Short communication. A form of 'parental presence/absence' (PPA) technique for the child patient with dental behaviour management problems.
Abstract: AIM: This paper reports on the use of early introduction of a specific parental presence/absence (PPA) behavioural technique to manage the initially uncooperative child. METHODs: Using a prospective design, 440 healthy children aged 3 to 10 years visited a paediatric dental practice within 33 months. Children exhibiting initially Frankl 'negative' and 'definitely negative' behaviour were empathically offered parental presence only if they were cooperative. Otherwise, the parent stepped out until behaviour improvement. statistics: t-tests and Chi-square tests were used to compare characteristics of initially cooperative and uncooperative children, as well as proportions of parents who were asked to leave the surgery. The technique's success was assessed by a one sample binomial test. RESULTS: 75 of the children presented as Frankl either 'negative' (30) or 'definitely negative' (45) at their first visit; 70 (93.3%, p< 0.001) responded to the PPA technique by displaying positive behaviour as their first visit progressed. 38 responded without the need to ask the parent to exit the practice room, while the other 32 responded only after their parent exited. 52 children had additional appointments, and 8 required an application of PPA at a second appointment; all children cooperated in all subsequent appointments. CONCLUSION: Early and empathic application of the PPA technique appears very successful in managing initially uncooperative child patients, suggesting that a randomised controlled trial of the technique is warranted

Key words: Behaviour management, negative behaviour, uncooperative child dental patient, parental presence
Article Type: Report
Subject: Parents (Influence)
Tooth diseases (Care and treatment)
Tooth diseases (Research)
Children (Behavior)
Children (Research)
Medicine (Practice)
Medicine (Methods)
Authors: Kotsanos, N.
Coolidge, T.
Velonis, D.
Arapostathis, K.N.
Pub Date: 06/01/2009
Publication: Name: European Archives of Paediatric Dentistry Publisher: European Academy of Paediatric Dentistry Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2009 European Academy of Paediatric Dentistry ISSN: 1818-6300
Issue: Date: June, 2009 Source Volume: 10 Source Issue: 2
Topic: Event Code: 310 Science & research Canadian Subject Form: Child behaviour
Geographic: Geographic Scope: Greece; United States Geographic Code: 4EUGR Greece; 1USA United States
Accession Number: 202074913
Full Text: Introduction

Dentists may expect to encounter dental behaviour management problems (DBMP) in about 10% of the children they see [Klingberg and Broberg, 2007]. DBMP may be overcome by effective communication and various behaviour management techniques, such as positive reinforcement of desired behaviour. However, when a child's behaviour is highly uncooperative, parental presence may negatively reinforce misbehaviour and the lack of affective dentist-patient communication prevents the application of these techniques [AAPD, 2008]. In this case, asking a parent to exit the surgery has been proposed as a technique to allow communication to start [Rayman, 1987]. The parent returns as soon as communication and cooperation improves, his/her return serving as positive reinforcement for the improved behaviour.

An earlier retrospective study [Kotsanos et al., 2005] involved children who initially displayed high levels of DBMP ('definitely negative' according to the Frankl scale, [Frankl et al., 1962] in the surgery with the parent present. Parents were asked to leave, and the child was told that his/her parent would be able to return as soon as he/she ceased crying and instead verbally communicated needs and wishes to the dentist. This technique (parental presence vs. absence; PPA) resulted in children agreeing to communicate with their dentist in 94% of cases. Subsequently, it was realized that communicating this 'policy' in an empathic way was very often enough for improvement of behaviour without needing to ask the parent to leave. Therefore, in anticipation of a future controlled study, this prospective study was undertaken in order to examine the impact of introducing PPA early in the dental appointment.

Materials and methods

Sample. All healthy children aged 3-10 years old (n = 440) who visited one urban paediatric dental practice during a 33 month period were eligible to be in the study. In this practice the Frankl ratings of patient cooperation were routinely made by the dentist for all normal children aged 3 years or older. No assertive techniques (such as hand over mouth) were used.

Technique application. At the beginning of each appointment, the parent was invited to remain in the surgery. If uncooperative behaviour was noticed, the dentist stopped and explained the office policy regarding parental presence in a very empathic way [Kotsanos et al., 2005]. The dentist told the child and parent: "I'm very happy to have mummy/daddy with us all the time, but when children cry, they cry more when mummy or daddy is near. I may have to ask her/him to step outside until you stop crying. Only raise this hand if you want something, instead. Would you help me keep mummy/ daddy with us?"

Following this, a parent was asked to give oral consent in case she/he would be asked to leave. If the negative behaviour continued, the parent was asked to step outside. The dentist reminded the child that their parent could return as soon as the crying stopped. When the child stopped crying, the dentist verbally reinforced the child and immediately asked his/her parent to come back into the surgery. The length of time the parent remained outside the surgery was recorded, and treatment resumed. If the child's behaviour did not improve after 8 minutes, the technique application was terminated and an alternative approach was discussed with the parent.

Statistical analysis. The data were analyzed with SPSS Version 14.0 for Windows. The ages of the children in the initially cooperative and uncooperative groups were compared by t-test. The gender, referral source, and reason for dental treatment distributions in the two groups, as well as the proportions of parents of 'negative' and 'definitely negative' children who were asked to leave the surgery were compared by Chi-square test. The proportion of initially uncooperative children whose behaviour improved after application of the technique was assessed by the binomial test.


During the study period, 75 children presented as Frankl 'negative' (n=30) or 'definitely negative' (n=45). All of their parents consented to the PPA technique. The remaining 365 patients were 'positive' or 'definitely positive' by the Frankl scale.

There were no significant age (5.18 yr [+ or -] 1.61, 5.56 yr [+ or -] 1.78, p>0.05) or gender (52% male) differences between the patients in the initially uncooperative and cooperative groups. Of the children with DBMP 33 (44%) were referred by general dentists (GDP) and 12 (16%) by paediatricians, compared with 84/365 (23%) and 48/365 (13%) of the initially cooperative patients. The remaining 30 children with DBMP (40%) and 233 initially cooperative children (60%) were self-referred. Referral sources were significantly different for the two groups of patients (Chi-square = 16.6, df = 2, p <0.01). There were 40 (53.3%) of the initially uncooperative patients who presented with symptoms or fear-provoking situations, such as pain or a request for extraction, and the remaining 35 (46.7%) came for other purposes, such as routine examinations. In the cooperative group, the respective numbers were 140/365 (38.4%) and 225/365 (61.6%). The inverse relationship between the two groups was statistically significant (Chi-square = 5.73, df = 1, p < 0.05).

Implementation of the PPA technique resulted in cooperative behaviour in all 30 of the children initially rated as "negative", and in 40/45 children initially rated as "definitely negative" (Figure 1), resulting in a 93.3% successful outcome, statistically significant by the binomial test (p< 0.001).

In 38 of the 75 initially uncooperative cases, explanation of the PPA policy resulted in cessation of DBMP, such that the parent was able to remain in the surgery (see Figure 1, left bar). In the remaining 37 cases, the child continued to display DBMP and the parent left the surgery (Figure 1, middle and right bars). The ratio of 'parent exit/no parent exit' was 34/11 for the 45 'definitely negative' children and 3/27 for the 30 'negative' children; this difference was significant (Chi square = 28.38, df = 1, p < 0.001). As seen in Figure 1, in the majority of the cases where the parent was asked to leave the surgery (32/37) the child's behaviour subsequently improved and the parent returned. For these children, the mean length of time a parent stayed out of the surgery was 4.15 ([+ or 0] 2.14) minutes.

There were 52/70 children responsive to PPA who returned for 1 to 5 additional appointments; 8 displayed negative behaviour at the second visit and were reminded of the PPA policy. In 6 of these cases, the reminder was sufficient for the child to cease the DBMP. The other 2 children continued to display DBMP and their parents were asked to exit the surgery; in both cases, the child's behaviour improved. There were 39/52 children who had additional appointments during the time of the study, and none displayed DBMP in any subsequent appointment.

An assessment of the 5 children who did not respond to PPA revealed that all were in the 'definitely negative' group. One parent re-entered the surgery during her child's crying. A second child was still wearing nappies/diapers, another was 'emotionally immature' [AAPD 2008], and the remaining two were so-called 'strong willed'.


This study is the second to document the success rate of a simple technique to help uncooperative children alter their behaviour. Previously Kotsanos et al. [2005] reported that a parent was always asked to step out of the surgery, while in the current study the PPA 'policy' was empathically presented as soon as a child displayed DBMP. Thus, 11/45 of the 'definitely negative' patients established communication just by hearing about the PPA policy, and their parents did not have to leave the surgery.

The proportion of children with DBMP seen in our sample is similar to those reported by others [Evans et al., 1991; Shaw et al., 1994; Baier et al., 2004]. In the present study, children with DBMP were almost twice as likely as cooperative children to have been referred by a GDP. They were also significantly more likely to present for invasive needs rather than check-ups and thus were more likely to be experiencing pain and fear. Further, their presenting symptoms meant that they would need to undergo more stressful procedures. Despite these characteristics, almost all of the children displayed cooperative behaviour at subsequent appointments, similar to the earlier report by Kotsanos et al. [2005], even for the first recall visit, indicating lasting communication benefits.

A minority of the children did not respond positively to the PPA technique. The AAPD [2008] guidelines stipulate that parental presence/absence is appropriate for all children unless the parent is unable to comply. As noted, one parent was unable to remain outside the surgery. In addition, in 4 other cases the PPA technique was not successful. According to the additional information available, these 4 children appear to have developmental or emotional issues that probably prevented them from being able to comply with the dentist's instructions. Therefore, our results suggest that this technique is only appropriate with normal children whose parents have agreed to abide by the instructions.

The results reported here suggest that a controlled trial of the technique is warranted. Future research, in which children with DBMP could be randomized to receive PPA or "usual" treatment, would be welcome in helping to understand the efficacy of the PPA technique.


The early application of the PPA technique appears to be successful in improving cooperation in initially uncooperative child patients.


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N. Kotsanos *, T. Coolidge **, D. Velonis *, K. N. Arapostathis *

Depts. of * Paediatric Dentistry, Aristotle University of Thessaloniki, Greece, ** Dental Public Health Sciences, University of Washington, USA.

Postal address: Dr N. Kotsanos. Dept. of Paediatric Dentistry, Dental School, Aristotle University of Thessalonica, GR-54 124, Greece.

Figure 1. Results of PPA in 75 Initially Uncooperative
Children: Parental Exit.

                         Negative   Definitely negative

Child cooperated,
without need for
parent to exit            27           11

Child cooperated,
only after
parent exited              3           29

Child did not
cooperative, even after
parent exited                           5

Note: Table made from bar graph.
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