Attitude of Some Nigerian Parents toward their Presence in the Operatory during Dental Treatment of their Children.

Background: Parental accompaniment of children during dental treatment has been a contentious issue with diverse opinions. One of the factors to be considered is the preference of the parent. The purpose of this study was to assess the attitude of some Nigerian parents toward their presence in the dental operatory while their children undergo dental treatment. Materials and methods: A cross-sectional study was conducted among 100 accompanying parents of children who attended the Paediatric Dentistry Clinic at the University College Hospital, Ibadan using a pretested questionnaire.
Results: Majority of the parents (91.0%) preferred to accompany their child when receiving dental treatment. Reasons for their choice were that they would motivate the child (65.9%) and child would feel safe (58.2%). Of those who wanted to remain with their children, (83.5%) reported that their presence would reduce child's fear by comforting and touching them during dental care. Child's age, parents' age, previous dental visits of child and parent were not found to significantly influence the attitude of parents toward their presence in the operatory. Reason for seeking treatment was related to preference for parental presence.
Conclusion: Majority of the parents preferred to stay with their children during dental treatment. The clinical significance is that dentists should endeavor as much as possible to maintain the child - parent pair during treatment since it is preferred by parents as they believe their children will be better motivated and feel safe. However, dentists sometimes may need to separate child from the parent for smooth treatment of their children. How to cite this article: Bankole OO, Olanloye OM, Ayebameru OE, et al. Attitude of Some Nigerian Parents toward their Presence in the Operatory during Dental Treatment of their Children. Int J Clin Pediatr Dent 2021;14(S-2):S167-S172.

Introduction

Research has shown that the prevalence of dental fear in children varies from 3-43% depending on methods of investigations and populations studied.[1] Dental fear is a major dilemma in pediatric dental practice and can lead to uncooperative behavior during dental appointments.[2] In an effort to overcome this challenge of dental fear in children, many suggestions have been put forward, one of which is parental presence or absence.

Parental presence or absence is one of the recognized behavior management techniques in dentistry that can be used to bring about cooperative behavior in children. This technique aims at reducing the child's anxiety toward dental treatment, preventing negative behavior and establishing effective communication between the child and the dentist.[3] However, despite its possible positive role, parental presence during a child's dental appointment is a controversial issue among dentists.[4]

Supporters of parental presence believe that the presence of the parent(s) during dental visits reduces child separation anxiety[5] and can minimize the use of premedication.[6] An earlier study revealed that keeping the mother - child pair intact during dental appointments produced more positive responses in preschool children.[7] It is believed that the mother's presence in the surgery allows the dentist to form a relationship with the mother and the child thereby improving compliance during treatment.[7] Another research reported that 80% of pediatric dentists in the United Kingdom support parental accompaniment of the child during the course of treatment, generally viewing parents as useful allies in effectively facilitating dental treatment for the child.[8] But non supporters to parental presence during children's visits state that parental presence can serve as a distraction for both child and dentist[9] and the children at times “play up” in front of their mothers increasing the probability of negative behavior during treatment.

Studies have also shown that majority of parents appear positively disposed to staying with their children during dental appointments. Kamp[10] and Certo and Bernat[11] showed that 66% and 75% of parents, respectively wanted to be present during their children's dental treatment. Other researchers revealed that 70.2% of Israeli parents,[12] 78.3% of Indian parents[13] and 97% of Saudi parents[14] preferred to stay with their children during dental appointments. On the other hand, only a minority (35.9%) of Iranian parents[15] wanted to remain with their children while undergoing dental treatment.

The ultimate goal of parental presence or absence is to minimize the child's anxiety toward dental treatment, accomplish smooth treatment and achieve a positive dental experience. However, the decision to include or exclude the parent may sometimes lead to parental dissatisfaction, thus it is important to have a feedback from parents on the issue.

Literature regarding parents’ preference toward child's accompaniment during dental care among Nigerians is scarce. Thus, this study aimed at determining the attitudes of parents of children who visited the Paediatric dental clinic of the University College Hospital in Ibadan, Nigeria toward their presence in the operatory during dental treatment of their children.

Materials and Methods

This study was a cross sectional study conducted over a two month period among parents of children attending the Paediatric Dentistry clinic of the University College Hospital, Ibadan in South-Western Nigeria. A convenience sampling method was used to recruit the study participants. Parents of consecutive patients who attended the clinic and met the inclusion criteria were recruited for the study.

Study Participants

All parents of physically healthy children attending the clinic with their wards were eligible to participate in the study while parents with children with special health care needs were excluded from the study. Only parents who were willing and consented to participate in the study were recruited. A total of 107 parents were eventually recruited.

Questionnaire

The study instrument consisted of the questionnaire used in the study by Abushal and Adenubi [14] and pretested among 10 parents who were not part of the study. The contents of the questionnaire were validated by pilot testing among 10 parents who were not part of the study population. Irrelevant and difficult items in the questionnaire were modified to ensure that the questions were easily understood by participants.

Procedure

The questionnaires were administered by two research assistants who had undergone training prior to the study. Information obtained included basic demographic data of parents and their children. Parents and children's past dental experiences, reasons for child seeking dental treatment, parents’ attitude toward accompanying their children while undergoing dental appointments and their views about dental procedures was asked. Child's social status was determined by the Socioeconomic Index Score by Oyejide[16] which makes use of parent's educational status and occupation. Each parent was scored on an educational scale with scores from 1 (university education) to 5 (illiterate) and occupational scale from 1 (senior public servants, professionals and business people) to 5 (full time house wives unemployed, students). The mean of the four scores was calculated as the social class assigned to the child with a mean of 1 as high, 2 and 3 as middle and 4 and 5 as low social classes, respectively.

Data Analysis

Data analysis was done using the Statistical Package for Social Sciences (SPSS) version 16.0. Chi-square statistics was used to test significance of categorical variables. Associations were considered significant when p -values were less than 0.05.

The research was approved by the Oyo State Research Ethical Review Committee in Ibadan, Nigeria.

Results

A total of 107 questionnaires were filled but seven were discarded due to missing information thus 100 questionnaires were used in this study.

Sociodemographic Characteristics of the Participants

Eighty (80.0%) of the accompanying parents were mothers and 18(18%) were fathers. Nine (9.0%) were less than 36 years of age while 29.0 (29.0%) and 40(40.0%) were in the 36-40 years and 41-45 years age groups, respectively. Twenty-two parents (22.0%) were 46 years of age and above. The children's mean age was 8.34 ± 2.73 years and 14(14.0%) were 5 years and below, fifty-three (53.0%) were between 6-10 years of age while 33 (33.0%) were between 11 and 15 years of age. Fifty-six of the children that presented at the clinic with their parents were males while forty-four were females. With regards to the birth order, 29(29.0%) and 31 (31.0%) were first born and second born children, respectively. Forty (40.0%) were third born children and above. Most parents (father; 84%/mother; 78%) had mainly university education.

Majority of the participants 73(73.0%) belonged to the high social class while 24(24.0%) and 3(3.0%) belonged to the middle and low social class, respectively (Table 1).

Table 1

Sociodemographic characteristics of the participants

Socio demographic variables	Frequency(N = 100)	Percentage
Accompanying parentMotherFatherBoth	80182	80.018.02.0
Parent age-group (years)<3636-4041-4546 and above	9294022	9.029.040.022.0
Child age-group2-56-1011-15	145333	145333
Ordinal position of the child in the familyFirst bornSecond bornThird born and above	293137	293137
Fathers educationUniversity graduate/equivalentSchool certificate/otherqualificationSchool certificatePrimary schoolIlliterate	8421022	84.02.010.02.02.0
Mothers education University graduate/equivalentSchool certificate/otherqualificationSchool certificatePrimary school	781192	78.01.019.02.0
Socio-economic statusHighMiddleLow	73243	73.024.03.0

Age and Social Class Related Parental Preference to Being Present in the Operatory during Treatment

Majority of parents aged ≤36 years (7; 87.5%) and >45 years (19; 90.5%) said they would like to stay with their children during dental treatment (p = 0.743). Among the 2-5 year old and 6-10 year age-group of children, 13(92.2%) and 48(90.6%) parents said that they would want to stay with their children during treatment while in the 11-15-year old age-group of children, 30(90.9%) parents said that they would want to stay with their children during treatment (p = 0.965).

Sixty-five (89.0%) and 23(95.8%) of parents of children in the high and middle class, respectively would stay with their children at dental appointments (p = 0.516) (Table 2).

Table 2

Effect of age, social status, ordinal position in the family and dental visits on parental accompaniment

Variables	Would you like to stay with your child during dental treatment (n = 100)		p-value
	Yes	No
Parent age-group<3636-4041-45>45	7(87.5)27(96.4)35(89.7)19(90.5)	1(12.5)1(3.6)4(10.3)2(9.5)	0.743
Child age-group2-56-1011-15	13(92.9)48(90.6)30(90.9)	1(7.1)5(9.4)3(9.1)	0.965
Social statusHighMiddleLow	65(89.0)23(95.8)3(100.0)	8(11.0)1(4.2)0(0.0)	0.516
Ordinal position in the familyFirst bornSecond bornThird born and above	27(93.1)29(93.5)33(89.2)	2(6.9)2(6.5)4(10.8)	0.770
Childs dental visitsChild previously visited the dentistNo prior dental visit	24(93.3)67(90.5)	2(7.7)7(9.5)	0.787
Parents dental visitsParents previously visited the dentistNo prior dental visit	44(89.8)47(92.2)	5(10.2)4(7.8)	0.680
Reason for seeking dental treatment (n = 96)Hole in toothPainful tooth/traumaaestheticsProphylaxis/routine	9(100.0)42(95.5)26(92.9)11(73.3)	0(0.0)2(4.5)2(7.1)4(26.7)	0.040*

*p< 0.05

Parental Preference Based on Parents and Children's Past Dental Visits

Forty-nine (49.0%) of the parents had previously visited the dentist and 16(32.7%) of these parents claimed they had unpleasant experiences. Twenty six (26.0%) of the children had previously visited the dentist and of these, 2(7.7%) had unpleasant memories of their dental experience (Table 3). With regards to the parent's past dental visits, 44(89.8%) of parents who had visited the dentists before and 47(92.2%) of those who had never visited the dentist requested to stay with their children during dental treatment (p = 0.787) (Table 2). Concerning the child's past dental visit, 24(92.3%) of parents whose children had previously visited the dentist requested to stay with their children while 67(90.5%) of parents whose children had never visited the dentist requested to stay with them during dental procedures.

Table 3

Parents and children's past dental visits and reason for seeking treatment

Variables	Frequency	Percentage
Parents previous dental visit (n = 100)YesNo	4951	49.051.0
Parents experience (n = 49)PleasantUnpleasant	3316	67.332.7
Child's previous dental visit (n = 100)YesNo	2674	26.074.0
Child's experience (n = 26)PleasantUnpleasant	242	92.37.7
Reason for seeking treatment (n = 96)Hole in toothPainful toothTraumaAestheticsScalingRoutine	924202896	9.024.020.028.09.06.0

Reasons for Children Seeking Dental Treatment

Reasons cited by parents for seeking treatment for their children were holes in child's tooth 9(9.0%), toothache 28(28.0 %), trauma to the teeth 20(20.0%), and unaesthetic arrangement of child's teeth 28(28.0%). Nine 9 (9.0%) children presented because patients wanted scaling and polishing of their teeth done while 6 (6.0%) came for routine dental check up (Table 3). More parents with children who presented on account of pain (95.5%) and problems of aesthetics (92.9%) wished to remain with their children during dental visits (p = 0.04). This finding was statistically significant (Table 2).

Parents Preferences Regarding Parental Accompaniment

Majority, 91(91.0%) of the parents stated that they wanted to stay with their children during their children dental treatment. Of these, 88(96.7%) desired to stay in the operatory with their children for the entire length of the treatment while 2(2.2%) wished to come in ask questions and stay for a while and then revert back to the waiting area. Nine parents (9.0%) did not wish to stay with their children during dental treatment. Their reasons were that they felt their children were old enough to receive treatment by themselves 4(44.9%), while 3(33.3%) stated that they don't like watching treatment procedures. Two parents (22.2%) said they could get some others things done (Table 4).

Table 4

Preferences for parental accompaniment

Questions regarding parental accompaniment	Frequency	Percentage
Will you like to stay with your child during dental treatment?YesNo	919	91.09.0
If yes what is your preference (n = 91)Stay entire visitEnter with child ask about treatment and leaveI will enter at the end to know what has been done	8821	96.72.21.1
If no state your reason (n = 9)My child is old enoughI can get some other things doneI don't like watching treatment procedure	423	44.422.233.3

Reasons for Parental Accompaniment

Of the 91 parents who wanted to be with their children, 60(65.9%) of the parents desired to be present so as to motivate the children, while 53(58.2%) believed that the child will feel more comfortable and safe. Thirty (33.0%) of parents wanted to be present to assist and control the child in case of misbehavior while 27(29.7%) stated that they as parents would be more comfortable. Twenty one (21.0%) parents stated that they just wanted to watch the dentist (Fig. 1).

Fig. 1

Respondents reasons for parental accompaniment (multiple responses)

Parental Attitude during Parental Accompaniment

Out of the 91 parents who desired to be present during child treatment, 76(83.5%) parents said they would comfort child by talking to child and touching child's hands and feet, 20(22.0%) stated that they would just watch, 6 (6.6%) said that they will just sit and keep silent while 4(4.4%) stated that they will force their child to cooperate.

Parents Perception about Parental Presence Withdrawal during Dental Treatment of their Child

When the parents were asked for their opinion about the dentist requesting they leave the operatory during their child's dental treatment, 51 (51.0%) indicated that they will leave immediately, 31(31.0%) said they would leave but discuss reasons later with the dentist while 18(18.0%) emphatically stated that would not leave the operatory. Reasons given by parents adamant about staying in the operatory during their child's dental treatment were that they felt they had a right to be with their child at all times and that they felt their children were too young to be left alone.

Parents Views about Dental Procedures

Thirty-six (36.0%) parents viewed extractions as the most frightening dental procedures Sixty-three (63.0%) parents were undecided as to which procedures they would be most scared of. Only one parent (1.0%) felt that tooth filling would be scary.

Discussion

Dental visits can be a stressful event for children and their parents as it may be associated with some degree of anxiety.[17] Parental accompaniment can considerably affect the environment of the dental visit and dental treatment as it may sometimes improve or deter the progress of the child's treatment.[18] This is because parents can influence their children either positively or negatively in the dental clinic, their anxiety can be easily transferred to their children thus impacting negatively on their child's behavior.[18]

Despite this fact, we cannot overlook the role parents play in the lives of their children. Parents know their children best, they are aware of their child's interests and worries.[10] Therefore, the dentist needs to evaluate the pros and cons of parental absence or presence during dental procedures and its possible influence on the outcome of treatment. It is also important to allow this decision of inclusion or exclusion to involve the parent(s) since they may be in a better position to say what is best for their child.

In this study, majority of the parents (91%) preferred to be present during the dental treatment of their children. This finding is similar to those among Arabian parents[14] but higher than those found in parents of children of German,[10] Israeli,[12] Indian[13] and Irish[19] decent. This difference may be associated with the difference in culture, Nigerian parents are quite protective of their children and are reasonably interested in knowing what is happening to their children at every given point in time. This explanation is buttressed by fact that majority (96.7%) of parents that wanted to be present in the operatory, wanted to remain there throughout the entire dental visit of their child. The child's age did not affect parental preference.

However, this finding is in contrast to those of Kamp,[10] Arathi and Ashwani[13] and Gisour and Bigdeli.[15] This could be as a result of cultural differences as the other studies were conducted in Germany and India. Nigerians have very strong family ties and values. Parents’ age, social status and child's ordinal position in the family and past dental visits also did not affect parental preference. However, parents wanted to be with children who were in discomfort due to pain and trauma as compared to those who came for prophylaxis/routine check.

The few parents (9%) who did not want to remain while their child was having treatment said they felt their children were old enough while others stated that they did not like to watch hospital procedures particularly as they were frightened by the sight of blood. Though this study did not find a significant relationship between children's past dental visits and parental preference toward child's accompaniment in the dental clinic it may still be useful to ask the parents about any dental phobias while taking the child's dental history as the result may influence the decision to allow or disallow the parent to be present during child's treatment. Failure to do this and allowing an anxious or fearful parent to be present may result in the transference of fear and anxiety to the child patient thus resulting in poor outcome of dental care.

A major reason given by parents who wanted to stay during treatment was to motivate the child. This finding is comparable to those in Arabian parents.[14] In children, parents play a major role in providing extrinsic motivation which invariably can determine the success of the dental visit. Parental motivation can be achieved by using comforting and reassuring words. Therefore, parents should be encouraged to motivate their children during dental treatment when deemed necessary.

In addition, the study revealed that a large proportion of parents also believed that their child would feel safe if they were present during treatment. Children may perceive the dental unit and care as frightening thus developing some degree of anxiety and reluctance to cooperate. Therefore, the physical presence of the parent's may provide some sense of safety and security alleviating this fear and ultimately leading to a successful dental treatment. However, the proportion of parents that felt that their presence would provide a sense of safety in this study was relatively lower than those found in Arabian[14] and German[10] studies. Other parents wanted to be present so as assist the dentist in controlling the child. This measure may not be perceived by the parent and child as aversive and therefore may have little or no negative psychological impact on child.

Concerning the behavior of parents when present during dental treatment of their child, majority (83.5%) reported that they would reduce the child's fear by comforting and touching the child. This behavior may be due to the fact that Nigerian parents believe that physical contact with the child during treatment will go a long way in ensuring a cooperative and relaxed disposition of the child. However, a few of the parents (22.2 %) reported that they would just observe the treatment without making contact.

This study revealed that some parents (18.0%) would insist on staying with their child even if asked by the dentist to leave. The display of reluctance to leave, further buttresses the desire of Nigerian parents to know what is happening to their child at every given time. About a third (31.0%) said they would leave but discuss reasons later with the dentist thus indicating that dentists should offer explanations as to rationale for action taken to the parent prior to the parental separation.

Parent-child separation during dental treatment is one of the methods that can be employed in behavior management, thus the issue of reluctance of parents to leave despite been asked to by the dentist may need to be addressed when it arises. Training and educating parents about their role in the team and the impact their absence may play in achieving a positive behavior modification of their child might be necessary. However, the dentist's decision to include or exclude the parent from the operatory during a child's treatment should be based on the child's behavior, past dental experiences of both the child and patient, the effect of parental involvement on the child, the dentists’ feedback from the parent and the comfort level of the operator.[6]

Symptomatic dental visits usually due to pain in children is common particularly in developing countries.[20] A fifth of these children in this study visited the dentist because of pain. For this reason, it is important to be able to make dental appointments as stress free as possible. Having parents with the children at such times may go a long way in reducing the child's anxiety.

Conclusion

This study showed that most parents preferred to be present in the operatory during the treatment of their children so as to motivate and provide some form of safety to the child, and to assist the dentist. Despite the fact that majority of parents were also willing to leave if requested to do so by the dentist, some showed some resistance by signifying that they would insist on staying or have a discussion about their exclusion with the dentist later. This shows that there is the need to adequately educate parents about the importance of the use of parental inclusion and exclusion as a tool for managing the child's behavior. Nevertheless, the decision to include and exclude should vary with each child and is one that should be taken with care after much consideration with the parents. This must be done so as to ensure that a positive behavior is obtained from the child and that the parent is satisfied.

Limitations of the Study

In Nigeria, a developing nation, awareness about visiting the dentist is low and dental attendance for children is seasonal and only spikes during vacation periods. Thus, the reason for the small sample size in this study. A larger sample size may have been more representative of the parents’ attitudes to parental presence during dental visits.

Clinical Significance

The clinical significance of this study is that dentists should endeavor as much as possible to maintain the child-parent pair during treatment since it is preferred by parents as they believe their children will be better motivated and feel safe.

Authors Contribution

OOB had the initial conception and design of study and contributed to analysis and interpretation of data, drafting of the article and revision of the manuscript. OMO contributed to the literature search, acquisition of data and revision of the manuscript. OEA and OOP contributed to revision of the manuscript.

Orcid

Olubunmi O Bankole http://orcid.org/0000-0002-5754-0855

Omobola M Olanloye http://orcid.org/0000-0003-0496-5929

Olusola E Ayebameru http://orcid.org/0000-0003-0686-008X

Bamidele O Popoola http://orcid.org//0000-0003-2037-9698