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Year : 2017  |  Volume : 35  |  Issue : 3  |  Page : 223-228

Behavioral changes during dental appointments in children having tooth extractions

Department of Social and Preventive Dentistry and Graduate Program in Dentistry, Federal University of Pelotas, Pelotas, Brazil

Date of Web Publication31-Jul-2017

Correspondence Address:
Mariana Gonzalez Cademartori
457, Gonçalves Chaves Street, Pelotas, RS
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JISPPD.JISPPD_195_16

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Background: Tooth extractions are associated with anxiety-related situations that can cause behavioral problems in pediatric dental clinics. Aim: We aimed to describe the behavior of children during tooth extraction appointments, compare it to their behavior in preceding and subsequent dental appointments, and assess the behavioral differences according to gender, age, type of dentition, and reason for extraction. Settings and Design: This was a retrospective study based on information obtained from records of children between 6 and 13 years of age who were cared for at the Dentistry School in Pelotas, Brazil. Materials and Methods: Child behavior was assessed during the dental appointment that preceded the tooth extraction, during the tooth extraction appointment, and in the subsequent dental appointment using the Venham Behavior Rating Scale. Statistical Analysis: Results were analyzed using the Pearson Chi-square and McNemar tests. Results: Eighty-nine children were included. Cooperative behavior prevailed in all the dental appointments. The prevalence of “mild/intense protest” was higher in the tooth extraction appointments than in the previous or subsequent dental appointments (P < 0.001). No significant differences in behavior were detected between the type of dentition (primary or permanent teeth), reason for extraction or gender. Conclusion: In this sample of children treated at a dental school, the occurrence of uncooperative behavior was higher during the tooth extraction appointments than in the preceding and subsequent dental appointments.

Keywords: Child behavior, pediatric dentistry, tooth extraction

How to cite this article:
Cademartori MG, Martins P, Romano AR, Goettems ML. Behavioral changes during dental appointments in children having tooth extractions. J Indian Soc Pedod Prev Dent 2017;35:223-8

How to cite this URL:
Cademartori MG, Martins P, Romano AR, Goettems ML. Behavioral changes during dental appointments in children having tooth extractions. J Indian Soc Pedod Prev Dent [serial online] 2017 [cited 2023 Feb 1];35:223-8. Available from: http://www.jisppd.com/text.asp?2017/35/3/223/211845

   Introduction Top

Children behavior in dental setting may vary depending on the child age, psychosocial characteristics, personality, family environment, and objective or subjective dental experiences.[1] Dental treatment is a situation with great fear- and anxiety-generating potential. These feelings can play an important role and cause aversive uncooperative behavior during dental appointments.[2] Children who are submitted to tooth extractions relate more pain, discomfort, and fear.[3]

Painful emergency treatments and those requiring the use of local anesthesia seem to worse children's behavior in subsequent dental appointments.[4] Pain experienced during dental treatment can also lead to anxiety during subsequent dental appointments,[5] suggesting that the type of dental procedure should also be considered by pediatric dentistry.

On the other hand, studies have shown the conditioning effect of subsequent dental treatment.[6] The experience gained in preceding dental appointments helps the child to cope with stressful dental procedures and to recognize the nonthreatening aspects of the dental appointments.[6] Thus, previous dental experience could influence behavior at subsequent dental appointments.[7],[8]

However, studies that investigate the connection between tooth extraction and behavioral manifestations are scarce. Therefore, it is important to evaluate whether tooth extraction has a negative influence on children's behavior during dental treatment and whether it can affect children's behavior in subsequent dental appointments. The aim of this study was to describe the behavior of children during tooth extraction appointments, compare it to their behavior in preceding and subsequent dental appointments.

   Materials and Methods Top

This study was approved by the Human Research Ethics Committee of the Dentistry School at the Federal University of Pelotas according to Protocol number 166/2010. A retrospective longitudinal study was conducted, with information collected from clinical records. The target population consisted of children assisted in the Paediatric Clinic of the School of Dentistry, Federal University of Pelotas, which were seen between March 2008 and July 2010. Permission to use patient data was obtained through the informed consent form by parents or legal guardians at the first dental visit.

To be included in the study, children should be aged 6–13 years and be a new patient in the pediatric clinic. Children should have had tooth extraction procedure, with local anesthesia, and have at least one previous and one subsequent dental appointment per extraction procedure. In addition, the children should have been assisted by the same dental student in the dental appointments. Only the first tooth extraction procedure performed, in the case, the child had more than one. Records stating children with the presence of any intellectual disability were not included in this study.

Data were assessed by checking the records of the children and were considered in the presence of demographic and clinical variables of interest. Gender and age of children were the demographic variables included. The reason for the tooth extraction (orthodontic treatment or caries) and the type of the tooth extracted (primary or permanent tooth) was also collected.

In the previous and subsequent dental appointments either preventive or operative procedures were performed. Preventive treatments included supervised tooth brushing, dental prophylaxis, and use of topical fluoride. Curative procedures included dental restorations without local anesthesia or use of a rubber dam.

The outcome of the study was the child behavior assessed during three sequential dental visits as following: before, during, and after the tooth extraction. A modified version of the Venham Behavior Rating Scale [9] was used to observe and rate children's reactions during dental care. The child's behavior was classified according to the following criteria:

  • Total cooperation: 😀 (Venham Behavior Rating Scale codes 0–1): No physical protests, enabling good working conditions; soft-voiced protests (moans or restrained tears) without interfering with treatment development, with or without movements; willing to follow instructions
  • Mild protest: 😀 (Venham Behavior Rating Scale codes 2–3): Crying; leg, arm, neck, and head movements; reluctant to comply with requests; attempting to interrupt the session, which, nevertheless, has a positive outcome
  • Intense protest: 😀 (Venham Behavior Rating Scale code 4–5): Physical restraint by one or more persons necessary; child tries to escape from the dentist's chair, covers his mouth; the session may have to be interrupted.

The child's behavior was rated at three different times: at the beginning of the dental appointment, during the dental treatment, and at the end of the dental appointment. The final score was determined by the peak score obtained at one of these three times.

The dental care of children was performed by 4th year dental undergraduate students, closely supervised by professors, PhD in Paediatric Dentistry. As a routine procedure, after each dental visit, the child's behavior, and the name of the student are registered in the dental record. To assess the child behavior during the dental visits, all students received 2 h of theoretical and practical training regarding the application of this scale before the beginning of the dental care in the pediatric dental clinic. In addition, during the dental appointments, the dental students used the tell-show-do, the voice control, the nonverbal communication, the positive reinforcement, and the distraction as behavior management techniques. All these information were registered in the dental records.

Data were double-typed and results were analyzed by Stata 12.0 (Stata Corporation, College Station, TX, USA) software. Descriptive analysis was performed to describe the absolute and relative frequencies and calculate the prevalence of interest variables of the study. For analytical purposes, the child's behavior was categorized as (1) “total cooperation” or (2) “mild/intense protest.” McNemar's test was used to compare the child behavior distribution on three distinct times: before, during, and after tooth extraction appointment. To evaluate the behavioral differences according to gender and age, Pearson's Chi-square test was performed. To assess the differences in the behavior according to age, the children were classified into the following two age groups at the time of the tooth extraction appointment: 6–10 and 11–13 years of age.

   Results Top

A total of 306 records were evaluated. Of these, 89 clinical records met the inclusion criteria. Thereby, 89 children aged 6–13 years (mean 9.2 ± 1.65 years), 40 (44.9%) of whom were boys, were included.

[Table 1] displays the distribution of the children's behavior in the dental appointment before, during, and after tooth extraction. On analyzing the recorded behavior distribution for each dental appointment, the prevalence of the “total cooperation behavior” was lower during the tooth extraction appointment (71.9%; n = 64) than in the previous (89.9%; n = 80) or subsequent dental appointments (91.1%; n = 81). On the other hand, the frequency of “mild/intense protest” was 10.1% (n = 9) before, 28.1% (n = 25) during, and 8.9% (n = 8) after the tooth extraction appointment.
Table 1: Distribution of children's behavior in dental appointments before, during, and after tooth extractions (n=89 children)

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The distribution of children's behavior by gender in dental appointments before, during, and after tooth extractions is shown in [Table 2]. No significant differences were found between boys and girls in terms of the behavior at dental appointments [Table 2]. The influence of the type of dentition (primary or permanent tooth) and the reason for tooth extraction on children's behavior were investigated. No difference was detected between primary and permanent teeth (P = 0.102) or tooth extraction for orthodontic reasons and caries (P = 0.827), [Table 3].
Table 2: Distribution of children's behavior by gender in dental appointments before, during, and after tooth extractions (n=89 children)

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Table 3: Distribution of children's behavior in tooth extraction appointments according the type of dentition and reasons of dental procedures (n=89 children)

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The “mild/intense protest” behavior of the children at the three different appointments according to age is shown in [Table 4]. “Mild/intense protest” behavior was higher during the tooth extraction appointment for both the age groups (27.4% and 28.9%, respectively). In general, a significant difference was found in the “mild/intense protest” behavior when the before-extraction (P< 0.001) and after extraction (P< 0.001) appointments were compared with the tooth extraction appointments. However, when behavior before and after tooth extraction appointment was compared, no significant differences were found (P = 0.705). However, on evaluating the children's behavior according to age, a significant increase in the “mild/intense protest” behavior was observed between before- and during-tooth extraction appointments (P = 0.004) and during- and after-tooth extraction appointments (P = 0.001) in older children. A significant increase in the “mild/intense protest” behavior was also observed between before- and during-tooth extraction appointments in children aged 6–10 years (P = 0.020). Nevertheless, when comparing pre- and post-tooth extraction appointments, none of the age groups showed significant differences.
Table 4: Differences in the frequency of “mild/intense protest” behavior in appointments before, during, and after extractions, according to age group (n=89 children)

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   Discussion Top

In general, cooperative behavior prevailed in the present sample, and a low prevalence of uncooperative behavior was observed during tooth extraction. Despite this fact, there was an increase in uncooperative behavior during the tooth extraction appointments compared to previous dental appointments.

There is a strong association between uncooperative behavior and too invasive dental procedures including tooth extraction.[9] Tooth extractions may cause anxiety during dental treatment because of the possibility of forceful or painful removal of the tooth, thus resulting in aversive behavior and raising protests from the child. The dental procedure may also represent a feeling of loss suggesting a “psychological insult” to the child.[10] The change in behavior during a tooth extraction is associated with the sensation of local anesthesia, unfamiliar or unpleasant tastes,[11] and fear of blood, which may lead to avoidance behaviors.[12]

A qualitative study observed that children externalize a specific anxiety related to dental local anesthetic injections and the presence of sharp instruments during dental treatment as an overwhelming sensory experience,[13] which reinforce the influence of clinical context on child behavior. Furthermore, the main complaints of boys and girls are creaking sounds and wiggling of the tooth during the extraction.[14] The sensation caused by manipulation of a tooth with an elevator or with the forceps, the sound of the instruments, and the pressure are very often interpreted as pain by the child.[15] This sensitivity to pain tends to be an important component of expectations about and reactions to dental procedures.[16]

Interestingly, child behavior in the subsequent dental appointment was no different from the child behavior in the dental appointment before the tooth extraction, suggesting that the tooth extractions neither triggered nor increased dental fear in subsequent appointments. This result highlights an important issue. A longitudinal study suggested that continued experience provides a decrease of dental anxiety levels, regardless of the dental procedure performed.[17] As children become familiar with the dental environment, they learn to distinguish between stressful and nonstressful procedures.[6],[18] This may explain the fact that behavior during the extraction was worse than the behavior in previous or subsequent appointments, but child behavior in subsequent dental appointment was no different from the child behavior in dental appointment before the tooth extraction. This result is similar to that found by Sjögren et al.[3] However, other studies have suggested that pain experienced during dental treatment can lead to anxiety [5] and worse child behavior [4] in subsequent dental appointments. These findings reinforce the need to adopt proper strategies to control pain and discomfort and adequate behavior management techniques to minimize dental fear during the dental appointments.[19]

In this study, eight children presented uncooperative behavior during their tooth extraction appointment, and also during pre- and post-tooth extraction appointments. Some studies have reported behavioral problems during both follow-up dental appointments and curative dental treatments.[20] This indicates that children's behavioral problems during dental appointments are not exclusively influenced by procedures performed. Other uninvestigated variables in this study as personality traits,[21],[22] general fears,[10] maternal characteristics,[23] and child–dentist relationship can also trigger feelings of fear and uncooperative behavior during dental appointment. Thus, the dentist's responsibility in predicting and dealing with the children's behavior should be emphasized. The dentist must work alongside child and his/her relatives, fitting the patient into the dental environment, and catering to his/her doubts and anxieties in the face of the treatment to be performed.

No association was found between the child's gender and behavior. Nevertheless, other authors have pointed out a higher prevalence of both fear and behavior management problems in girls.[24],[25] These could be due to a combination of biological and sociological differences [24] that allow them to show their emotions more easily.[25] In a study by Naoumova et al.,[15] girls experienced significantly more pain during local anesthesia than during tooth extraction, but a significant difference was not found between the genders.

Changes in the behavior were significant for older children, probably because they are capable to express their exact feelings and anxiety verbally [19] depending on the procedure performed. Furthermore, older children also had a greater number of tooth extractions,[26] and therefore, had higher chances of previous negative experiences related to invasive dental procedures. However, it has been reported that younger children exhibit the most negative behaviors during dental procedures and are the most difficult to control.[27]

Convenience sampling may be cited among the limitations of this study. We recommend that different age groups be evaluated in future studies, taking into account the mothers' and children's psychosocial characteristics besides the clinical characteristics, as these can also influence children's behavior. In addition, different operators participated in the study. However, to avoid differences in child behavior because of the operator's characteristics, each child was attended by the same dental student in all the three dental appointments.

Some strength keys should be highlighted. First, this is a longitudinal study, with data obtained from patient records. Second, this study measured the children's behavior using a valid and reliable tool, easy to apply and adequate for the children's reactions.[9] Noteworthy, all the students enrolled in the pediatric dentistry clinic are previously trained to use universally accepted behavior guidance techniques in pediatric dentistry with both cooperative and uncooperative children [28] and to assess children behavior using the Venham Behavior Rating Scale. Finally, all dental treatments performed were closely supervised by professors, who were pediatric dentists.

   Conclusion Top

In our sample of children treated at a dental school, uncooperative behavior occurred more frequently during the tooth extraction appointment than in preceding and subsequent dental appointments, especially in children aged 11–13 years. No significant difference in child behavior was detected between tooth extractions of primary and permanent teeth or between tooth extractions for orthodontic reasons and caries.


The authors would like to thank the Professor Dione Dias Torriani (in memorian) for her commitment and dedication to this research group of child behavior in pediatric dentistry.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

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  [Table 1], [Table 2], [Table 3], [Table 4]

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