Appropriateness of various behavior rating scales used in pediatric dentistry: A Review

Frankl’s behavior rating scale (FBRS) (1962)

FBRS, developed in 1962, is one of the most widely used behavior evaluation scales in pediatric dental research and in daily clinical practice. It classifies child behavior into four groups according to the child’s attitude during dental treatment.^[4] It consists of four behavior categories ranging from definitely positive to definitely negative which are assigned by the treating clinician and can be applied at various stages during treatment. It is considered as one of the most reliable tools developed for behavior rating of children in dental setting.^[4,5] However, this classification does not provide definite items for observation [Table 1].

Global rating scale (GRS) (1965)

The 5-point GRS of overall behavior is scored by the child’s dentist and is a measure of both the successful completion of treatment at the visit and of the dentist’s perception of the child’s anxiety. It is simple to use and reliable to evaluate the responses of anxious pediatric patient to treatment^[6] [Table 2].

Corah’s dental anxiety scale (Corah and Pantera, 1968)

This scale was originally developed to measure dental anxiety and fear in adult dental patients. It consists of a four questionnaire with five answers for each of them. The total scores range between 4 (not anxious) and 20 (extremely anxious). This scale is generally applied to older children, who are able to understand the questions.^[7]

Visual analog scale (VAS) (1969)

VAS consists of 10 cm horizontal line with two poles: Unsatisfactory and satisfactory [Figure 1]. It can be used both as a self-report and as an observational tool. A vertical line across the horizontal line is used to mark the operator’s assessment of the child’s behavior. The point where the vertical line crosses the horizontal line is measured with a ruler to give a score to the nearest centimeter. The VAS is validated for use with anxious dental patients^[8] when compared to other scales it is found to be more sensitive and simpler to use [Figure 1].

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Figure 1:

Visual analog scale.

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Categorical rating scale

It was developed by Nazif (1971). This scale is popular among researchers. It monitors and measures behavior at specific time spots in the visit in each category (crying, cooperation, apprehension, and sleep). The scores from the four categories of the scale are summed up to give an overall time point score and then divided by the number of the time point periods. The scale is found to be a reliable tool if used to score a patient’s response to a specific treatment such as local anesthetic agent.^[9]

1. Crying:

   1 = screaming

   2 = continuous crying

   3 = mild, intermittent crying

   4 = no crying

2. Cooperation:

   1 = violently resist/disrupts treatment

   2 = movements which make treatment difficult

   3 = minor movements/intermittent

   4 = no movements

3. Apprehensive:

   1 = hysterical/disobey all instruction

   2 = extremely anxious/disobeys some/delays treatment

   3 = mild anxious/compiles with support

   4 = calm/relaxed/follows instruction

4. Sleep:

   1 = fully awake

   2 = drowsy

   3 = asleep/intermittent

   4 = sound asleep.

In 1975, Wright proposed a modification of FBRS.^[10] He represented the symbols. Definitely positive was represented as (++), positive (+), negative (−), and definitely negative (--) [Table 3].

Behavior profile rating scale (1978)

Melamed et al. developed this rating scale which consists of 27 behavioral aspects during dental visits.^[11] This scale was designed to allow an independent observer to record the frequency of the disruptive behavior during 3 min observation periods. Four of the items apply to behavior of the child on separation of the mother, while the other 23 statements assess office behavior; 2 of them concern the dentist, and the remaining 21 concern the behavior of the child. Each of the 27 behaviors is weighted by a factor that reflects the degree of its disruptiveness. The total Brief Psychiatric Rating Scale (BPRS) [Figure 2] score is obtained by multiplying the frequency at which a behavior in each category occurs (across 3 min intervals) by its weighted factor. These weighted frequencies are then added across categories and the sum is divided by the number of 3 min intervals. In this way, the total BPRS score is a measure of the average frequency of fear-related behaviors per 3 min interval. Aartman et al.^[10] stated that of the behavioral measures, Melamed’s BPRS is to be preferred to the FBRS, Venham’s, and VAS. The main reason is that it measures the behavior of the child more precisely and that it has superior psychometric properties.^[10] However, it can be a complicated score to calculate and takes a significant amount of time, also requires an external observer other than the treating dentist^[11,12] [Table 4].

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Figure 2:

Raghavendra, Madhuri, and Sujata Pictorial Scale for boys.

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Venham’s behavior rating scale

Venham et al. introduced and explored the use of 6-point cooperative behavioral scale also called uncooperative behavior rating scale.^[13] The scale describes child’s behavior in details and provides more information about pediatric patients with negative and disruptive behavior. It is a 6-point scale, with scale points anchored in objective, specific, and readily observable behavior and classifies child’s behavior into six groups. The dentist indicates the patient’s behavior by picking a number from 0 to 5 according to the scale after the dental visit or at specific time spots of it. Venham et al. pointed out that the scale is a reliable and valid scale and provides interval level measurement. They found that the used behavioral labels accurately capture the essence and variable manifestations of “uncooperative behavior” in young children. In the same survey, it is demonstrated and the scale is proven as a useful instrument for assessing child’s responses to dental stress^[13,14] [Table 5].

Venham anxiety and behavioral rating scale

These two scales assess the anxiety and uncooperative behavior of children in the dental setting. Both scales consist of five behavioral defined categories ranging from 0 to 5 with higher score, indicating greater level of anxiety or lack of cooperation. A high degree of reliability is seen for both scales, even for untrained observer^[13] [Table 6].

Modification and adaptation of FBRS

Machen and Johnson described an adaptation of FBRS (1991). According to the new version of the scale, two independent rates evaluate children’s behavior in dental setting in the range from definitely positive to negative and definitely negative at five different moments.^[14]

1. Separation of the child from the parent

2. First reaction of the child in dental setting

3. Attitude toward the dental staff

4. Behavior during the treatment

5. Behavior after the treatment.

The extra category could be expressed as (±), leading to the suggested modified Frankl categories of behavior are as follows:

Rating 1: Definitely negative (−): Refusal of treatment, crying forcefully, fearful, or any other overt evidence of extreme negativism

Rating 2: Negative (−): Reluctant to accept treatment, uncooperative, some evidence of negative attitude but not pronounced

Rating 3: Negative positive (±): Fluctuation between uncooperativeness and some evidence of unpronounced negative attitude, and cautious acceptance to treatment with reservation shifting throughout the visit

Rating 4: Positive (+): Acceptance of treatment; at times cautious, willingness to comply with the dentist, at times with reservation but patient follows the dentist’s directions cooperatively

Rating 5: Definitely positive (++): Good rapport with the dentist, interested in the dental procedures, and laughing and enjoying.

Raghavendra, Madhuri, and Sujata Pictorial Scale (2015) (RMS-PS)

RMS-PS is an innovative scale for the assessment of child’s dental anxiety. It comprises a row of five faces ranging from very happy to unhappy. Two separate sets of photographs were used for boys and girls. The children were asked to choose the face they feel like about themselves at that moment. The scale was scored by giving a value of one to very happy and five to the very unhappy face.^[15]

The RMS-PS has many advantages such as:

1. Attractive as it is colorful and easily understood by children.

2. It takes very short time to complete the test.

3. It gives immediate feedback about the anxiety of the child to the dental clinic to the dental team, in the waiting room itself. It can also be used to get the feedback in subsequent visits also so that we can treat accordingly with the appropriate behavior management technique.

4. With original color photographs in RMS-PS, the child can identify themselves better with them as compared to black and white and cartoon figures used in Venham’s pictorial test and facial index scale.

RMS-PS is kept separate for girls and boys to maximize its acceptability among both the genders [Figures 2 and 3].

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Figure 3:

Raghavendra, Madhuri, and Sujata Pictorial Scale for girls.

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