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Pediatric Dentistry I
Forth Year

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Pedia psychology

  1. 1. Psychological growth • Every child has a rhythm & style of growth and no two children, even in same family, develop in exactly the same pattern • The psychological & physiologic age of the child must be considered in the diagnosis of behavior problems& treatment planning  Infancy period (Birth to 1 year)  Toddler hood period (1 to 3 years)  Preschool period (3 to 6 years)  School period (6 to 12 years)  Adolescent years (12 to 19 years)
  2. 2. Infancy period (Birth to 1 year) • Infancy represents the first critical period for personality growth & the development of a sense of trust. Then develop feelings of security that last throughout life. • At the age of 6 months (teething ,bite on anything) • Prenatal teeth • Child clinical exam can be done by: 1) Seating on his mother's legs on the dental chair, Or 2) The child is placed in-between the mother &the dentist on other chair.
  3. 3. Toddler hood period (1 to 3 years) • The child moves from the sensori-motor stage (in infancy) to pre operational stage. Objects are now grasped and put in order. • In the dental clinic, the child takes orders from his mother through her facial expressions, also tone of voice. • (tell-show-do technique). • Without exception the child should be accompanied by a parent to the treatment room.
  4. 4. Preschool period (3 to 6 years) • At the stage the child now grips with the development of a sense of initiative and imagination so the child explores the world of people & things also imagines himself in a variety of roles & activities. • The 3-year old child (desire to talk ,enjoy telling stories to the dentist & assistants) • The child is closely attached to his parents • During the late preschool period the child now able to be easily separated from his parents • Waiting room (full of toys )
  5. 5. School period (6 to 12 years) • At this age the child achieve enough trust also initiative to become involved in the private world of children. • Becomes a part of peer group. • He takes orders from dentist as he takes orders from his teachers in school
  6. 6. Adolescent years (12 to 19 years) • Hormonal activity usually associated with rapid physical growth, genital maturity and changing environmental expectation so adolescence is a period of uneven biologic, psychological and social development • The dentist should deal with them through firmness and authority.
  7. 7. BEHAVIOUR Definition : The term behavior is broadly used to include the entire complex of observable and potentially measurable activities including cognitive and physiological classes of response.
  8. 8. I. WRIGHT’S CLASSIFICATION A) Co-operative (Positive behavior) 1. Co-operative behavior Child is cooperative, relaxed with minimal apprehension. 2. Lacking in Cooperative Ability • Includes very young children with whom communication cannot be established. • Another group of children who lack in cooperative ability is of those with specific debilitating or disabling conditions. • Physical and mental handicap children are also included under this.
  9. 9. 3. Potentially Cooperative • Has the potential to cooperate, but because of the inherent fears (subjective/ objective) the child does not cooperate. B). UN- COOPERATIVE BEHAVIOUR 1. Uncontrolled /Hysterical/ Incorrigible  Usually seen in the preschool children at their first dental visit.  Temper tantrums i.e. the physical lashing out of legs and arms , loud crying and refuses to cooperate with the dentist.
  10. 10. 2. Definite/Obstinate behavior • Can be seen in any age group. • Usually in spoilt or stubborn children. • These children can be made cooperative. 3. Tense cooperative • These children are the border line between the positive and negative behavior. • Does not resist treatment but the child is tensed at mind.
  11. 11. 4. Timid Behavior/Shy • Usually seen in a overprotective child at the first visit. • Is shy but cooperative. 5. Whining type • Complaining type of behavior allow for treatment but complains throughout the procedure. 6. Stoic type • Seen in physically abused children . • They are cooperative and passively accept all the treatment without any facial expression.
  12. 12. 1. COOPERATIVE • The child is physically and emotionally relaxed . • Is cooperative throughout the procedure. 2. Tense cooperative • The child is tensed and cooperative at the same time. Lampshier classification (1970) 3. Outwardly apprehensive • Avoids treatment initially, usually hides behind the mother, avoids looking or talking to the dentist. • Eventually accepts dental treatment.
  13. 13. 4. Fearful:  Requires considerable support so as to overcome the fears of dental treatment. 5. Stubborn/Defiant  Passively resists treatment by using techniques that have been successful in other situations. 6. Hypermotive  The child is acutely agitated and resorts to screaming kicking etc. 7. Handicapped  Physically/mentally, emotionally handicapped.
  14. 14. III.FRANKEL’S CLASSIFICATION (1962) (Frankel’s behavior rating scale) Rating Behavior 1. Definitely Refuses treatment, crises negative (- -) forcefully extremely negative behavior associated with fear. 2. Negative (-) Reluctant to accept treatment and displays evidence of slight negativism.
  15. 15. Rating Behavior 3. Positive (+) Accepts treatment, but if the child has a bad experience during treatment, may become uncooperative. 4. Definitely Unique behavior, looks positive (++) forward to and understands the importance of good preventive care.
  16. 16. a). Normal or bold  The child is brave enough to face new situations, is co-operative, and friendly with the dentist. B). Tasteful or timid  The child is shy, but does not interfere with the dental procedures. IV. WILSON’S CLASSIFICATION (1933) c). Hysterical or rebellious  Child is influenced by home environment – throws temper- tantrums and is rebellious. d). Nervous or fearful  The child is tense and anxious, fears dentistry.
  17. 17. Reactions of the child to the dental experience • There are at least 5 negative reactions to the dental experience: 1) Fear 2) Anxiety 3) Resistance 4) Timidity 5) Crying
  18. 18. Fear: • Dentistry should never be employed by the parents as a threat. Also, taking the child to the dentist should never be implying punishment. *** Types of fear *** A- Native fear: it is an instinct present in every human being B- Objective fear: It originates from a frightening or painful experience in the child's past that faced the child himself C- Subjective fear: it is based on feelings and attitudes suggested to the child by others around him without the child having had the experience himself. Subjective fear may be acquired by imitation and may be transmitted from parents
  19. 19. Anxiety • Anxious children are essentially fearful of new experiences and their reaction may be violently aggressive such as temper tantrums in dental office. • Child is truly fearful the dentist may be sympathetic and starting working slowly but if the child demonstrating a temper tantrum the dentist may demonstrate authority & mastery of situation.
  20. 20. • The child may display temper tantrums or head beating or may develop vomiting habits or may make no attempt to talk plainly. • Withdrawal is another manifestation of anxiety • This is observed in the case of the first time patient. This is the child who tries to hide behind his mother; he looks to the floor or another direction. • The timid child needs to gain self confidence and confidence in dentist Timidity
  21. 21. A- Obstinate crying: Siren-like noises, temper tantrum, kicking, biting, usually no lacrimation. B-Frightened crying: Profusion of tears, constant wailing sound, convulsive and rasping, cry tends to hysteria rather than temper tantrum C-Hurt crying: lack of or very low volume tears may be the only manifestation moaning, respiration may be affected if child hold his breath D-compensatory crying: Wailing or whining sound as the dentist makes sounds of similar volume, not loud but consistent, no tears or sobs
  22. 22. • Behavior management problems are what the dentist observe while the dental fear and anxiety is what the patient feel. • Some children present behavior management problem without having fear and anxiety. • Some Children having dental fear and anxiety but able to cope up with situation. • Some children experience dental anxiety and fear and present behavior management problems
  23. 23. • Age • Dentist • Maternal anxiety • Past medical history • Time & length of app • Patient awareness of the problem • parents
  24. 24. 1. Personal Factors A. Age B. General fear and anxiety. C. Temperament. D. Other problems e.g.DAMP 2. External Factor A. Parental Dental fear & anxiety. B. Social Situation of the family. C. Ethnic background of family. D. Child rearing and child’s role in society. 3. Dental Factor A. Pain B. The Dental Problems Factor affecting child Behavior in dental clinic
  25. 25. Factor affecting child Behavior in dental clinic Factor involving Child Growth and development of child  Personality & tempermant of child. a) Type 1 Positive of mood. b) Type 2 Difficult children. c) Type 3 Slow to warm up  Formal learning experience  Social and adaptive skill.  I.Q. of child.  Past Dental & Medical Experience.  Awareness of dental problem. 1. Appearance of Dental Office. 2. Personality of Dentist 3. Dental’s skill & Speed 4. Dentist’s conversation 5. Attention to the Pts. 6. Use of praise and reward. 7. Dentist’s self control. Factor involving Dentist
  26. 26. 1. Socioeconomic Status 2. Culture 3. Maternal Anxiety 4. Familial Disorders 5. Parental-Child relationship 6. Sibling influence
  27. 27. • Over Protective and dominant prevent the natural development of the child toward independence; for example, the parent insists on remaining with the child, • Over Indulgent (manipulative) excessively demanding (appointment time; course of diagnosis or treatment) • Under affectionate • Rejecting (neglectful) • Authoritarian • Hostile Parents :- {A} poor personal experiences in the dental office, {B} a general negativism toward health professionals, {C} feelings of insecurity in a foreign environment, or
  28. 28. The functional inquiry –During the inquiry, two primary goals: (1) To learn about patient and parent concerns and (2) To gather information enabling a reliable estimate of the cooperative ability of the child –Functional inquiries are conducted in two ways: (1) By a paper and pencil questionnaire completed by the parent (2) By direct interview with child and parent
  29. 29. Parent education (instruction to parents) • Not to voice their own personal fears in front of their child toward dentistry. • Not use dentistry as a threat of punishment. • Familiarize their children with dentistry by taking the child to the dentist to become accustomed to the dental office. • Not bribing their child to go to the dentist. • Parents shouldn't challenge the dentist's authority or contact the operator filed
  30. 30. • It should be warm and stimulate homely environment. • Appointment should be short. • Children should not kept waiting not more than 30 minutes. EFFECT OF DENTIST’S ACTIVITY: • Data gathering and observation :- Should be collect by child steps in dental clinic during history taking and dental procedure being carried out.
  31. 31. Child's first dental visit • The ideal time of the first visit is at one year of age • To safeguard against problems such as baby bottle tooth decay, teething irritations, gum disease, and prolonged thumb-sucking • Preparation for the visit (Talk to child about what to expect) • What will happen on the first visit (examination, prophy; OHI; fluoride application)
  32. 32. Fundamentals of behavior management • is means that the dental health team effectively and efficiently performs treatment for a child and, at the same time, instills a positive dental attitude. {1} The team attitude (warmth and interest , pleasant smile, using nick names ) {2} Organization (dental office staff , well organized, written treatment plan ) {3} Tolerance ( dentist ability to tolerate any misbehaviors from the child) {4} Flexibility (Since children are children, lacking in maturity, the dental team has to be prepared to
  33. 33. BEHAVIOUR MANAGEMENT 1 PRE APPOINTMENT BEHAVIOUR MODIFICATION. A.Audiovisual modeling B. Introductory appointment C. Patient modeling D.Pre-appointment mailing. 2. COMMUNICATION : It can be verbal or non verbal 3. BEHAVIOUR MODIFICATION A. Behavior shaping. B. Tell, show & Do. C. Desensitization D. Modeling E. Contingency Management F. Retraining
  34. 34. 4. BEHAVIOUR MANAGEMENT A. Distraction/ Externalization B. Parental Presence or absence. C. Audio analgesia 5. AVERSIVE CONDITIONS A. Voice Control B. Home (Hand Over mouth exercise C. Hypnosis D. Coping E. Confusion F. Implosion Therapy
  35. 35. • The Objectives are establish the good rapport with patient & to develop the positive behavior. Done by A. Audiovisual modeling B. Patient modeling 1. Sibling 2. Other Children C. Reappointment e-Mailing Any greeting, cartoon, comic ( conveying the procedure COMMUNICATION :- To establish good relationship with child. 1. Verbal (Steps A. Establishment of Communication B. Establishment of Communicator C. Message Clarity Use of the Euphuism :- Using Other words other then original D. Problem Ownership : take all blame on yourself. E. Active listening of child. F. Appropriate response. 2. Non Verbal : It is the reinforcement & guiding of behavior through contact, posture & facial expression.
  36. 36. Instead of… We prefer to say… Radiographs or x-rays Tooth pictures Poke with explorer or sharp instrument Tooth counter Suction Mr. Thirsty or Thirsty Straw Cavities Sugar Bugs Fluoride treatment Tooth vitamins Laughing gas/Nitrous Oxide Happy Air Give a shot or use a needle Spray sleepy juice Mouth prop Tooth chair or pillow Use a rubber dam Keep the tooth dry with a raincoat Clamp Tooth hugger or ring Drill the tooth Polish the tooth Fillings Paint or polish
  37. 37. A. State General task/ Goal to child at the outset B. Explain necessity for the procedure. C. Divide Explanation for the procedure. D. Make all explanation at the child’s level of understanding. E. The successive approximation (T.S.A.) 1. Behavior Shaping: It is that procedure which very slowly develops behavior by reinforcing successive approximation of desired behavior until the desired behavior comes to be. 2. Tell show, and do : The dentist should demonstrate the various instruments step by step before there application telling, showing and doing. 3. Desensitization :- Patient is taught to relax while procedure is going on with least anxiety evoking stimulus. Sequence: 1. Introduction 2. Orientation 3. Clinical Examination 4. Oral Prophylaxis 5. Restoration 6. Extraction. PROCEDURE
  38. 38. 4. Modeling A. Audiovisual Modeling B. Live Modeling 5. Contingency Management :- It is a presentation or withdrawal of reinforcement. It can be positive or negative. Objective: To reinforce desired behavior It can be 3 Type: 1. Material reinforcement 2. Social Reinforcement 3. Activity Reinforcement 6. Retraining:- Designated to fabricate positive values in place of negative behavior that has develop. BEHAVIOUR MANAGEMETN TECHNIQUE A. Distraction: Process by which the attention of child is focus away from the sensation associated with dental treatment. B. Parental Presence or absence C. Audio analgesia – like pleasant music. D. Visual fantasy – like Hypnosis & Day dreaming.
  39. 39. Distraction • Five senses • a CD-player • watching a movie • pleasant smell ,(smell of oil of cloves or eugenol ), aromatherapy heaters • Use of Choice-Based Distraction • Taste (drinks from the refreshing (water, fresh juice ) Contingent Escape Allowing the child to stop treatment gives him a sense of control. e.g.: raising hand when he wants to stop - Tell the child that you will need him to let you work on his teeth for a count of 10 & then stop & allow him to rest for a while
  40. 40. • Hypnotic language patterns are an effective instrument for supporting fear- and pain-free treatment. Hypnosis has nothing to do with witchcraft or submission but makes use of the child's natural state of relaxation and imagination. It enables your child to focus more on pleasant things whilst unpleasant things fade into the background and your child leaves our practice feeling good. • What do we do? • Use positive concepts • Explain in a language suitable for children • Reinforce positive feelings with praise • Tell stories • Constant physical contact gives a feeling of safety and security Your child's state: • Reduced pain perception • Altered perception of time • Concentrated on inner self (introspection) • Thus less distracted by external stimuli • Positive memory of the treatment
  41. 41. 1. Voice Control : Should be controlled alteration of voice volume. 2.(HOME:- Hand over mouth exercise): Use in very uncooperative child. A hand is placed over the child’s mouth and behavioral expectation are calmly explained close to the child’s ear. When desired behavior comes than removal of hand In this procedure airway is not restricted Modification of HOME is HOMAR (Hand over mouth Airway restricted): Generally avoided because restriction of airway.
  42. 42. (A) Hand -Over- mouth • An extreme measure in dealing with an uncooperative child. • Involves holding the child in the dental chair; the dentist should gently but firmly places his hand over the child's mouth. Then the dentist speaks quietly but clearly into his ear to reassure him and explains the procedures about to be done in an attempt to establish confidence. • Isn't a punishment measure
  43. 43. (B) Physical restraints • Range from holding a child's hands during injection procedure to full body restraint • for patients who are not capable of understanding the dental procedure ,some physically or mentally handicapped patients. (1) To control body movements: * pedi-wrap: it is reinforced nylon mesh sheet with Velcro fasteners and is supplied in small, medium or large sizes. The child's arms are placed by his side and the wrap is then fastened over his chest. * Papoose board *Triangular sheet * Beanbag dental chair sheet * Safety belt * Extra assistant
  44. 44. (4) To control the oral cavity: •intraoral mouth prop: like wraped tongue blades, intraoral bite block ( is a medium hard rubber wedge that is inserted between the occlusal surfaces on the side of the mouth where the treatment is not performed). * extraoral mouth prop: like Molt mouth prop which is constructed of metal and covered with rubber tubing.
  45. 45. Practical considerations Scheduling:- • Time of the appointment may influence child's behavior especially young child, early morning hours. The suggestion was based on the facts that the child is alert and the dental team is fresher in the morning. • Appointment length should be short not more than 30 minutes especially for young and fearful child.
  46. 46. Local anesthesia Relative analgesia Oral or rectal sedation Intravenous sedation General anesthesia Pharmacological behavior management: -