IntroductionBehavioral in ensuring a better quality of dental

IntroductionBehavioral management has shown to provide a successful treatment of young children (1,2). There are young children which will exhibit a disruptive behavior in a dental appointments , which can either be easy or difficult for the dental practitioner to carry out the dental treatment (3,4) Young children who exhibit these kind of disruptive behavior can interfere with the dental treatment and lead to a poor quality of dental care (1). AmericanAcademy of Pediatric Dentistry (AAPD) has introduced 10 behavior management methods in their 1991-1992 and was revised the guidelines in 2015 for Behavior Management(1,5) Five management techniques consist of communication techniques, including:voice control, tell-show-do, positive reinforcement, distraction, and nonverbal communication. Besides that are the hand-over-mouth exercise (HOME) technique and physical restraint. There are the pharmacological interventions such as conscious sedation, nitrous oxide, and general anesthesia. Dentist find these techniques useful in ensuring a better quality of dental care and reduce the risk of injury towards the child. Dentist can no longer conduct these techniques without the awareness and consent received from the parents. They should not assume that the young children’s parents are completely aware and approve of these techniques (3) Health professionals should obtain an informed consent form the young children’s parents/guardians before conducting any behavioral management towards the patient. The health professional can be held liable if any sort of management technique was conducted on the patient before obtaining a consent from the parents(6) In a conference and workshop on behavior management conducted by the American Academy of Pediatric Dentistry in 1988 the participants have agreed that informed consent must be obtained from the parents before specific behavior management technique may be performed (American Academy ofPediatric Dentistry 1988).Hence, the aim of this study is to assess the parents towards various behavior management techniques used. The objective of this study helps us determine the acceptance of the patients parents towards various techniques used by dental practitioners towards young children patients. With this study we analyze the most and least preferred behavior management technique by parents towards their children in a dental clinic Materials and methodA total of ¬100 subjects volunteered  for this study. Before conducting this study on the parents they are informed of the study content. Participants will study the photos which demonstrate the frequently used behavioural management techniques. The behavioural management techniques are1. Tell-show-do (TSD): The dentist or assistant explains to the child what is to be done using simple terminology and repetition and then shows the child what is to be done by demonstrating with instruments on a model or the child’s or dentist’s finger. Then the procedure is performed exactly as described. Praise is used to reinforce cooperative behavior. 2. Voice control (VC): The attention of a disruptive child is gained by changing the tone or increasing the volume of the voice. Content of the conversation is less important than the abrupt or sudden nature of the command. 3. Positive reinforcelnent (PR): This technique rewards the child who portrays any behavior which is desirable. Rewards include compliments, praise,or affectionate physical contact. 4. Hand-over-mouth-excercise (HOME): The disruptive child is told that a hand is to be placed over the child’s mouth. When the hand is in place, the dentist speaks directly into the child’s ear and tells the child that if the noise stops the hand will be removed. When the noise stops the hand is removed and the child is praised for cooperating. If the noise resumes the hand again is placed on the mouth and the exercise repeated.5. Physical restraint by the dentist (PRD): The dentist restrains the child from movement by holding down the child’s hands or upper body, placing the child’s head between the dentist’s arm and body, or positioning the child firmly in the dental chair. 6. Physical restraint by the assistant (PRA): The assistant restrains the child from movement by holding the child’s hands, stabilizing the head, and controlling leg movements.7. Papoose Boardsa and Pedi-Wrapsb (PR): These are restraining devices for limiting the disruptive child’s movement. The child is wrapped in these devices and placed in a reclined dental chair. 8. Sedation (SED): Sometimes drugs are used to sedate a child who does not respond to other behavior management techniques or is unable to comprehend the dental procedures. Often, these drugs are administered orally. 9. General anesthesia (GA): The dentist performs the a Olympic Medical Corp., Seattle, WA. b Clark Associates, Worcester, MA. dental treatment with the child anesthetized in the operating room.This questionnaire allowed the parents to rate each of these management techniques in accordance to their willingness to have them used on their children upon dental treatment. As well as getting their cooperation prior to the dental treatment. These questions will be a single horizontal line running lengthwise across the middle of a page. Each parent will score each question out of 10. The higher the scoring will indicate the most accepted and the least will indicate the least accepted. The level of acceptance is compared by taking the mean for each of the 10 behavioral management techniques. Figure 1: Survey ResultsTable 1:S.NO TECHNIQUE RESPONDENTS PERCENTAGE (%) MEAN VALUE 1. Tell-show-do (TSD) 915/1000 91.5 9.152. Voice Control 768/1000 76.8 7.683. Positive Reinforcement 892/1000 89.2 8.924. Hand Over Mouth Exercise(HOME) 608/1000 60.8 6.085. Physical Restraints by an assistant 274/1000 27.4 2.746. Papoose Board and Pedi Wraps 147/1000 14.7 1.477. Sedation 458/1000 45.8 4.588. General Anesthesia 163/1000 16.3 1.63Figure 1: Mean distribution A survey was distributed to adult parents. The parents has to score a value from 1-10 depending on their acceptance towards that technique being implements on behavioral management of children in pediatric dentistry.  The participants had to score all 10 techniques depending on their liking and preference. Based on the results, the most accepted methods of management which was widely accepted by parents are tell-show-do(91.5%), positive reinforcement (89.2%)and voice control (76.8%) It can be seen that a majority of the parents prefer a proper communication between the child and the dentist. Allowing the child to understand their surrounding and allow the dentist to preform the treatment without any interruption for the patients side. 60.8% of the parents were moderately accepting of HOME being used to manage pediatric patients. This is then followed by sedation, in which nitrous oxide or any sort of sedation methods with 45.8% acceptance. Lastly, the least accepted behavioral management techniques used by dentists towards pediatric patients was found to be physical restraint (27.4%), general anesthesia (16.3%) and finally the least accepted method of all is the usage of papoose board with 14.7% acceptance Discussion There are various behavioral management techniques made available for dentist to use for pediatric patients. These techniques are often used by the dentist in order to effectively deal with pediatric patients with many different responses. Each child will response to dentistry differently. For each child’s behavior there will be a dentist who will respond in a way that could help the child to adapt to the dental experience in a positive manner, the dentist should be capable of changing his/her own behavior to meet the individual child’s needs at a particular moment.(7) Based on our results the most accepted behavioral technique is tell-show-do followed by positive reinforcement. There has been a study conducted in which forty-six parents completed survey forms for analysis and it was deduced that Tell-show-do was rated as the most acceptable technique followed by , followed (in order of decreasing acceptance) by:  nitrous oxide sedation, general anesthesia,active restraint, oral premedication, voice control, passive restraint and hand-over-mouth. Comparing our study as well as the study mentioned above we can say that the common factor is having the most accepted technique to be tell-show-do. However the difference is that positive reinforcement is the 2nd most accepted in our study but in the other study sedation is found the be the most accepted after tell-show-do(8) In another study, they have found similar rustles having tell-show-do to be the most accepted management technique(9). The most accepted technique in another study (10) was positive reinforcement (81.1%) followed by TSD(76.7%) . It is as expected that the least invasive and aggressive technique is the most accepted. This statement was similarly said in another ariticle whether they have found the least invasive methods, tell-show-do and positive reinforcement, to be the most accepted (3) Physical restraint and papoose board/pedi wrap was not generally well accepted by the parents in our study. There is a supporting article while shows that, they have found the least accepted technique was restraint (1.1%) (10) In our study sedation is not completely rejected by the parent to allow the dentist to preform the treatment in a smooth manner. However in another study and hypnosis were entirely unacceptable to 30.1% while sedation was unacceptable to 15.6%. (10) Another study showed that, Papoose Board and general anesthesiawere viewed with equal disapproval wherea sedation was viewed distinctly more favorably than general anesthesia and was grouped with HOME(3). This can be correlated to our study in which sedation was more accepted by parents compared to general anaesthesia, physical retrainsts and papoose board/pedi wraps. It was said by Wein- stein et al. 1982 (11) that physical restraint was used in pediatric dentistry in an attempt to control fear-related behaviour, however it was showed that in 85% of cases the child’s poor behaviour continued. The same author later found that when chairside assistants held a child patient it was very effective Weinstein et al (12) Fields (13) reported that whole-body restraint in the form of a Papoose Board was the least acceptable management technique to parents. In a later survey the great majority of mothers who had been involved in its use for their own children were very positive about the technique (14) This study showed that , most parents (84.5%) responded they would preferred to  stop the treatment of an uncooperative child, or to stop and calm the child and then resume treatment. The rest (14.5%) said they would help the dentist even to the point of restraining their child. (10) With respect to the Papoose Board, in our study the findings indicate that only 14.7% of the parents have chosen this management technique to be less acceptable. Whereas in another study , their findings show that Papoose Board was ranked the least accepted technique and it was similar to our study ar it was ranked below general anaestheis(16). Similarly in a study conducted on mothers which reported that most mothers approved the use of Papoose Board(16,17) They thought the Papoose Board was necessary to perform the treatment despite its being stressful for the child, and would have had it used on their other children should they require it. It was found in a study that the use of a Papoose Board was consistently unacceptable with all dental procedures, but acceptance of this technique was greatest for use with an emergency extraction(18)There has been studies which show a correlation between Hand Over Mouth Exercise and Voice Control such as the study done by Marilyn Goodwin Murphy. This author has found that there was a positive relationship between approval of HOME and approval of voice control (3). In a study, they have found that only 7.8% of the parents accepted voice control as on of the behavioral management techniques (10,15) in our study we can see that over 76.8% of th parents have preferred Voice control as one of the behavioral management techniques. Likewise in a study,it was found that there was a marginal acceptance of voice control. (16) 60.8% of the parents have accepted Hand Over Mouth Exercise (HOME). There haves been studies conducted to see whether or not there are pedodontist who practice this technique used on pediatric patients. Reports have shown that only 34% of the dentists reported that they had decreased their use of HOME(19) For HOME, thee are a variety of ways in which the technique is used, but hand-over-mouth with airway restriction was viewed as inappropriate. There has been some concern which was expressed about HOME where use in times of intense media coverage of child abuse and molestation. However this technique is intended to facilitate treatment without causing harm to the child. (20) It was acknowledged by Casamasimo 1993 that using HOME as a skill on controlling the patient varies greatly between dentists and that while results can be impressive it can also be ‘downright ugly’. (7,21)HOME was described by Craig the purpose of the technique is to gain the attention of a child to allow communication this aids in allowing the dentistry explaining what kind of treatment is being done towards the child.(7,22) It might be better to described HOME in terms of negative reinforcement where the child’s behaviour of stopping the protest and being quiet is reinforced. Through this there will be cessation of the unpleasantness of the child of not being allowed to protest loudly and of having his/her limbs restrained.(7) there has been a study in which they have found that children do not remember, nor are affected by, hand over mouth/restraint experiences (23) In a UK survey 51% of the paediatric dentists surveyed thought that the child would come to fear dental treatment if HOM were used (7,24)Generals anesthesia is another way of managing pediatric patients if they are making it difficult for the dentist to conduct the treatment. This method can sometimes be used as it is said to be the best to put the child completely to sleep and finish of all the treatment in a single, stress-free visit(25) In a study conducted among dentist to see whether or not a they prefer using general anasthesia and sedation as a management technique and it was found that, a percentage of respondents had decreased their use of conscious sedation (21.9%) and increased their use of general anesthesia (23.1%) over the past five years. (19) A similar study was conducted on the dentist in Saveetha dental college and it was found that 43% of the dentist would choose general anasthesia as a management technique and 57% of them would not recommend general anasthesia as a method of management children (26) Conclusion We can conclude that parents prefer a management technique which required the dentist to communicate and interact with their child. By doing so this will create a bond between the dentist and the child. The child will not be afraid and will be more open towards accepting a treatment