Page 59 when mutually agreed upon, include opportunity for the dentist to be assured of ongoing parental consent. This enables the dentist to remain alert for changes in parental expression, verbal or body language to indicate a disapproval of the direction approaches is being taken. From a practice management vantage, permitting parents in the dental operatory has potential to allow parents opportunity to not miss what the dentist is able to accomplish with their child.
CONFLICTS OF INTEREST: None.
This project was supported by the Research Foundation of the American Society of Dentistry for Children, IL, USA.