Knee-to-Knee position for oral examination in infants and toddlers: an assessment of attitude & practice of Pediatric Dentists in Bengaluru city.

Introduction

One of the primary goals of Paediatric Dentistry is the prevention of oral and dental diseases. The oral examination and regular follow-up of a child at a very young age will play a pivotal role in the prevention and management of oral health problems, and thereby lay a foundation for a lifetime free of preventable oral diseases1,2. The American Academy of Paediatric Dentistry states that every infant should receive an oral health risk assessment from his/her primary health care provider or qualified health care professional by 6 months of age.3

The first dental examination of an infant/toddler should be simple, short, comfortable and adequate. However, oral examination of an infant/toddler during the first dental visit and the subsequent preventive/therapeutic visits may be challenging to the Paediatric dentist.

There are many positions used to examine infant/ toddlers. The dental chair can be raised and adjusted to simulate a physician’s examination table. The infant then lies supine at the foot of the dental chair. This position enables adequate visualization of the teeth and oral cavity4 . A designated dental examination table was developed to perform oral examinations of infants until they are old enough to be seated on the conventional dental chair5 . The most traditional used position is the Kneeto-Knee position. In this position, the dentist and the parent are seated face to face with their knees touching. The infant is placed on the parent’s lap, facing the parent, with legs wrapped around the parent’s waist. While the parent holds the child’s hands, the child is laid back, resting the head in the dentist’s lap (FIGURE 1). This position enables the child to see and feel the parent while the dentist performs the examination. The position allows for visualization of the oral cavity by both the parent and the dentist.6,7

Hence, as the Knee-to-Knee technique does not require any additional devices and also enables the infant/toddler to see and feel the parent while being examined by the dentist, the present survey was conducted to assess the attitude of Paediatric dentists in Bengaluru city towards the use of Knee-to-Knee positioning technique for dental examination and minor procedures in infants/ toddlers.

Materials & Method

A descriptive cross-sectional survey was designed, wherein a pre-validated questionnaire which was adopted based on a similar study conducted by Noy et al (2019)8 was distributed among a convenience sample of 62 Paediatric dentists in Bengaluru city. The questionnaire comprised of 12 questions that ascertained the demographic data, professional experience and attitude of the Paediatric dentist’s towards the Knee-to-Knee position for dental examination.

Statistical analysis:

Data were analysed using the IBM SPSS statistics software version 18.5. The participant responses were calculated and depicted in percentages.

Results

A total of 62 Paediatric dentists participated in the survey. About 38 (61.8%) were females and 24 (38.7%) were males. Among the participants 16 (25.8%) had experience <5years, 17 (27.4%) had experience of 5-10years and 29 (46.8%) had experience of above 10 years (TABLE 1).About 56 (90.3%) participants reported using Knee-toKnee position for dental check-up (TABLE 2). Also, 47 (78.3%) of the Paediatric dentists also performed minor procedures in Knee-to-Knee position (TABLE 3). Gender and seniority of the respondents did not correlate with the use of this positioning for additional procedures (TABLE 4). Performances of minor dental procedures other than oral examination in Knee-to-Knee position are depicted in TABLE 5.The most commonly performed minor dental procedure was interim therapeutic restorations (27.4%) followed by oral hygiene instructions (17.8%). About 90% of the participants reported positive attitude of parents toward Knee-to-Knee position. It was observed that the Knee-to-Knee position was most commonly used in the 0-2 year age group for both examination and minor dental procedures. About51.7% respondents reported that they stop the procedure in Knee-to-Knee position and continue in dental chair once the child is cooperative.

Tables and Illustrations:

Discussion

Early oral examination of infants, as per the recommendations by the AAPD will lead to prevention and timely intervention of oral and dental diseases. However, examination of infants/ toddlers can be challenging due to their lack of maturity and co-operative abilities. The Knee-toKnee position is one of the simplest methods for the oral examination of infants. It makes the parent an active participant in the procedure and tends to make the child feel more secure. Hence, the present survey was conducted to ascertain the attitude of Pediatric dentist’s towards the use of this position for oral examination of infants and also to determine if this position is used for performing minor treatment procedures. As literature search by the authors of the present study for similar studies lead to the identification of only one study by Noy et al(2019)8 , direct comparison of the results have been made with it.

In the present study 90.3% of the participants reported using the Knee-to-Knee position for oral examination of infants/toddlers in comparison to 97% in the study by Noy et al(2019)8 . The percentage of the participants using Knee-to-Knee position for minor dental procedures is 78% in the present study which is comparable to 76% in the study by Noy et al(2019)8 . The most commonly performed minor dental procedure was interim therapeutic restorations (27.4%) followed by oral hygiene instructions (17.8%). Smoothening of the fractured tooth was the least performed procedure. Although Knee-to-Knee position is one of the simplest methods, the possibility of foreign body aspiration or swallowing due to uncontrolled movements of the infant/toddler who is laid on the flexible and soft thighs of the parent and dentist is a major limitation. Furthermore, limited or difficult access to suction is another considerable concern in young patients.

Conclusion:

The Knee-to-Knee position, with its advantage of closeness to parent and prevention of separation anxiety in infants/toddlers can be used for the oral examination and simple preventive procedures like fluoride application, oral prophylaxis and oral hygiene instructions. Caution should be exercised while performing restorations and extractions due to the fear of foreign body swallowing/aspiration by the infant/toddler.