In 1895 McElory wrote, “Although the operative dentistry may be perfect, the appointment is a failure if the child
departs in tears". This was the first mention in the dental literature of measuring the success or failure of a
child’s appointment by anything other than technical proficiency.
One of the most important skills that a paediatric dentist must learn is the ability to guide paediatric patients
through their dental journey without subjectingthem to negative experiences. In fact, behaviour management
influences the attitude of children towards dental treatment, and consequently their future dental health.
Promoting a positivedental attitude requires a good communication and relationship based on trust between
the dentist,parent/caregivers,and the child;the paediatric triangle.Behaviour guidancetechniques can beboth
pharmacological and non-pharmacological or a combination of both. However,no one method can beapplicable
to all situations,thus thevarious techniques mustbe tailored to individual patients and practitioners. (American
Academy of Paediatric Dentistry,2011) (Campell et al, 2011).
Classifying children cooperative behaviour
Numerous systems have been developed to classifyingthebehaviour of the children in the dental environment.
The knowledge of these systems can be an asset to the dentist in several ways: It can assist in directing the
management method, it can provide a means for systematically recording behaviour, and It can assist in
evaluatingthe validity of current research.
1. Wright’s clinical classification places children in three categories:
Lackingin cooperative ability
Cooperative children are reasonably relaxed.They have minimal apprehension.They may be enthusiastic.
They can be treated by straightforward, behaviour-shaping approach. When guidelines for behaviour
established,they perform within the framework provided.
Lackingin co-operative ability refers to children who are too young with whom communication cannot be
established or those with specific disabilities with whom cooperation may never be achieved.
Potentially cooperative children arethose who are havingsome behaviour problems. However, they have
the capability to perform cooperatively after the useof behavior modification techniques.
2. Frankl behavioural ratingscale:
The scaledivides theobserved behaviour in to four categories,rangingfromdefinitely negativeto definitely
positive (table:1). A shortcoming of this method is that the scale does not communicate sufficient clinical
information regardinguncooperative children.Therefor, the user of this scalemust qualify and categorize
the child’s reaction,specially if thechild is judgeas (-) or (--).
1 - - Definitely negative
Refusal of treatment, forceful crying,fearfulness,or any other overt
evidence of extreme negativism.
2 - Negative
Reluctance to accept treatment, uncooperative, some evidence of
negative attitude but not pronounced (sullen,withdrawn).
3 + Positive
Acceptance of treatment; cautious behaviour attimes; willingness
to comply with the dentist, at times with reservation, but patient
follows the dentist’s directions cooperatively.
4 + + Definitely positive
Good rapportwith the dentist, interest in the dental procedures,
laughter and enjoyment.
After obtainingmedical and dental history,a functional inquiry conduction ishighly recommended from
behavioural pointof view. Itcan be obtained usually by either questionnaireor direct interview. During
interview, consider the followingquestions:
How do you think your child has reacted to pastmedical procedures?
How do you rate your own anxiety at the moment? (because parental anxiety usually transmitted to
Does your child think there is anythingwrong with his or her teeth? (there is tendency toward negative
behaviour when the child believes that a dental problem exists,McDonald et.al.2004)
How do you expect your child to react in the dental chair?
What school do your child attend?
Do you expect your child to be advanced in learning, progressing normally or a slow learner? (It is of
paramount importance that the level of the child’s cognitive development is assessed before
behavioural / communicative management techniques are applied. (American Academy of Paediatric
Other avenues that can be explored includerewards and consequences used in the home environment. These
provideinsightin to the type of behavioural management techniques that would be acceptableto the parent.
Anxiety, Fear and Phobia
A good understandingof the difference between anxiety, fear and phobia is required beforechoosingbehaviour
management strategies. Anxiety is a reaction child would exhibitto an unknown, ill-defined or not immediately
Fear is the trigger of the stress responsesystem as a reaction to a known perceived threat or danger. Fears are
normal aspectof development and temporary in nature. (The national scientific council of the developing child,
Table 1: Frankl behavioural ratingscale
Phobia is havingan unreasonableand excessivepersistentfear of an object or a situation leadingto avoidance
of that situation.Phobia often causes distress thatinterferes with normal functioning.Itislesslikely thatchildren
with no previous dental experiences will be phobic. (MacLeavy, 2008)
Dental phobia can bebest explained with what is called fear conditioning.Thatis,pairinga neutral stimulus(i.e.
going to the dentist), which does not usually elicita negativeemotional responseto aversivestimulus (i.e.pain)
that produces fear. Conditioned fear is not simply forgotten overtime, but it has to be unlearned. One way of
actively unlearningnegativefear responses to a specific stimulusisby introducingthe aversivestimulus ata low
level of intensity whilethe fearful individual isin a safecontext. (The national scientific council of thedeveloping
child,2010) This cognitive behavioural therapy is similar to floodingand systematic desensitization techniques
practiced in dentistry for the management of dental fear and phobia.
Every effort should be made to reduce fear and prevent phobia in the firstplace.It is notalways possiblefor all
procedures to be painless or totally comfortable for patients, but good behaviour guidance accompanied with
empathy, compassion and positive body language, would decrease the likelihood of developing a persistent
negative impact. (Duggal et al, 2013) It is well known that communication is mostly about our body languages
and the volume, tone and rhythm of our voices.What we say only count for 7% of the communication process.
Verbally reassuringpatients,only reassures clinicians rather than patients. It is how it is said rather than what,
that is important. (Bellis,2013)
Behaviour Management Techniques
Behaviour management is the mean by which the dental health team effectively and efficiently perform
treatment for the child,and at the same time instil a positivedental attitude.
Basic non-pharmacological behaviour management techniques based on positivereinforcement include:
(Duggal et al, 2013)
Basic behaviour management approaches are not always sufficient to manage some patients and more
specialized and complex approaches aresometimes required. Too anxious children,children who had negative
pastdental experiences,those who areused to havingtheir own way athome or those who arephobic to certain
aspects of dental treatment; are often difficult to manage with just basic management skills. Those complex
strategies are based on aversive conditioning and include: negative reinforcement, floodi ng and hand over
mouth exercise(H.O.M.E). (Duggal et al, 2013)
When all of the above behaviour management techniques fail to achieve desired cooperation,pharmacological
behaviour management strategies such as sedation areused wherever suitable.Inhalati on sedation with nitrous
oxide is the most popular type of sedation used in the UK. For very young children,disabled patients,patients
with complex medical conditions or complex cases, treatment can be performed under general anesthesia as
the lastor only resort.
Positive reinforcement involves rewarding good behaviours and strengthening their occurrence as well as
ignoringnegative behaviour.In order for that to be effective, itis advised thatappraisinggood behaviour takes
placeimmediately followingany behaviour that the dentist is attempting to strengthen. (MacLeavy, 2008) The
more immediate the reinforcement follows the response,the stronger the association between the cue and the
response. (Wright,et al 2014) There areno contraindicationsfor this type of reinforcement, in fact it is suitable
for every patient who is ableto communicate. (American Academy of Paediatric Dentistry,2011)
Stickers or badges given at the end of the appointment are successful methods of selective reinforcement,
however, social stimuli arethe most powerful reinforcer. Social stimuli can beverbal or in a form of nodding or
smiling. It has been shown that specifically appraising good child’s actions (i.e. I like the way you open your
mouth) aremore effective than general comments (you havebeen a good girl today).(Campell atal,2011) (Fayle
Aversive conditioningis a formof behaviour therapy in which an aversivestimulus ispaired with an undesirable
behaviour in order to reduce or eliminatethat undesirablebehaviour.(Duggal etal, 2013) The aversivestimulus
is often an object or event that causes strong feelings of dislikeor disgust.The goal of aversiveconditioningis
to establish an emotional statethatwill inhibitor counter theinitial undesirableact. (Strand,2005) Both aversive
conditioning and punishment involve the onset of an aversive stimulus following the performance of an
unacceptable behaviour, however, concepts are different. Aversive conditioning does not modify the child’s
behaviour by simply providingpunishmentbut rather links thatbehavi our to an aversivesensation,which would
inhibitthe unpleasantbehaviour. (Strand,2005)
Aversive conditioning is indicated in normal children who are older than 3 years and are momentarily
uncontrolled. It is contraindicated in patients who lack the cooperative ability, with whom communication
cannot be established.Aversiveconditioningaims to:
Establish better communication.
Gain control of behaviour.
Protect the child frominjury
Eventually makes the child’s dental experience a pleasantone.
Negative reinforcement, flooding, selective exclusion of parents and H.O.M.E, are all example of aversive
conditioning. These approaches are often deployed where all other avenues to establish communication with
the child havefailed. Those should not be used routinely,but as a method of lastresort.They are only used on
one occasion to establish communication with the child and should be followed by positive reinforcement.
(Duggal et al, 2013)
Does aversiveconditioningincreasedental fear?
Evidence suggests that high levels of fear are most attributed to aversive conditioning during childhood.
However, most studies in that field areof poor methodological quality. Most of them are of retrospective type,
which makes them vulnerableto recall or memory bias. (Moraes,2002)
The process of negative reinforcement involves the removal, reduction, postponement or prevention of
stimulation when an undesired action is performed. (Duggal et al, 2013)
Removal or reduction of an ongoing stimulation produces a behaviour that is called “escape”. Escape involves
respondingin the presence of an undesirablestimulus in order to terminate it. (Iwata, 1987)
Postponement and prevention producea behaviour thatis called avoidance,which involves acquiringa response
that prevents an aversivestimulus fromoccurring. (Iwata,1987)
Hand Over Mouth Exercise (H.O.M.E)
Hand over mouth exerciseis a negative reinforcement strategy that is often employed to deal with hysterical or
tantrum-likebehaviour to establish an effectivecommunication.It was suggested by some authors thatthis is a
method of a lastresortthatshould be employed on children who are healthy and areat leastthree years of age
to securetheir attention. (Fayle& Tahmassebi,2003) (Roberts, 2010)
When patient cries hysterically,hands areput firmly on the patient mouth without blockingthe airway.This is
combined with strict instructions to stop crying for the hand to be removed. When the patient indicates
willingness to cooperate, hand is removed and patient is reassessed. Repeat if patient start crying again until
behaviour is shaped. (Roa, 2012)
Although this might be an effective way of controllingthechild’s behaviour this isan unacceptablebehaviour in
the UK. Itcould be very easily misinterpreted as an assaultand perceived as a formof physical restrain. (Fayle&
Tahmassebi,2003) (Roberts, 2010)
A patient starts cryingon the chair,so you tell parents to waitoutside your surgery. Excluding
parents is the negative stimulus and in order for that stimulus to terminate, the patient should
stop crying. When your patient stops crying you ask the parents to come back into the room
again,which means that you have removed the aversivestimulus. Your patient has “escaped”
the negative situation by showingan acceptablebehaviour.
Your patientfrom the previous example starts cryingagain.You turn to the parents to ask them
to leave, but the patient stops crying this time before the parents leave. Your patient has
“avoided” the aversivesituation.
Itis acceptableunder theAAPD guidelines to useH.O.M.E, although incidenceis decreasing. (American Academy
of Paediatric Dentistry, 2011) In the UK it is regarded as extreme and unacceptable by the majority of parents
and dental practitioners. (Henry, 1984) (Welbury et al, 2012) The GDC guidelines maintaining standard has
stated that any form of intimidation isnever justified,and in caseof exceptional circumstancesa special consent
is a necessity.(MacLeavy, 2008) (Fayle& Tahmassebi,2003) (American Academy of Paediatric Dentistry,2011)
"There can be no justification for intimidation or, other than in the most exceptional circumstances, for the use
of physical restraint in dealing with a difficult patient. When faced with a child who is uncontrollable for whatever
reason, the dentist should consider ceasing treatment, making an appropriate explanation to the parent or
representative and arrange necessary future treatment for the child, rather than continuing in these
circumstances." (GDC guidelines maintainingstandards,2001).
There is a variation of H.O.M.E where the child’s airway isdeliberately restricted,named hand-over-mouth with
airway restriction (HOMAR). This is to be universally condemned and should never be used. (Roberts, 2010)
Flooding is simply exposing patients to their greatest fear without them being harmed or endangered in any
way. It is a type of desensitization for the treatment and extinction of dental phobia.(Duggal et al, 2013)
In the previous example it might be acceptableto put the child on the chair,butit will notbe a wisedecision to
stick a needle in a needle phobic patient to let them facetheir fears.
Although, floodinghas gota great chanceof success,it may not be the most adaptivemethod of respondingto
a realistic danger. Reducing fear may reduce a child’s future caution in risky situations. Fear is a natural good
and protective behaviour which can be excessiveand unreasonableatsome points in life (Bell,2005) .
Flooding and systemic desensitization are two major exposure-based techniques that share some of the basic
ideas but differ in the approach of which the are applied.
a) Fears develop because the individual anticipates that contact with a particular object or event would
resultin a negative outcome.
b) Both the anxiety and the featured outcome are excessiveand unrealistic.
c) Escape or avoidanceof the feared situation is reinforced when the negative outcome does not occur.
Escapeand/or avoidancebecome a conditioned responseto the feared stimulus.
Helping the child confronting their fears of sitting in the dental chair by placing them in the
chair,which allows themto realizethat this was not so threatening after all.
(Duggal et al, 2013)
d) A successful treatment would involve breaking the link between the feared stimulus and anxiety and
the conditioned response; which is escapeor avoidance.
Flooding would break the link between the feared stimulus and the conditioned response. Systematic
desensitization on the other hand is more concerned about stimulus and anxiety separation.(Bell,2005)
Summary: Positive or Negative Reinforcement?
Negative reinforcer strengthen behaviour when they are removed. Positive reinforcer strengthen behaviour
when they are present. In both cases the effect of reinforcement is the same - the probability of response is
Although punishment and negative reinforcement are both different, negative reinforcement starts by
introducing a negative stimulus which is then removed following an acceptable behaviour. Application of an
aversivestimuli could beviewed as a formof punishment,and punishmentweakens behaviour. (Baron & Galizio,
In some countries, aversivebehaviour management techniques are acceptable(includingpapooseboards) and
are common practice. Could this practicecondition fear in children and grow phobic adults who might be very
frightened of visitingthe dentist in the future? The main goal of paediatric dentistry is to promote acceptance
of dental treatment, and by the repeated and the unjustified application of such aversive methods,it is fear and
anxiety that is promoted.
Negative reinforcement (that would not breach the child’s dignity) issuggested,as mentioned above, to be used
to gain tantrum patient’s attention and establish communication (i.e.parental exclusion).It is then advised for
that to be followed by a positive reinforcement. So, simply speaking, negative gets you started, while positive
keeps you going.
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