Perception of Pediatric Dentists on Child Patient Behavior and their Dental Care Management during the COVID-19 PandemicABSTRACT
Objective: To evaluate the perception of Brazilian pediatric dentists (PD) regarding the behavior of child patients and their dental care management during the COVID-19 pandemic.
Material and Methods: A self-administered online questionnaire was answered. Professionals who assisted children and/or adolescents, who had a postgraduate degree in Pediatric Dentistry, and worked in public and/or private services, were considered eligible for the study. Demographic information, perception of behavior changes of children and adolescents during appointments and the use of behavioral management techniques (Remained the same; Reduced/suspended or Increased employment) were collected. Fisher's exact test was used (p<0.05) to assess the association between the use of behavior management techniques and the perception of the child’s behavior in the consultation during the pandemic.
Results: A total of 231 PD participated, of which 45.6% noticed a worsening in the behavior of children and adolescents during the pandemic. Regarding the management of child behavior, appropriate/physical contact was the technique that had the greatest reduction/suspension of use (77.6%), followed by the distraction technique using toys and books (55.9%). A higher prevalence of protective stabilization use (p<0.001) and positive reinforcement (p=0.002) was identified among PD who noticed a worsening of the behavior.
Conclusion: The COVID-19 pandemic interfered with the dynamics of pediatric dental appointments regarding the use of some behavioral management techniques, as well as the perception of child behavior.
Keywords:
Pediatric Dentistry; Pandemic; Coronavirus; Dental Care.
Introduction
COVID-19, caused by SARS-CoV-2, had its first records in China at the end of 2019, spreading rapidly throughout the world, and was characterized as a pandemic by the World Health Organization on March 11, 2020. SARS-CoV is a highly transmissible virus that spreads through respiratory droplets and aerosols from infected individuals and can also be transmitted, to a lesser extent, through contact with previously contaminated surfaces [1,2].
In the face of the pandemic scenario, dentists, with the aim of maintaining the safety for staff and patients, have adopted new attitudes and measures to control and prevent COVID-19 [3,4], such as greater rigor in the use of personal protective equipment and the removal of objects from the waiting room and office that could be touched and that were not easily disinfected [5].
It should be noted in this context that Pediatric Dentistry faced unique difficulties, given that some peculiarities of this area, such as the use of toys and other devices during appointments to distract the patient and divert their attention from what can be perceived as a nasty procedure. The use of techniques like this is part of behavioral management and is intended to alleviate anxiety/fear and provide a positive care experience for the pediatric patient [6].
Children and adolescents have been psychologically affected by the pandemic. Fear, uncertainties, isolation, and lack of social relationships led to behavioral problems among them [7-10]. These altered patterns of behavior, together with stricter biosafety protocols, may have interfered with the dynamics of pediatric dentistry appointments, with regard to the behavior of the child patient and the use of behavioral management techniques [11]. Thus, the objective of this study was to analyze the perception of Pediatric Dentists in Brazil regarding the behavior of child patients and their dental care management during the COVID-19 pandemic.
Material and Methods
The article was written in accordance with the recommendations of the “Strengthening the reporting of observational studies in epidemiology” [12].
Ethical Considerations
This project was approved by the Ethics and Research Committee of the Faculty of Dentistry of the Federal University of Pelotas (Opinion number 4.913.636). Prior to the questions, the Informed Consent Form was made available, where the professional was invited to answer the questions voluntarily and informed of the objectives, risks and benefits of the study.
Study Design and Population
This observational, cross-sectional study was carried out with Brazilian Pediatric dentists. All professionals who assisted children and/or adolescents in their routine, had a postgraduate degree in Pediatric Dentistry (specialization, residency, master's or doctorate), and work in public and/or private service were considered eligible for the study. Professionals who had clinical activity developed entirely as professors at an educational institution were excluded.
Given a target population of approximately 9,000 Brazilian pediatric dentists [13], it was estimated that 369 responses would be needed to guarantee a 95% confidence interval and a 5% margin of error. Dentists were invited through their e-mails, WhatsApp® and Instagram® to answer an online self-administered questionnaire from December 2021 to May 2022. Councils, graduate centers, regional and Brazilian Pediatric Dentistry associations were asked to send an email to registered dentists inviting them to respond to the questionnaire.
An Instagram® profile was created where publications were made, some sponsored, about the study and messages were sent directly to the professionals. In addition, the disclosure was made on WhatsApp® by sending the link to the questionnaire to dentists and groups of Pediatric Dentists, thus seeking greater adherence by professionals.
Questionnaire and Pre-Test
The survey was hosted on the SurveyMonkey® platform with questions related to professional profile (gender, workplace, age, size of the city where they work and time since graduation) and referring to behavioral changes and behavior management techniques employed during the pandemic (Table 1). For the “positive pre-visit imagery” technique, a specific question was asked due to its being a more recent strategy and because it can be used even at a distance, potentially favoring its use during the pandemic period and social isolation.
Questions and alternative answers for the questionnaire related to children and adolescent behavior changes and behavior management techniques during the COVID-19 pandemic.
Response options regarding the workplace could be: public and private, public only, or private only. Age was answered in years and categorized into: 20-29, 30-39, 40-49 and 50-59 years. The size of the city where they works was questioned according to the number of inhabitants: Small (up to 100,000 inhabitants), medium (from 100,000 to 500,000 inhabitants) and large (more than 500,000 inhabitants). As for the time since graduation, the following options were given: Up to 5, 5 to 10, 10 to 15, 15 to 20, 20 to 25 and more than 25 years.
The questionnaire was pre-tested by 14 dentists, with professional profiles that are part of the research exclusion criteria, to evaluate the wording of the questions.
Statistical Analysis
Data analysis was performed using the Stata 16.0 program (StataCorp LLC, College Station, TX, USA), where a descriptive analysis was performed with the presentation of the relative and absolute frequencies of the studied variables. To analyze the association between the perception of Pediatric Dentists about the children and adolescents’ behavior in consultations and the use of behavior management techniques, Fisher's Exact test was used (p<0.05). Unanswered data were treated as missing data and identified in the table.
Results
The survey was answered by 276 participants; 6 were excluded since they acted exclusively as professors, 39 did not answer all questions, and were removed, totaling a sample of 231 Brazilian Pediatric Dentists. The profile of the participants is described in Table 2. Most of the professionals interviewed were female, aged between 30 and 39 years, had graduated more than 25 years ago, worked only in the private service and in large cities' ports.
When asked about the patient behavior during dental care in the pandemic, 45.6% of Pediatric Dentists noticed a worsening in the behavior of children and adolescents and 48.3% did not notice changes (Table 3).
Perception of Brazilian pediatric dentists regarding the behavior of children and adolescents during appointments during the COVID-19 pandemic period.
Changes in the use of behavioral management techniques in the care routine of Brazilian pediatric dentists during the COVID-19 pandemic are demonstrated in Table 4. Appropriate/physical contact was the technique that had the greatest reduction/suspension of employment (77.6%), followed by the distraction technique using toys and books (55.9%). The other techniques showed a low percentage of reduction/suspension: protective stabilization (14.3%); positive reinforcement (10.6%); distraction with television (8.2%); nitrous oxide inhalation (12.7%); sedative drugs (12.5%). Most dentists (71.3%) reported that they continued using the positive reinforcement technique (delivery of souvenirs/gifts at the end of the consultation) during this pandemic period, and also a high percentage (73.8%) stated that they continued using the protective stabilization technique. The use of television (62.7%) and tablet (53.4%) were also resources that continue to be used for distraction by most Pediatric dentists. Most dentists reported that they continued to use sedation techniques with nitrous oxide, drug sedation and general anesthesia during the pandemic period (Table 4).
Impact of the COVID-19 pandemic on the use of behavioral management techniques in the care routine of Brazilian pediatric dentists.
Regarding the behavioral management technique called positive pre-visit images, among respondents, 65.1% (n=149) reported that they do not use it, 15.7% (n=36) started using it during the pandemic and 19.2% (n=44) already used it before that period.
There was a statistically significant relationship between the perception of children and adolescents behavior in dental appointments during the pandemic and the use of protective stabilization (p<0.001) and positive reinforcement (p=0.002) management techniques (Table 5), since it was observed an increase in the use of the aforementioned techniques among those participants who noticed a worsening in the patient behavior during consultations in the pandemic period. There was no association between the perception of behavior change and the other management techniques (p>0.05).
Use of behavioral management techniques by pediatric dentists according to their perception of the behavior of children and adolescents in dental care during the COVID-19 pandemic.
Discussion
The results of this study showed that almost half of pediatric dentists noticed a worsening in the behavior of child patients during dental care during the pandemic period. Among the behavior management techniques, those that had the greatest reduction/suspension in their use were appropriate/physical contact and distraction with toys/books, and an increase in the use of protective stabilization techniques and positive reinforcement was found among dentists who observed a worsening in the behavior of children and adolescents. Only 15.7% of respondents started using the positive pre-visit imagery technique during the pandemic.
The worsening in child behavior observed may be related to some measures implemented during this period. The closing of schools and the restriction of movement of people had a profound impact on the activities and routine of children and adolescents [14], causing negative effects on their mental health and behavior [7-10]. Added to this, the greater rigor in the use of Personal Protective Equipment (PPE), a measure adopted during the pandemic to minimize the risk of contamination during dental care, may have surprised children by restricting the visibility of the professional's face [15], in addition to hindering the use of non-verbal communication techniques, such as facial expression. A study carried out in 2020, at the height of the pandemic, showed that 64.22% of the pediatric dentists interviewed had difficulties in child care due to the implementation of these extra PPE [16]. Data from a survey carried out with Indian Pediatric Dentists showed not only difficulties reported by these specialists in interacting with patients, but also the perception of greater anxiety in children due to PPE [17].
It is known that at the beginning of the pandemic and during periods of lockdown, most dental appointments were suspended or postponed, being limited to emergency care only [4], that is, in many cases the children had already arrived at the office in pain, which may trigger greater fear and anxiety in the child during the appointment, and may also be related to the worsening behavior observed by Pediatric Dentists during this period.
Added to this, the impact on personal and professional lives that the pandemic had on dentists may also have influenced the conduct of care and their perception of patient behavior. The results of a recent systematic review indicated that the COVID-19 outbreak affected the dental profession with psychological consequences, with fear, anxiety and stress being the most commonly observed symptoms among professionals [18]. Torres et al. [16] showed that 59.11% of Brazilian Pediatric Dentists felt insecure about performing dental care during the pandemic and 83.78% felt more stressed during this period.
According to the AAPD [6], the use of behavioral management techniques in pediatric dentistry patients aims to alleviate anxiety/fear and provide a positive care experience. Changes in the frequency and use of these techniques due to the pandemic may also be one of the factors associated with behavioral changes in patients.
In the present study, appropriate/physical contact was the technique that had the greatest reduction in employment. This is probably because one of the strategies adopted during the pandemic to reduce the chances of transmission of the virus was the limitation, whenever possible, of close contact among people. Since this form of non-verbal communication helps to improve the effectiveness of other communicative management techniques [6], the reduction in its use may have impaired the management of pediatric dental care.
It is known that toys and other devices are commonly used in pediatric dentistry to distract the patient and divert the child's attention from what may be perceived as an unpleasant procedure within the office environment [6]. In this research, in general, a greater decrease in the use of devices to distract patients was reported in relation to toys/books. The potential justification for this is that the need or impossibility of disinfection ended up further limiting the use of these resources [19]. On the other hand, the screens (tablet, television) were kept by most Pediatric Dentists. It is important to emphasize that there are practical indications for the use of screens and that their use would not be indicated for children under two years of age; in addition, family practices regarding their use should be considered [20].
A high percentage (71.3%) of respondents in this study reported having continued using the positive reinforcement technique by delivering gifts/souvenirs at the end of the consultation during the pandemic, and only 10.6% reduced its use. In addition, a higher prevalence of increased use of this technique was identified among those who noticed a worsening in the behavior of children and adolescents during this period. In the process of establishing desirable child patient behavior, it is important to provide appropriate feedback. Thus, positive reinforcement is an effective technique for rewarding desired behaviors and thus strengthening their return [6]. This is one of the most used techniques and the delivery of rewards and gifts is part of the routine of most Pediatric Dentists [21], during the pandemic it could be maintained, since adaptations were suggested, such as packing the gifts individually and delivering the gift, not letting the others be touched by the patient [22].
Some behavioral management techniques can be used even before the child enters the dental office, such as the use of pre-visit positive images, which consists of sending videos/photos/books to patients to be viewed before their appointment so they can know what to expect during their dental visit. Considering that the professional during the pandemic should already receive the patient while dressed, using this technique could be a good strategy during this period, since it would allow the child to meet the dentist without previously using personal protective equipment [23,24]. According to Gangwal et al. [25] and Rashwan et al. [26], the use of positive pre-visit imagery has been shown to be effective in improving behavior and reducing anxiety in pediatric patients. However, in the present study, a large percentage of dentists reported not using the technique, which may be related to the fact that it is a relatively recent technique, as it was introduced in the guide of the American Association of Pediatric Dentistry in 2015 [27]. On the other hand, a survey carried out with Indian Pediatric Dentists showed that 80% of the professionals interviewed began to focus on pre-consultation behavior modifications through video calls in the post-pandemic scenario [17].
It is known that most children can be effectively controlled using basic behavioral guidance techniques; however, occasionally, more advanced techniques are required, such as protective stabilization, which aims to restrict the patient's movements during the procedure [7]. In this study, a higher prevalence of increased use of this technique was identified among those who noticed a worsening in the behavior of children and adolescents during consultations during the pandemic. The use of protective stabilization in Pediatric Dentistry is a controversial subject, since parents may not often have a good acceptance of its use, thus, risks, benefits and alternatives must be discussed before obtaining informed consent for the technique [28]. Another point that can be considered in this study is that the greater adoption of this technique observed in patients with negative behavior may be related to the impossibility of rescheduling returns for more behavioral management consultations, due to the context of the pandemic and the need for immediate treatment and emergency care in some cases.
In this survey, a high percentage of professionals reported having continued using the technique of sedation with nitrous oxide and ¼ increased its use during the pandemic. During this period, there was a discussion about the use of this technique, due to the potential conduction of aerosols during the use of a nitrous oxide mask, in addition to the potential risk of needing life support measures that involve manipulation of the airways and the use of a net hospital [29]. For some authors, during the pandemic period, nitrous oxide inhalation became even more important in the treatment of non-collaborating patients [30], since they represent a greater threat of spreading aerosols, which can be produced by talking, coughing, and crying [31]. Likewise, there was a report by ¼ of Pediatric Dentists that the increased use of drug sedation, another advanced technique for adapting behavior.
The present study has limitations that must be considered and, therefore, considerations must be made when extrapolating the results found. The representation of all Brazilian Pediatric Dentists was not obtained, and some answers may have been influenced by memory bias, since the questions considered the entire pandemic period. A significant difference was observed in the number of respondents among the questions in this study. Probably, it occurred because this study is an arm of a larger study with many questions and the participants had the option of skipping some questions. It is also necessary to consider the possibility of response shift [32], because perhaps if the questionnaire had been applied at the beginning or during a peak period of the pandemic, the interviewees might have had a different perception. During the period in which this study was carried out, the pandemic situation was already more controlled and professionals were already more adapted to the new circumstances, in order to better deal with them. In addition, as this is a cross-sectional study, it is not possible to predict whether there is causality between the analyzed variables (perception of behavior in appointments vs. use of behavioral management techniques).
Conclusion
This study demonstrated that the COVID-19 pandemic can interfere with the dynamics of pediatric dental appointments regarding the use of behavioral management techniques, with a decrease in the use of certain techniques such as appropriate/physical contact and distraction with toys and books. Added to this, almost half of the Pediatric Dentists noticed a worsening in the behavior of pediatric patients during this period, and an increase in the use of protective stabilization techniques and positive reinforcement was noticed, with a greater prevalence among the Pediatric Dentists who noticed behavioral changes.
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Financial SupportThis study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - Brasil (CAPES) - Finance Code 001.
Acknowledgments
We would like to thank all Brazilian Pediatric Dentists who supported this research by voluntarily responding to the questionnaire.
Data Availability
The data used to support the findings of this study can be made available upon request to the corresponding author.
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Edited by
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Academic Editor:
Wilton Wilney Nascimento Padilha
Publication Dates
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Publication in this collection
08 Dec 2025 -
Date of issue
2026
History
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Received
15 May 2024 -
Reviewed
07 Jan 2025 -
Accepted
26 Feb 2025
