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Year : 2020  |  Volume : 38  |  Issue : 2  |  Page : 119-125

Phlebotomy for obtaining platelet-rich fibrin autograft in children for pediatric dental procedures: Parental views, understanding, and acceptance

Department of Pediatric and Preventive Dentistry, Inderprastha Dental College and Hospital, Ghaziabad, Uttar Pradesh, India

Date of Submission06-Jan-2020
Date of Decision21-Feb-2020
Date of Acceptance04-May-2020
Date of Web Publication28-Jun-2020

Correspondence Address:
Dr. Kapil Gandhi
46/1, Site IV, Sahibabad Industrial Area, Ghaziabad - 201 010, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JISPPD.JISPPD_4_20

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Background: The negative perception of parents toward invasive dental procedures has always created a barrier in delivering successful treatment to pediatric patients. Surprisingly, little is known about the perspective of parents and the impact of demographic and psychological factors guiding their decision. Aim: To evaluate the acceptability of phlebotomy for obtaining platelet-rich fibrin (PRF) to be used in pediatric endodontic procedures among parents of children. Design: A cross-sectional study design was used for the survey. The design involved interviewing the parents of children aged 3 to 14 years, who fulfilled the inclusion criteria and were indicated for regenerative pulp therapy using PRF. Materials and Method: The sample included one hundred and fifty shortlisted parents who were made to answer questionnaires on sociodemographic data and psychological variables. A single pediatric dentist educated the parents individually on the procedure, risks, and benefits of PRF, following which parental consent and views were recorded in the developed performa. Results: Consent of 63.3% was recorded at the end of the study. Parenting pattern and parental dental anxiety were found to have significant correlation with the treatment acceptance. Conclusion: It is the responsibility of the pediatric dentist to communicate the treatment strategies in a manner that is acceptable to the parents for which a thorough knowledge about parental factors is necessary. This study helps in identifying such factors and highlights the importance of demonstration aids in parental education and motivation.

Keywords: Pediatric endodontics, parental acceptance, parental factors, phlebotomy, platelet-rich fibrin

How to cite this article:
Gandhi K, Goswami P, Malhotra R. Phlebotomy for obtaining platelet-rich fibrin autograft in children for pediatric dental procedures: Parental views, understanding, and acceptance. J Indian Soc Pedod Prev Dent 2020;38:119-25

How to cite this URL:
Gandhi K, Goswami P, Malhotra R. Phlebotomy for obtaining platelet-rich fibrin autograft in children for pediatric dental procedures: Parental views, understanding, and acceptance. J Indian Soc Pedod Prev Dent [serial online] 2020 [cited 2022 Sep 26];38:119-25. Available from: http://www.jisppd.com/text.asp?2020/38/2/119/288229

   Introduction Top

Phlebotomy is known to be one of the most distressing episodes for pediatric patients in medical practice.[1] Otherwise known as “venesection,” phlebotomy is the drawing of the patient's venous blood for laboratory investigation or therapeutic measures.[2] Pediatric dentistry involves the use of phlebotomy for routine blood analysis and preparation of platelet concentrates as agent for pulp capping and regenerative pulpotomy as well as in procedures such as apexogenesis or dentofacial trauma management.[3],[4],[5]

At present, the second-generation platelet aggregate, platelet-rich fibrin (PRF), has shown promising results in the prospects of regeneration in the biomedical field.[6] PRF is autologous in nature and causes sustained release of growth factors (such as transforming growth factor-beta, platelet-derived growth factor, vascular endothelial growth factor, and matrix glycoproteins) from the fibrin mesh. Placement of PRF at the surgical site has shown favorable outcomes in hemostasis, wound healing and sealing, angiogenesis, graft stabilization, bone growth, and maturation as well as dental pulp cell proliferation and differentiation.[7]

It may very well be assumed that despite its promising properties, the preparation of PRF being an invasive procedure will continue to pose a challenge for its use in young children who are anxious and fearful of needle prick. Children and guardians reporting to a pediatric dental clinic are usually apprehensive, unaware of the treatment strategies, and infused with subjective fear. In this scenario, any dental procedure that requires the administration of local anesthesia combined with phlebotomy in a single appointment might make the patient more uncooperative and have a negative impact on his attitude toward dental treatment. Such response will be a matter of serious concern for both the parent and the pediatric dentist. It may therefore be regarded as one of the reasons why PRF goes underutilized in pediatric dental practice.

Scientific literature confirms that negative emotions experienced by the parents tend to create a barrier in successful delivery of treatment to pediatric patients.[8] This is because parental anxiety, exaggerated reassurance are closely related to the child's ability to cope with the treatment procedure.[9] Surprisingly, little is known about the inclinations, beliefs, or motivation of the parents and the social as well as psychological factors involved in their decision-making. Therefore, the present study was planned to evaluate the acceptability of phlebotomy for obtaining PRF to be used in pediatric endodontic procedures among parents of children reporting to dental clinic and analyze whether the demographic and psychological factors or use of demonstration guides influenced their decision.

   Materials and Methods Top

The study was approved by the Institutional Ethical Committee (IRB No. 067) and written informed consent was obtained from the parents who participated in the same.

Study population

A cross-sectional observational study was carried out in the department of pedodontics and preventive dentistry over a 6-month period (July–December 2018) among parents of healthy pediatric patients who had at least one primary/young permanent tooth indicated for regenerative endodontic procedure. Potential participants (parents) were excluded if (1) the child presented with any preexisting medical condition (American Society of Anesthesiologists' Physical Status Classification System of Grade 2 or greater),[10] (2) the child required special health-care needs during delivery of the treatment, (3) the child was scheduled for an emergency dental appointment, (4) more than one child was present at the time of dental visit, and (5) more than one parent was attending during the dental appointment.

Study design

The eligible candidates were given a brief description of the study purpose and process, following which a formal request was made to participate in the study. A total of 150 parents who consented for the research protocol were interviewed in the counseling room by a single interviewer on the basis of a questionnaire.


The questionnaire was divided into five sections and included 21 items and subitems. The first section included details of the child such as age, sex, and presence or absence of any past dental experience. The second segment included demographic details of the parents such as age, relation with the child, marital status, educational background, and occupation. Educational level was assessed according to the International Standard Classification of Education (ISCED 2011) on a scale of level 0–8 and the highest achieved level of education of the participant was used.[11] The presence or absence of past dental experience of the parents was also taken into account. In the third section, the parents were given a set of thirty questions to determine their parenting style as authoritative, authoritarian, or permissive.[12] Parental dental anxiety was calculated using Norman Corah's dental anxiety scale (DAS) in the fourth section. DAS is a four-item measure in which the respondents are given four dental-related situations and asked to rate their anxiety on a scale of 0 (no anxiety) to 5 (severe anxiety).[13] Following this, the participants were classified to have either no anxiety or moderate, high, and severe anxiety. The parents were briefed about the necessary instructions for filling the questionnaire and were given 20 min to fill the same. All the parents were thereafter educated about PRF as a novel agent in pulp therapies, the technique involved, and the associated risks using educational modules by the interviewer.

Educational modules

The interviewer carried out the parental counseling on PRF. It was made sure that the child patient was not present during counseling process. The procedure was verbally explained along with the possible risks involved. A pamphlet was specifically designed for this step which included pictorial demonstration of preparation of PRF and its use in dentistry, its advantages, and the alternative dental materials currently being used in pediatric pulp therapies. This was followed by a video demonstration of 2 min and 30 s on PRF preparation in a child patient. A short interactive session between the participant and the interviewer was thereafter carried out to clarify any doubts regarding the contents of the education modules.


Parental consent on if they would opt for pulp therapy using PRF in their child was recorded in the last section of the questionnaire along with reasoning for the same. The parents were given three options as to either (i) reject the treatment or (ii) accept it and go ahead with the procedure in the same visit or (iii) consult at home and reject or accept the treatment in the second visit. A set of reasons were enlisted for the parents [Figure 1] to choose in order to support their decision. Any other reason provided by the parent was also recorded.
Figure 1: Enlisted reasons for parents in decision-making

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Statistical analysis

Data were analyzed utilizing the Statistical Package for the Social Sciences (SPSS) 2.0 software (SPSS Inc., Chicago, IL, USA). A descriptive analysis was initially performed to describe the characteristics of the sample. Chi-square test was used to assess if any significant relationship existed between the independent categorical variables and the overall final consent given by the parents in the two visits combined. A layered Chi-square test was thereafter carried out to evaluate the same. Binary logistic regression analysis was done to obtain odds ratios for parental consent and each independent variable. Hosmer and Lemeshow test was performed to evaluate whether the predicted probabilities matched with the observed probabilities.

   Results Top

Parents of 150 pediatric patients willingly participated in the present study, of whom 86 (57.3%) were fathers and 64 (42.7%) were mothers. The mean age of the participating parents was 35.91 ± 5.59 years. Of the 150 pediatric patients, 80 (53.3%) were males and 70 (46.7%) were females, with a mean age of 7.95 ± 2.86 years. The categorization of children into three age groups was done according to the WHO guidelines:[14] Group I (3–5 years), Group II (6–11 years), and Group III (12–14 years). 48% of the pediatric patients and 53.3% of the parents reported of having previous dental experience. The parental education level was classified according to the ISCED 2011. ISCED 0–3 that represents up to 12 years of education was classified as a low education level, and ISCED 4–8, which is more than 13 years of education, was classified as a high education level. 50.7% and 49.3% of the participating parents belonged to low and high education groups, respectively. After assessing the scores of parenting style questionnaire, 79 (52.67%) of the parents were categorized as authoritative and 71 (47.33%) of them were identified as authoritarian. No parent with permissive parenting pattern was encountered in the present study. Dental anxiety scores were recorded for individual participants and 58 (38.67%) were classified as nonanxious and 92 (61.33%) parents were found to have dental anxiety. An overall final consent of 63.3% was recorded at the end of the study.

A statistically significant relation was found between the consent and the parenting pattern (P = 0.01) as well as with parental dental anxiety (P = 0.029), while all other factors were found to be nonsignificant [Table 1]. It was evaluated that the parents were more likely to give consent for a male child and the relationship was statistically significant (P = 0.00). Moreover, fathers were more willing to consent for the procedure (P = 0.05). It was also found that parents gave consent if the child had no past dental experience (P = 0.00), and if they themselves have had a dental history (P = 0.00), the associations were statistically significant. Higher number of parents consented if the child belonged to age Group II (6–11 years) (P = 0.05). Furthermore, higher number of nonanxious parents (P = 0.05) and the ones belonging to higher education group (P = 0.01) consented for the procedure, the relations being statistically significant [Table 2]. 30.26% of parents have cited reasons such as “autologous graft compared to dental material” and “success rate shown by PRF” when accepting the invasive treatment, whereas “fear of parent” (25.0%) and “risk of trauma during phlebotomy” (19.79%) were the two most cited reasons by the parents who did not give consent for the use of PRF in their child [Figure 2].
Table 1: Dependence of consent on the independent categorical variables

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Table 2: Layered Chi-square test to assess the dependence of consent on variables

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Figure 2: Reasons cited by parents in support of consent

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Of the 22 parents who gave consent in the second visit after discussing at home, 18 (81.8%) did not opt for the procedure. Thirteen out of these 18 parents said “lack of consent from other parent” was their reason for not giving the consent.

The odds ratio for parenting type was found to be 2.302, with 95% confidence interval of 1.078–4.916. This shows that the odds of authoritative parents accepting the treatment are 2.302 times odds of authoritarian parents [Table 3].
Table 3: Strength of association between final consent and categorical variables

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P = 0.155 was achieved after carrying out the Hosmer and Lemeshow test, which signals that there is acceptable match between the actual and predicted probabilities. One has to get an insignificant P value because the goal is to derive predictors that would accurately predict the actual probabilities.

In the present study, the overall predictive accuracy was determined to be 62.7%, i.e., using the various predictors taken in our study, one can successfully classify if the patient's parent will give consent or not. It was also observed that model predicted better (84.2%) for those who have given affirmative consent [Table 4].
Table 4: Overall predictive accuracy of the study model

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   Discussion Top

It is known that attitude of patients toward their dental health is usually permissive when compared to overall health. This may be due to lack of awareness on the importance of good oral health and the anxiety associated with dental treatment. Communication between patient and dentist is therefore of prime importance to build a positive dental attitude in the patient. However, in pediatric dentistry, a three-way communication is to be framed as the parents are the proxy decision-makers for the child's treatment needs. Involving an invasive dental procedure in this scenario definitely complicates the communication and raises the dental anxiety in both the treatment seeker and accompanying parent.

The main objective of the present survey was to identify the social, demographic, and psychological factors that are involved in the parents' acceptance of an invasive procedure like preparation of PRF for regenerative pulp therapies in children. It also intended to consider if the use of educational modules such as pamphlet and video demonstration would help the parents in the better understanding of the procedure and in turn reflect in their decision. The effects of factors such as child's age and gender, parental age and gender, previous dental experience of child and parent, parental educational level, and their dental anxiety were specifically investigated. The present study shows that parenting pattern and parental dental anxiety can be major determinants in the acceptance of the treatment.

In the present study, two of three parenting patterns were encountered. The authoritative parenting pattern consists of factors such as rational guidance, expression of affection, and encouragement of independence, whereas authoritarian control, supervision of the child, and control by anxiety induction are the characteristic features of authoritarian parenting.[12] In the present study, 73.4% of the authoritative parents have accepted the invasive dental procedure. The difference between acceptance of treatment by authoritative and authoritarian parents was evaluated to be statistically significant. Authoritative parents have logical interpretation of a situation and would always encourage, guide and show confidence in their child's capabilities. The acceptance of PRF may therefore be attributed to the factors governing the parenting pattern.

Higher number of nonanxious parents have shown acceptance of the invasive procedure and were willing to extend support to their child as well as the pediatric dentist for the successful completion of the treatment. An interesting observation was, of the 40 parents in the anxious group who did not give consent, 28 (70%) cited either “fear of parent” or “risk of trauma during phlebotomy” or both as the reason for not accepting the treatment. This might indicate that dental anxiety or dental fear of the parents themselves is interfering with the child's proposed dental treatment. Variables such as age and gender of the child or record of his/her past dental experience, age and gender of the parent, educational level, and religion did not show any positive correlation with the consent given by parents. A larger sample size would probably yield better results in this context.

Statistically significant correlation of consent for treatment was observed when treating a male child compared to a female child. Child with no past dental experience and treatment of child within age range of 6–11 years also secured more consents for treatment from their parents than others. Similarly positive consent was secured for treatment when the consenting parent was a father than mother, parent having a past dental history of treatment, a non-anxious parent and parents having higher educational qualification. The reason for consenting in cases of male child may be explained on the basis of marked favoring for sons compared to daughters in India regardless of demographic factors.[15] Positive consent was recorded more from the fathers which again points toward the patriarchal social norms prevalent in India. Majority of the parents consented to carry out the procedure in 6–11 years olds, which may be due to the fact that very young children will find it hard to cope with an invasive procedure and adolescents relate dental fear and anxiety particularly with injections and drilling.[16] Participants who have had a dental experience were found to be more relaxed and showed interest in learning more about PRF, e.g., uses in medical field and use of PRF in adult patients. Parents with children who did not have a dental history were more willing to guide their child through the invasive treatment and showed more interest in making the experience a pleasant one. Participants belonging to higher educational levels had an easier and better understanding of the concept of PRF and some even reported of having heard the term earlier. These parents also came up with queries and were looking forward to actively participate in the treatment.

Majority of the participants, who opted to decide in the second visit, did not consent for the proposed treatment protocol. “Lack of consent from mother/father” was the reason shown by 13 of the 18 participants, which clearly indicates the lack of understanding of the subject on part of the decision-maker at home as he/she could not be provided with verbal explanation and audiovisual demonstration. Furthermore, a paternal fashion of decision-making is prominent in India which comes into light in this regard and may be vaguely identified as a hindering factor in delivery of successful dental treatment to children.

To assess the understanding of the concept of PRF and its risks and benefits, the parents were requested to defend their decision by showing reason(s) for the same. Parents were also allowed to cite multiple reasons if needed. Of the participants who accepted the treatment, 30.26% pointed to “autologous graft compared to dental material” and another 30.26% cited “success rate shown by PRF;” “cooperative child” (15.13%) and “no risk of allergy/ingestion of dental material” (14.47%) were among the other reasons shown along with “others” like “whatever the dentist believes will be in the best interest of the child” (9.87%). “Fear of parent” was the reason shown by 25% of the parents who did not accept pulp therapy using PRF. Other causes cited were “risk of trauma during phlebotomy” (19.79%), “age of child” (17.71%), “uncooperative child” (13.54%), “lack of consent from mother/father” (13.54%), “other” factors such as “never heard of PRF before”/”baby tooth will fall off”/”no need to use blood for dental treatment” (6.25%) and “risk of infection during procedure” (4.17%).

It may be inferred upon that majority of the participants who consented for carrying out the procedure in their child did understand the concept revolving PRF, i.e., its autologous nature and the benefits arising from the same. Parents were also able to assess their child's level of cooperation based on the age and cognitive development before providing consent for an invasive therapy. The use of pamphlet demonstration provided the parents with thorough knowledge about PRF, while video demonstration helped them to visualize the entire setting and decide for themselves if their child will be able to cope with it. It is of great value and support if the parent would wish to guide the child through the treatment without overreassurance or being a silent spectator. Authoritative and nonanxious parents would probably be the ideal ones in this regard. More studies with larger sample aiming to assess the relation of sociodemographic and psychological factors on the acceptance of invasive dental treatment by parents should be carried out to confirm the results found in this investigation.

   Conclusion Top

It is true that parental factors might create barriers in delivering successful dental treatment, especially an invasive one. However, with proper demonstration of the procedure and explanation regarding its advantages and disadvantages, parents may be directed to decide in the best interest of their child. This paper highlights that parenting pattern and dental anxiety have positive correlations with treatment acceptance. An overall predictive accuracy of 62.7% was achieved in our study which may help pediatric dentists to be more aware of concealed parental factors and tailor the communication accordingly.


The authors of the manuscript have no potential competing financial interests regarding this article.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Young SS, Schwartz R, Sheridan MJ. EMLA cream as a topical anesthetic before office phlebotomy in children. South Med J 1996;89:1184-7.  Back to cited text no. 1
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Patidar S, Kalra N, Khatri A, Tyagi R. Clinical and radiographic comparison of platelet-rich fibrin and mineral trioxide aggregate as pulpotomy agents in primary molars. J Indian Soc Pedod Prev Dent 2017;35:367-73.  Back to cited text no. 3
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  [Table 1], [Table 2], [Table 3], [Table 4]


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