Behaviour Management and Local Anesthesia

Fadi Kass DMD, Msc, FRCD(c)

April 4th 2008

1426 McPhillips St

Winnipeg, MB

Who is more afraid?

• Child• Dentist

Objectives of treating a child patient

• Perform the necessary task– Efficiently– Safely

• Instill positive attitude towards the dental team and oral habits

How can we do this?

• Pharmacological techniques– Sedatives– General anesthesia

• Non-pharmacologic– Restraint– Behaviour

Managment

Behavior Management Techniques:

• Humour• Distraction• Tell Show Do• Positive reinforcement• Adverse reinforcement

– Voice Control– Parental Abscence

IF THE PARENT IS AFRAID ... THE CHILD

WILL ALSO BE AFRAID.

Word SubstituteShot Pinch,

pushAnaesthetic Sleepy waterDrill Cleaner,

TicklerExplorer Tooth counterRubber dam Raincoat

Child Psychology

• Many publictions in the psychological literature on parent-child relationship.

• We can learn 2 major skills:– Reflective listening– Using descriptive praise

Communication through reflective listening:

• 1951, Carl Rogers introduced us to reflective listening or 'active' listening as it is referred to today.

• It is the process where you mirror the emotional communication of the child through verbal or nonverbal means.

'active' listening

• In a situation where there are strong emotional overtones

• Unlike adults who are socialized to conceal their fears of oral health, children do not.

• As clinicians treating children, we all too often deny kids their feelings instead of acknowledging them.

• Child: “I'm scared”• Dentist: “there is nothing to be scared

of”

• Children feel what they feel. Their feelings are a fact. Do not deny them this.

• These feelings must be mirrored by the clinical staff so that they appreciate that their feelings are being recognized.

• Accepting the child's emotions permits them to develop the sense that their feelings are not all that strange.

• Feelings must be addressed before behavior can be improved.

• Child: “I'm scared”• Dentist: “I understand. Sometimes

new things are scary. It is okay to be scared. Sometimes I'm scared of things I do not understand or have not done before”

• Reflective listening has the positive effect of reassuring children that what they are going through is a normal part of the human experience.

• It permits children to 'own' their feelings, thus respecting a child's autonomy.

• Never argue with what the children are feeling – don't attempt to convince them what they are feeling or sensing is not so.

Reinforcing behavior through descriptive phrase

• Positive reinforcement as we know is a very useful tool to promote good behavior

• There are however, appropriate and inappropriate ways of doing so.

• According to Ginott, “The single most important rule is that the praise deal only with the child's efforts and accomplishments . . . not with their character and personality”

• All too often, in attempting to gain children's cooperation, we use phrases such as “good boy” or “you're a wonderful kid”

• Praise of desirable behaviors is consistent with the principle of operant conditioning as outlined by Skinner.

• However, with kids, the child understands that the clinician is in an evaluative role relative to their behavior and that the child's behavior can easily be 'bad' at a future point in time.

• Such evaluative praise can create a sense of anxiety in the child over possible failure in the future.

• Use descriptive praise, where you are not judging the character of the child but more their actions.

• Rather than saying “good boy”, say “It make my job so easy when you hold still like that, we can work so much faster as a team”.

Local Anesthesia . . .

Objectives…

• Local Anaesthetics & Behaviour Management– When do you need to

use LA?– Acceptable language?– How do you make an

injection less painful?– Adequate anaesthesia?– Anaesthetizing a

frightened/ anxious child

Objectives…

• Properties of Common Local Anaesthetics– Topical anaesthetics– Types & duration of anaesthesia– Calculating the maximum dose of local

anaesthetic

• Complications– Local– Systemic

When to use LA?• Not required for:

– Sealants– Preventive resin restorations– Buccal restorations (majority)– Disking teeth– Fitting bands or cementing appliances

• Required for:– Amalgam or composite restorations extending

> ¼ of the way into dentin– Stainless steel crowns– Pulpotomy / pulpectomy– Extractions

Never lie to a child . . .

• Need to gain child’s trust• Side step any questions such as “am I

getting a needle?”– “Good question, let me count your

teeth first”• Never surprise a child. • “Ok now, I’m going to push here . . .”

• use terminology you feel will be better received by the child -- e.g. “Sleepy juice”

• Let the child know what the anaesthetic will make their cheek/lip/tongue feel like– Puffy, soft, tingly, fat, etc…

• AVOID the words hurt, pain, pinch, mosquito bite, etc…

How to make an injection less painful

• Most important: DISTRACT• Use topical• Warm the anesthesia solution, makes a

huge difference• Infiltrate with 30 gauge, block with 27

gauge• Shake the cheek• Inject slowly and smoothly, do not rush

Adequate anaesthesia?

• Ask the child where it feels - numb, tingly, sleepy, fat, itchy, weird, different – and any other word you think they might choose to describe it…

• Have them point to the area that feels “different”

• Gold standard: induce a painful stimulus in the area you believe is anaesthetized (e.g. explorer tip into the gingiva) – watch eyes/reaction

Anatomic Variations• Mandible

- Mandibular foramen in children 4 years old and less is below the plane of occlusion. The foramen moves superiorly in the ramus with the eruption of 6’s

AdultsAdults

ChildrenChildren

Approximate duration of action of Local Anaesthetics

• Use the shortest acting local that will allow you to complete the job

• Soft tissue anesthesia always longer than pulpal

• I block with mepivicaine (no epi) lasts 2-3 hours

• Infiltrate with lidocaine 3-4 hours

Calculating the maximum dose of

Local Anaesthetic for a child

Maximum Recommended Dose (mg/kg) x Child’s Weight (kg)

Anaesthetic Concentration (mg/ml) x Volume of Carpule (ml)

e.g. The maximum amount of 2% Lidocaine with 1:100,000 epi for a 17 kg child would be:

4.4 mg/kg x 17 kg = 74.8 mg = 2.08 carpules

20 mg/ml x 1.8 ml 36 mg

Rule of thumb – 1 carpule per 20 pounds

Complications - Local• Masticatory trauma

– Use short acting local anaesthetics; post-op instructions

• Needle breakage in soft tissue

– Avoid bending needle; minimize movement in tissue; don’t submerge needle to the hub

• Haematomas

• Trismus

• Infections

• Nerve damage from needle

Complications – Systemic• Allergic Reaction

– Extremely rare with amide anaesthetics– Methylparaben is a preservative used to

increase the shelf-life of epinephrine containing anaesthetics – possible allergen

– If the patient/parent is truly worried about an allergy to local anaesthetic, refer them to their physician for testing

Local Anaesthetic Toxicity Cont’d• Minimal to moderate overdose levels:

- Talkativeness, apprehension, excitability, sweating, vomiting,

disorientation, increased blood pressure, heart rate, and

respiratory rate

• Moderate to high overdose levels:

– Tonic-clonic seizure activity followed by generalized CNS

depression, depressed blood pressure, heart rate, and

respiratory rate

– Death.

• Treatment of anaesthetic overdose:

– #1 treatment - prevent it from occurring!

– Mild cases: stop LA, administer O2

– Moderate-severe: activate EMS, administer O2

Some Tips…

• Pass the syringe behind where the child does not see it

• Talk a lot, don’t stop talking

• ALWAYS have your assistant gently restrain (“hold”) the patient’s hands/arms to avoid sudden movements

Thank You