Non pharmocological behavior management

BEHAVIOR MANAGEMENT –
NON-PHARMACOLOGICAL
METHODS,BEHAVIOR SHAPING

CONTENTS:
• Introduction
• Definitions
• Classifications of child behavior
• Factors influencing child behavior
• Non-pharmacological behavior managements
• Conclusion
• References

 Successful dentistry for children depends not only on
the dentist’s technical skills but also on his ability to
acquire & maintain a child’s cooperation
 Most children strive to be cooperative; in these
instances the dentist must support the child’s behavior
 When a child is uncooperative; this behavior should be
altered & controlled
 Guidance of a child’s behavior in dental office is
prerequisite to complete dental care
INTRODUCTION

 BEHAVIOR-
Behavior is any activity that can be observed , recorded and measured.
 BEHAVIOR MANAGEMENT-
Behavior management is the means by which dental health team effectively and efficiently
performs treatment for a child and at the same time instills a positive dental attitude.(WRIGHT,1975)
 BEHAVIOR SHAPING-
It is the procedure , which slowly develops behavior by reinforcing a successive
approximation of desired behavior until desired behavior comes into being.
DEFINITION

 BEHAVIOR MODIFICATION:
It is defined as the attempt to alter human behavior and emotion in a beneficial
manner according to laws of modern learning theory.(EYSENCK,1964)

BEHAVIOR GUIDANCE: It is a continuum of interaction involving the dentist, the
dental team, the patient and the parent directed towards communication and education
‘which ultimately builds trust and allays fear and anxiety’.
The AAPD guidelines have stated (2011) the goals of behavior guidance
• To establish communication
• Alleviate fear and anxiety
• Deliver quality dental care
• Build a trusting relationship between dentist and child
• promote the child’s positive attitude toward oral/dental health and oral health care.

CLASSIFICATION OF CHILD’S BEHAVIOUR
OBSERVED IN DENTAL CLINIC
Various behavioue evaluation scales:
 Wilson – 1933
 Frankl – 1962
 Visual analogue scale - 1970
 Lampshire – 1970
 Nazif – 1971
 Wright – 1975
 Melamed et al – 1978
 Gracia-godoy - 1986
 Venham et al – 1990
 Machen and jhonson – 1991
 Facial imaging scale
 Modified child dental anxiety scale.

Rating 1: Definitely negative
Refusal of treatment, crying forcefully, fearfulness, or any other overt evidence of
extreme negativism.
Rating 2: Negative
Reluctance to accept treatment, uncooperative behavior, some evidence of a
negative attitude but not pronounced
Rating 3: Positive
Acceptance of treatment, at times cautious, willingness to comply with the dentist,
at times with reservation but follows the dentist’s directions cooperatively.
Rating 4: Definitely positive
Good rapport with the dentist, interested in the dental procedures, laughing and
enjoying the situation.
THE FRANKL BEHAVIOR RATING SCALE (1962)

Wright gave the symbols to Frankl’s 4 types of behavior.
• Rating 1: Definitely negative (--)
• Rating 2: Negative (-)
• Rating 3: Positive (+)
• Rating 4: Definitely positive (++)
Eg: restoration with GIC (+) (-) Local anesthesia.
PINKHAM’S CLASSIFICATION:
• Category I - Emotionally compromised child
• Category II - Shy, introvert child
• Category III - Frightened child
• Category IV - Child who is adverse to authority.
WRIGHT’S MODIFICATION OF FRANKL’S BEHAVIOUR
RATING SCALE (1975)

WRIGHT’S CLASSIFICATION (1975)
 Cooperative children are reasonably relaxed.
They have minimal apprehension. They may
be enthusiastic. They .can be treated by a
straight forward, behavior-shaping approach.
When guidelines for behavior are established,
they perform within the framework provided.
 lacking in cooperative ability.
This category includes very young children with
whom communication cannot be established and
of whom comprehension cannot be expected.
Because of their age, they lack cooperative
abilities.

Another group of children who lack cooperative ability is those with specific
debilitating or disabling conditions. The severity of the child's condition prohibits
cooperation in the usual manner.
At times, special behavior guidance techniques are used for these children. Although
their treatment is accomplished, immediate major positive behavioral changes cannot
be expected.
 The nomenclature applied to a Potentially cooperative child is behavior
problem.When a child is characterized as potentially cooperative, clinical
judgment is that the child's behavior can be modified; that is, the child can become
cooperative.

Uncontrolled behavior:
• This is typically presented by 3 to 4 years old children at their first dental visit or by
older children at the time of injection.
• There is loud crying, kicking and temper tantrums.
Defiant/obstinate behavior:
• This child has been termed as ‘spoiled kid’ by Lampshire in 1970.
• He controls his behavior in a sense by challenging the authority of the dentist.
• Typical responses are ‘I do not want my teeth fixed’ or ‘you can’t make me open
my mouth’.
• These children have potentially severe emotional problems that are manifested at
home, school and other areas of life.

Timid behavior:
• Often expressed by young children, particularly at the initial dental appointment.
• It is a result of child’s anxiety about the dental experience and how he is expected to
perform in the office.
• The child’s anxiety may prevent him from listening attentively to the dentist, so
instruction must be given slowly, quietly and repeated when necessary.
• Once the child gains confidence in the dentist he can become excellent patient.
Tense cooperative borderline behavior:
• They are extremely tensed; body language is different; tremor in voice; sweating
palms, hands.
• They can be cooperative if behavior is managed well

Whining behavior:
• The child with this type of behavior can be extremely
frustrating to treat.
• He allows treatment but he whines throughout the entire
procedure.
Stoic behavior:
Such children are generally cooperative. He sits quietly
and passively accepts all dental treatment including the
injection without protest or any sign of discomfort.
physically abused.

• Attitude or expectation of dentist can affect the outcome of treatment
• Child will respond with the type of behavior expected
• +ve statements increases the chance of success
I] Positive approach
• Children responds best to natural & friendlier attitude
• Made to feel good by using nick names, noting child’s school
accomplishments – demonstrates friendly & caring attitude
II] Team attitude
• Dental team must be flexible as the situation demands
III] Flexibility
FUNDAMENTAL PRINCIPLES OF
BEHAVIOR MANAGEMENT

• Each dental office must devise its own contingency plans
• Each member should be aware in advance of what is expected of them &
what to be done
• Delays & indecisiveness can build apprehension in young children
IV] Organization
• Children – either white or black; nothing inbetween
• Important for building trust – truthful in explaining the children about
procedures
V] Truthfulness
• Dentist’s ability to cope with misbehaviors while maintaining composure
VI] Tolerance

Objectives of behavior management Snowder, 1980
• To establish effective communication with child and parent.
• Gain child and parent confidence for dental treatment.
• Teach child positive aspect of preventive dental care.
• Provide a comfortable, relaxing environment to the child.

PEDODONTIC TRIANGLE:
• Pedodontic triangle was first explained and conceptualized by GZ Wright in 1975
and was later modified by McDonald et al. in 2004.Vivek et al. 2012
DENTIST-PATIENT-PARENT and DENTIST-
PARENT RELATIONSHIP

Factors
influencing
child’s
behavior
Under the
control of
dentist
Not under the
control of
dentist
Under the
control of
parents
(mother)

• Dentist’s attitude can support a child in his attempt to establish proper
behavior
• Methods by which dentist approaches & deals with child patient are of
critical importance to child’s reaction & attitude towards dental treatment
I. Dentist’ anxiety
• Not a sig. factor influencing the behavior of most children (Cohen,1973)
• Certain associative fears may be unduly influenced by what dentist wears
• Less formal attire – beneficial effect
II. Dentist’s attire
FACTORS UNDER THE INFLUENCE OF
THE DENTIST

• Short appointment (less than 30 min) – short attention span of
children
• Early morning appointment – more rested & cooperative
• Appointment during nap time – irritability
• Time of appointment should be dependent on the dentist’s
convenience rather on child’s behavior (Lenchner, 1966)
III. Length & time of day of treatment
• pleasant environment relieve anxiety (carpeted, pastel colored
rooms & small nursery chairs) (Swallow, 1972)
• Fear provoking instruments are kept out of visual field
IV. Dental environment

• Pre-visit letter helps to prepare the child
• Initial visit is only diagnostic
• Confirms day & time of appointment
• Gives specific information – fees, accompanying person
• Pre-appointment behavior modification
• Audiovisual - Films & tapes
• Live models – siblings, parents
V. Pre-appointment procedures (Tuma, 1954)
• Giving gifts to children
• Pleasant reminder of appointment
• Never bribe a child
• Sending b’day cards
VI. Tangible reinforcements (recognition for children)

• Intellectual age of 3 years signifies maturational readiness to
accept dental treatment
• Children with any form congenital problem together with
excessive concern by parents – behavioral problem
I. Growth & Development
• Deficiency influences the overall physical & cognitive
development
• Hungry children; skipping meals – do not perform to expectations
II. Nutritional factors
• Negative experiences – uncooperative
• Pain experienced during previous hospital situations
III. Past medical history
FACTORS NOT UNDER THE INFLUENCE OF
THE DENTIST

• First born
• immediate family environment is parents
• Higher competencies to live up to - Over achievement
• More anxious & more sensitive
• Middle born
• Seeks, attention, recognition & graciously works to get it
• Outgoing, suggestible & looks for +ve approbation
• Less competent model to follow - realistic
• Last born
• More defiant, irritable, feeling of inferiority
• Sibling rivalry – dentist should not make comparisons between siblings
IV. Ordinal position, Sex & spacing in family

• Can have both –ve or +ve behavior on child
• More effective with 4-year old children (Ghose et al, 1969)
V. Sibling & peer influences
• Tendency of –ve behavior if child is aware that problem exists –
apprehension transmitted by the parent
• Educating the parent about the value of arranging 1st dental visit
prior to any dental problem
VI. Awareness of dental problem
• Low economic status – decreased awareness – visits once
problem occurs - highly anxious
• High economic status – preventive program
VII. Socio economic status

• Mother gives excessive care for child in terms of feeding,
dressing, bathing.
• Constantly involved with child’s daily social activities and
may not allow him to participate in risk-involving games
• Excessive concern about routine dental condition
• Infantizes the child, retards normal psychological maturation
Overprotective : Submissive, shy,
anxious
FACTORS UNDER THE INFLUENCE OF
THE MOTHER

• May be associated with overprotective or
dominant natural trait
• These parents give child whatever he might want,
as far as financially possible including toys, candy
and clothes
• Relative such as grandparents are also
overindulgent
Overindulgence: Aggressive, spoilt, demanding,
displays temper tantrums

• Usually well behaved, but may be unable to
cooperate, may cry easily
• May vary from mild detachment to neglect.
• Mother becomes less emotionally supportive of her
child due to her outside interests, employment, or
because the child is unwanted.
UNDER EFFECTIONATE:
• Aggressive, overactive, disobedient Mother behavior
is characterized by neglect of the child, severe
punishment, nagging and resistant to spending time
and money on the child.
REJECTING:

• The authoritarian parent chooses technique for
controlling child behavior that may be termed
non love oriented
• Discipline often takes the form of physical
punishment or verbal ridicule
• The authoritarian mother will insist that the
child stick to her set of norms and will extend
much effort to train child along those lines
AUTHORITARIAN : EVASIVE

Mother’s behavior Child’s behavior
Overprotective Submissive, shy, anxious
Overindulgent Aggressive, demanding,
displays temper tantrums
Overindulgent Aggressive, spoiled,
demanding, displays
temper tantrums
Underaffectionate Usually well behaved, shy or
cry easily
Rejecting Aggressive, overactive or
disobedient
Authoritarian Evasive & dawdling
Parenting types by
BAUMRIND – 1978
MACCOBY AND MARTIN - 1983

 NON-PHARMACOLOGICAL(PSYCHOLOGICAL APPROACH)
-Communication
-Use of second language
-Tell-show-do
- Desensitization
-Modeling
-Behavior shaping
-Contingency management
-Externalization
-Distraction
-Assimilation and coping
-Parental presence or absence
-Retraning
-Visual imagery
-Voice control
-Use of poetry and drawings
-Hypnosis
-Hand over mouth technique
-Protective stabilization
 PHARMACOLOGICAL MANAGEMENT
-Pre-medication
-Conscious sedation
-General anesthesia
CLASSIFICATION:

NON- PHARMACOLOGICAL BEHAVIOR
MANAGEMENT:

 Communicative management is universally used in pediatric dentistry with both the
cooperative and uncooperative child (chambers,1976)
-By involving in conversation, the dentist not only learns about the patient but may also
relax the patient
Types of communication :
1) Verbal communication by speech
2) Nonverbal communication -Expressions without words like hand shaking , eye
contact , smiling
3) Both verbal and non verbal
COMMUNICATION:

COMMUNICATING WITH CHILDREN
• Establishment of communication
• Establishment of communicator
• Multisensory communicating
• Active listening
• Message clarity
• Voice control
• Problem ownership
• Appropriate response

- Euphemisms are substitute words, which can be used in the presence of child .
-The dental staff as well as dentist should oriented to the use of second language .
USE OF SECOND LANGUAGE(EUPHEMISM)

Given by Pinkham in 1985
- Sudden and firm commands that are used to get the child attention and stop
the child from his current activity
Objective:
1.Attention and compliance
2.To avoid negative or avoidance
behavior
3.To establish authority
VOICE CONTROL:
Indications:
Uncooperative and inattentive patients

Contraindications:
Children who due to age, disability, mental or
emotional immaturity are unable to understand.
AAPD 2015 :
• Voice control is a deliberate alteration of voice volume,
tone, or pace to influence and direct the patient’s behavior.
• Objectives: gain the patient’s attention and compliance;
avert negative or avoidance behavior; and establish
appropriate adult-child roles.
• Indications: May be used with any patient.
• Contraindication: Patients who are hearing impaired.

Tell-show-do(TSD),the cornerstone of behavior management was given by Addleston.
 Specifically , the dentist tells the child what is going to be done in words the child
can understand .Second , the dentist demonstrates to child exactly how the
procedure will be conducted . Finally ,practitioner performs the procedure exactly
as it was described and demonstrated .
Objectives :
 To teach the patient aspect of dental visit and to familiarize him with the
dental settings.
 To shape the patients response to various procedures.
TELL-SHOW-DO:

TELL:
Tell the child before you do it, while you are
doing it and after you have done it . You voice should
be soft , yet firm, confident , and continuous .
You should be truthful with the child and if the
procedure is going to be painful or uncomfortable , say
so.

SHOW:
 Demonstration of the visual , auditory, olfactory and tactile aspect of the procedure in a
carefully defined, nonthreatening setting.
 The dentist can either demonstrate on himself or an inanimate object.
 The noise of running handpiece shows the child through the hearing medium . A pinch on
the arm before anesthesia administration demonstrate to the child how the pinch of the
injection in the mouth might feel.
 Bring equipment from behind the child or the visual
level is preferred.

DO :
 Without deviating from explanation and
demonstration dentist perform the previewed
operation .
 In doing, do what you said you would do.
 Do not do until the child has clear awareness of what
it is you are going to do.

INDICATIONS:
 First visit
 Subsequent visits when introducing new dental procedure
 Fearful child
 Apprehensive child because of information received from parents/peers.
This is effective in children more than 3 years of age.
• Levy and Domoto (1979) observed TSD as one of the most highly employed
behavior management technique.
• Beretz et al. (2003) found that 97% of pediatric dentists use this technique.
• Sharma A and Tyagi R (2011) from their retrospective study concluded that
TSD modifies the behavior of child and aids in achieving the treatment goals
effectively in all age groups.

 This technique was demonstrated by James and popularize by Wolpe.
It means take away ones sensitivity to a type of behavior.
 This is used in children having pre-established fears and uncooperative
behavior.
 Desensitization accomplished by teaching the child a competing response such
as relaxation and then introducing progressively more threatening stimuli.
 Is an effective method for reducing maladaptive behavior .
DESENSITIZATION:

-Introduced by Bandura ( 1969).
-It is based on one’s learning or behavior acquisition occurs through observation of
suitable model performing specific behavior.
-Synonyms : imitation , observational learning , identification, internalization , coping .
-Modeling seems to improve behavior of the apprehensive child who have had no
previous dental experience .
 Types of modeling:
1. Audiovisual
2. Live modeling by parents , sibling etc.
MODELING:

OBJECTIVES OF MODELING:
 Stimulates acquisition of new behavior .
 facilitating the behavior already in the patients in more
appropriate manner.
 Elimination of avoidance behavior .
 Extinction of fear.
ADVANTAGES OF MODELING:
 Patient’s attention is obtained.
 Designed behavior is modeled.
 Physical guidance of the desired behavior.
 Reinforcement of the desired behavior

It is defined as a process which slowly develops a behavior
by reinforcing successive approximation of the desired
behavior until the desired behavior is expressed(Lencher
and wright,1975)
 It is based on stimulus- response theory i.e most behavior
is learned and that learning is the establishment of a
connection between a stimulus and a response
 when shaping the behavior the dentist is teaching to a
child to behave .
BEHAVIOR SHAPING:

Outline of behavior shaping model
1. State the general goal or task to the child at the outset.
2. Explain the necessity for the procedure. A child who
understands the reason is more likely to cooperate.
3. Divide the explanation for the procedure.
4. Give all explanations at a child's level of understanding.
Use euphemisms appropriately.
5.Use successive approximations.
6. Reinforce appropriate behavior
7. Disregard minor inappropriate behavior.

- The presentation of positive reinforcers or withdrawal of negative
reinforcers is termed contingency management.
- It include :
 Positive reinforcement
 Negative reinforcement
 Omisssion or time out
 Punishment
CONTIGENCY MANAGEMENT:

Positive reinforcement: It is the presentation of the pleasant stimulus and is done to
appreciate the child for the good behavior. Either of the reinforcers can be used.
Negative reinforcement: Withdrawal of the unpleasant stimulus like high speed handpiece.
Care should be taken not to confuse this punishment. The unpleasant stimulus is withdrawn
and not given to the child. It is similar to deemphasis or substitution type of retraining.
Time-out (or) omission: It is the withdrawal of the pleasant stimulus to reinforce good
behavior. Asking the mother (pleasant stimulus for the child) to stay out of the dental
operatory to make the child cooperative is an example of time-out.
Punishment: It is the presentation of the unpleasant stimulus to the child, e.g. voice control,
hand over mouth exercise (HOME).

Types of reinforcers :
 Social – e.g. , praise , positive facial expression , physical
contact by shaking hand , hug ,pat on shoulder.
 Material - may be given in the form of games ,toys.
 Activity reinforcers – Involving child in some activity like
watching TV shows , visit to park.

- It Is the process by which child’s attention is focus away from
the sensation associated with dental treatment by involving in
verbal or dental activity.
Objectives:
- To decrease perception of unpleasantness
- to interest and involve children .
EXTERNALIZATION:

- The patient is distracted from the sound and/or sight of dental treatment thus
reducing anxiety.
- Objective is to relax the patient and to reduce anxiety during treatment.
- Use stories and fairy tales.
- Use slow instrumental music .
- Types of distraction:
1) Audio distraction
2) Audiovisual distraction .
DISTRACTION:

• White noise
• Providing a sound stimulus of such intensity that the patient finds it
difficult to attend to anything else.(Gardner,Licklider 1959).
• Pleasant music
AUDIO ANALGESIA

• Humor is defined as a stimulus that helps people laugh and feel happy
• Relaxes a fearful and anxious child and parent
• Forming and maintaining a relationship
• Increases the interest and involvement of the child
• Transmits essential information in a non threatening way.
HUMOR

• The visual imagery technique is believed to work with children because
they have good ability to imagine and fantasize.
• Ayer (1973) describes visual imagery where children were asked to
imagine that they were playing with their dogs.
VISUAL IMAGERY

 Stress can act to increase pain perception while coping decrease it by process
called assimilation .
 Coping is defines as the cognitive and behavioral efforts made by an
individual to master, tolerate or reduce stressful situations (Lazaue ,1980) .
Coping effect may be of two types :
1.Behavioral – are physical and verbal activity in which the child engages to
overcome a stressful situation .
2.cognitive - Efforts which involves manipulation of emotions .
ASSIMILATION AND COPING:

Sand Tray Therapy
Margaret Lowenfeld, Dora Kalff, Goesta Harding, Charlotte Buhler, Hedda Bolgar, Lisolotte Fischer,
and Ruth Bowyer.
Sand tray therapy is a form of expressive therapy that is sometimes referred to as sandplay
therapy or the World Technique.
Sand tray therapy emphasizes what the person in therapy is experiencing at that moment, and
therapists are actively involved in facilitating current experiences of awareness and growth. As
individuals in treatment are required to open up emotionally—sharing their deepest thoughts and
feelings as they happen—the therapeutic relationship in sand tray therapy must be strong in order
for the treatment to be effective.
In contrast, sandplay therapists focus on the unconscious and seek to provide people in therapy
with a free, protected space and the opportunity to communicate nonverbally. As such, sandplay
therapists do not interpret, interfere with, or direct the person in therapy in any way, and analysis
takes place after the therapy session.
While verbalization is an essential aspect of each sand tray session, sandplay therapy may be
more effective for children or for individuals who are unable to express themselves verbally due
to past trauma.

OBJECTIVES:
• To avert avoidance behavior
• To establish authority
• To gain patient’s attention and compliance
PARENTAL PRESENCE AND ABSENCE:

Advantages of parental absence
a) Overcoming parental conditioning
b) Avoiding communication interference
c) Avoiding parental interference
Advantage of parental presence
a) Supporting and communicating with the child
b) Very young patients.

- Use of poetry is employed in children above 7yrs of age .
- The poem is written as collective effort, the dentist contributing one line and child next.
- Use of drawing is useful for children of 3-5 yrs of age .
- Child is given a paper and pencil or crayon and ask to draw some picture.
Advantages:
-It allows repetition without monotony .
- The rhyme and rhythm can be used to guide the child towards the information to be
implied .
- It gives the child sense of achievement and increases self esteem.
USE OF POETRY AND DRAWINGS:

Magic trick: a behavioural strategy for the
management of strong willed children.
Peretz B, Gluck G, Int J Paediatr Dent 2005; 15:429–436
Design This study was a randomised controlled trial.
Intervention Children identified as manifesting strong-willed behaviour (refusal to enter room and/ or sit
in the dental chair) were selected and assigned, randomly, to test or control groups. Children in the test
group (“Magic+”) were shown a magic trick using a magic book (pictures erased magically then drawn
again) prior to being encouraged to sit in the chair whereas those in the control group (“Magic−”) were
managed with ‘tell–show–do’ and positive reinforcement.
Outcome measure: The behaviour of the two groups was assessed by measuring the time taken from the
beginning of the session to the child sitting on the dental chair; whether radiographs were successfully
taken; and using Frankl’s behaviour category1, as rated by the dentist.
Results Thirty-five children, aged between 3 and 6 years, were allocated to each group. Time to sitting on
the dental chair was significantly shorter in the Magic+ group (P 0.001) and radiographs could be taken
in significantly more children (91%; P 0.0013) than in the Magic− group (54%). The Magic+ group
demonstrated more cooperative behaviour as categorised by Frankl.
Conclusions This study demonstrates that a magic trick improved cooperation of strong-willed children by
expediting the movement of the child into the dental chair and allowing the dentist to take radiographs
more easily.

- It was first suggested by Franz A Mesmer in 1773
-It is defined as state of mental relaxation and restricted awareness in which subjects
are engrossed in their inner experiences such as imaginary are less analytical and
logical in their thinking and have enhance capacity to respond to suggestions in an
automatic and dissociated manner
Uses:
1. To reduce nervousness and apprehension
2.To eliminate defense mechanism that patients used to postpone dental work
3.To control functional or psychosomatic gaping
4.To prevent thumb sucking and bruxism
5.To induce anesthesia
HYPNOSIS:

- This technique was first described in 1920 by Dr. Evangeline Jordan
Other terminologies :
- Aversive conditioning by Lenchner and Wright in 1975
- Emotional surprises therapy by Lampshire
- Hand over mouth airway restricted (HOMAR) by Levitas in 1947
- Aversion by Crammer in 1973
HAND OVER MOUTH TECHNIQUE:
Indication :
A healthy child who is able to understand and cooperatewho exhibit defiant,
hysterical behavior to dental treatment.

Contraindication :
- Immature child
- When it prevents child from breathing
- When the dentist is emotionally involved with child
Objectives:
1) To gain child attention enabling communication with dentist so that appropriate
behavioral expectation can be explained.
2) To eliminate inappropriate avoidance behavior to dental treatment and to
establish appropriate learned responses.
3) To assure child safety in delivery of quality dental care

Partial or complete immobilization of the patient is sometimes a necessary and
effective way to diagnose and deliver dental care to patients who need help in
controlling their extremities.
The parents must be informed and the consent must be documented, before
immobilization is used, they should have a clear understanding of the type of
immobilization to be used, the rationale, and duration of use.
This decision should take into consideration the patient’s emotional development,
physical and medical considerations, dental need, other alternative behavioral
modalities and the quality of dental care.
PROTECTIVE STABILIZATION:

Indication :
 A patient who requires diagnosis or treatment and cannot cooperate because of lack of
maturity.
 A patient who requires diagnosis or treatment and cannot cooperate because of mental or
physical disabilities .
 When the safety of the patient or practitioner would be at risk without the protective
use of stabilization .
Contraindication:
 A cooperative patient
 As punishment
 A patient who cannot be safely immobilized because of underlying medical or systemic
conditions
 It should not be used solely for the convenience of the staff.

Restraints are usually needed for children who are hyperactive, stubborn or defiant
Types of restraints-
a)For body-
• pedi wrap
• papoose board sheets
• Beanbags with straps
• Towels and tapes
b) For extremities- velcro straps
posey straps
PHYSICAL RESTRAINTS:

c) For mouth - mouth blocks
- mouth props
- molt mouth prop
- rubber bite block
- finger guards
d) Others – straps are attached to dental unit to restrain a child waist and legs.
- sheets used to restrain patients movement.Eg;papoose board/ pedi
wrap.

AAPD 2015
The decision to use protective stabilization must take into consideration:
• Alternative behavior guidance modalities
• dental needs of the patient
• the effect on the quality of dental care
• the patient’s emotional development
• the patient’s medical and physical considerations

AAPD 2015 Indications:
• A patient who requires immediate diagnosis, urgent care, and/or limited treatment and
cannot cooperate due to emotional or cognitive developmental levels, lack of maturity,
or mental or physical conditions.
• A patient who requires immediate diagnosis, urgent care, and/or limited treatment and
uncontrolled movements risk the safety of the patient, staff, dentist, or parent without
the use of protective stabilization.
• Sedated patients to help reduce untoward movement

AAPD 2015 Contraindications:
 Cooperative non-sedated patients.
 Patients who cannot be immobilized safely due to asso-ciated medical,
psychological, or physical conditions.
 Patients with a history of physical or psychological trauma due to
immobilization (unless no other alterna-tives are available).
 Practitioner’s convenience.

REFERENCES:
• Pediatric dentistry infancy through adolescence- Pinkham
• Pediatric dentistry total patient care-Stephen wei
• Dentistry for child and adolescent – Mc Donald and Avery
• Textbook of pediatric dentistry-Nikhil marwah
• Textbook of pediatric dentistry- Shobha tandon
• Internet sources

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