behavior management

Behaviour management is important because a pediatric dentist is handling a cognitively, physically mentally and emotionally maturing child.

Is it necessary to let patient cry Is it necessary to let patient cry throughout the treatment…?throughout the treatment…?

Or post the patient to general anesthesia….?!!

PEDODONTIC TREATMENT TRAINGLEPEDODONTIC TREATMENT TRAINGLE

CHILDCHILD

DENTIST DENTIST PARENTSPARENTS

SOCIETY

The major difference in treating adults & children is in adults its 1 to 1 relationship. However treating a child is a pedodontic treatment triangle.

Tell the parents not to voice their own personal fears in front of the child.

Tell the parents never to use dentistry as a threat or punishment.

Not to Tell Anything About what Dentist Going to Do

Parents counseling

CO-OPERATIVE TENSE CO-OPERATIVE

OUTWARDLY APPREHENSIVE

FEARFUL

STUBBORN

HYPERMOTIVE

EMOTIONALLY IMMATURE HANDICAPPED

LAMPSHIRE’S CLASSIFICATION

Under The Control of The Dentist

• Dental office• Dentist’s attitude• Dentist attire• Presence or absence of parents• Presence of older sibling

FACTORS AFFECTING CHILD’S BEHAVIOR IN DENTAL CLINIC

Effect of Dentist’s Activity & Attitude

2. JENK’s six categories of activities by a dentist

a) Data Gathering & Observation

b) STRUCTURING Objective is to explain the child importance of dental

treatment and its purpose in a manner the child understands

TOOTH BRUSHINGWASHING THE MOUTH WITH VACCUM AND 3

WAY SYRINGE

CLEANING THE TEETH WITH BRUSH IN HAND

PIECE

DRILLING A VITAL TOOTH WITH AIR

TURBINE

ANESTHETIC SOLUTION REFERRED AS WATER TO PUT TOOTH TO

SLEEP

MOTIVATING PATIENT TOWARDS ORAL

HEALTH

STRUCTURING STRUCTURING

c)Externalizationc)Externalization

Attention, perception, sensation are on the site of injection, eyes closed, mouth open, body rigid and drawn from other stimuli. In such case externalization helps.

c) Externalization

DistractionAttention is focused away

Involvement

Involve the child so that child’s verbal or motor discharge do not interfere in treatment procedure

d) Dentist Attitude

• Empathy and support:- it’s the capacity to understand & experience the feelings of another without losing one’s objectivity

• E.g. :- permit the child to express their feeling

– Comforting the child when it is appropriate by touching or reassuring pat

– Providing a structuring situation which child can feel secure

e) Flexible Authority

• The dentist authority must be tempered with a degree of flexibility or compromise in order to meet the needs of the particular patient or situation

f) Education & Training

3.EFFECT OF DENTIST’S ATTIRE:

--avoidance of the white coat.

• Length of Appointment should be short• Appointment time should be early

• avoid nap time.

Non-Pharmacological Methods Communication Behavior Shaping

(modification) --Desensitization --Modelling --Contingency

management Behavior Management --Audio Analgesia --Biofeed back --Voice Control --Hypnosis --Humor --Coping --Relaxation --Implosion Therapy --Aversive Conditioning

TYPES OF COMMUNICATION Verbal CommunicationNon Verbal CommunicationBoth

Universally used in pediatric dentistry with both co-operative and uncooperative child.

Fundamental form of behavior management.

1.Communication by Chambers 1976

What to talk with the patient..? • Try to call by nick name, Give compliments about • Using animation Explain about the procedure briefly (tooth sleeping, worms

in tooth)• Keep the patient occupied in your conversation through out the procedure

Systemic Desensitization• It involves the step by step elimination of the fear,

anxiety • Most Effective Methods for reducing maladaptive

anxiety teaches the patient to substitute an appropriative or adaptive response – relaxation for maladaptive response anxiety its called as reciprocal inhibition its usually done by a behavior therapist– Tell Show Do is a similar approach where telling,

showing, doing is continues from the child entry to clinic where each person, instrument, procedure, is introduced to the patient to orient the child such that he will cope-up with the situation

INDICATIONS:• First Visit

• Subsequent visits when introducing new dental procedure

• Fearful Child

• Apprehensive Child because of information received from parents.

First visit

Desensitization by JosephWolpe1975

Behavior Shaping (modification)

TELL SHOW DO TECHNIQUE

By ADDLESLON 1959

2.Modeling by Bandura 1969• Procedure involves allowing a patient to observe one or

more individuals (models) who demonstrate a positive behavior in a particular situation.

• Modeling can be done by --Live Models --Filmed Models --Posters --Audio-visual aids

• Modeling should not be of minor surgery, blood

3.Contingency ManagementPositive Reinforcer (Henry W Fields 1984)

• Negative Re-inforcer by Stokes & Kenndy 1980 is one whose contingent withdrawal increases the frequency of behavior.It is usually the termination of an aversive stimulus.e.g.:withdrawal of the mother S E P (selective elimination of parent)

Audio Analgesia by Gardner, Licklider 1959 : Or `White Noise’ is a method of reducing pain. This technique consists of providing a sound stimulus of such intensity that the patient finds it difficult to attend to anything else.

Biofeed Back by Buonomono 1979:involves the use of certain instruments to detect certain physiological processes associated with fear.

Humor:helps to elevate the mood of the child

COPING by Lazaue 1980

• Voice Control:It is modification of the intensity and pitch of one’s own voice in an attempt to dominate the interaction between the child and the dentist.It reminds the child that the dentist is an authority figure to be obeyed

Relaxation:This technique is used to reduce stress and is based on the principle of elimination of anxiety.

Hypnosis by Romanson 1981: It is an altered state of consciousness characterized by a heightened suggestibility to produce desirable behavioral and physiological changes.

Implosion Therapy: Sudden flooding with a barrage of stimuli which have affected him adversely and the child have no other choice but to face the stimuli until a negative response disappears.It mainly comprises of Home,Voice Control and Physical Restraints.

Aversive Conditioning: It is a method of managing extremely negative behavior.

HOME(Hand over mouth exercise)• It was introduced by Evangeline Jordan in the year 1920.

• The purpose of the Home technique is to gain the attention of a child so

that communication can be achieve.

INDICATIONS

--3 TO 6 YRS OLD.--Healthy child who can understand but who exhibits defiance and hysterical behavior during treatment.--A child who can understand simple verbal communication.--Children displaying uncontrollable behavior.

CONTRAINDICATIONS• Child under 3 years of

age.• Handicapped/Immature

Child.• Physical, mental and

emotionally handicap.

.

PHYSICAL RESTRAINTS• Last resort for handling

uncooperative/handicapped patients

• Restraints are usually needed for children who are hyper motive,stubborn or defiant.

• Physical Restraints involve restriction of movement of the child’s head,hands,feet or body.

• It can be:--Active :-restraints provided by the dentist,staff or parent without the aid of restraining device.

--Passive:-with the aid of restraining device.

Assistance for Immobilization(Parental aid during an examination)

Physical aids to keep patients mouth (Molt mouth prop)

Mouth props with Mouth props with

suction tipssuction tips

Pappose board in use

Immobilization for control of body & extremities

(Patient in a pedi-wrap)

Head positioner

Immobilization for the extremities(Posey strap on wrist)

Immobilization aids for head stabilization( Proper positioning of the dentist’s hands, forearm & body)

Immobilization for control of body & extremities(Patient lying in a beanbag dental chair insert)

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