This presentation gives a a comprehensive view on the various non pharmacological behavior management techniques in pediatric dentistry.

1. Good morning!
1

2. NON-
PHARMACOLOGICAL
BEHAVIOR
MANAGEMENT
Dr. Pratima Kolekar
MDS II
2

3. 3
• Mc Elory (1895) wrote :
“ Although operative dentistry may be
perfect, the appointment is a failure
if a child departs in tears.”

4. CONTENTS
PART I :
• Introduction
• Pedodontic Treatment Triangle
• Pediatric dental patients
• Classification of children’s co-operative behavior
• Fear and Anxiety
• Psychometric Assessment of dental fear and anxiety
• Variables influencing children’s dental behavior
4

5. 5
 PART II
• Definitions
• Fundamentals of behavior guidance
• Behavior guidance techniques
• Pre-appointment behavior shaping
• Basic behavior guidance techniques :
 Communicative management
 Tell-show-do
 Voice control
 Modelling
 Contingency management
 Distractions
 Memory restructuring
 Desensitization

6.  PART III
• Advanced behavior guidance
 Protective stabilization
 Aversive conditioning
• Recent advances in behavior guidance
• Conclusion
• Previous year question papers
• References
6

7. INTRODUCTION
• For optimal management of children, the dental
surgeon must understand why certain behavior
patterns occur and how to deal with them effectively.
• The first dental visit of child- full of anxiety for
both the parents and the child.
7

8. 8
• As the pediatric dentist usually relies on the co-
operation of the child for rendering effective
treatment, the first appointment is very important
for establishing rapport and gaining trust of the child.
• Behavior management- an integral part of pediatric
dental practice.

9. 9
• A major difference between the treatment of children
and adults is the relationship.
• 1:1 relationship
Adults
• 1: 2 relationship
Children

10. PEDODONTIC TREATMENT
TRIANGLE
10
1975 2014

11. 11
Vivek Padmanabhan, Dr Kavitha Rai, Dr Amitha M Hegde. Pediatric dentistry
treatment triangle - A Review and A New Model Journal of Health Sciences and
Research. 2012;3(1):35-6.

12. PEDIATRIC DENTAL
PATIENTS
12

13. 13
Stone & Church classification (1975) :
• Infant (0-15 months)
• Toddler (15 moths to 2 years)
• Preschooler (2-6 years)
• Middle year child (6-11 years)
• Adolescent (>11years)
R. J Mathewson , Robert E.Prismosch.Fundamentals of pediatric dentistry

14. 14
2- year old
• Self-centred, solitary, easily frustrated, easily
distracted and completely dependent on adults
Attention span 1-5 minutes Keep appointment times
short
Special feature Concentrates on one thing
at a time.
Lives in the present
Concentrate only on the
child and avoid
interruptions from parents
or other staff
Favourite word No! Avoid asking questions
which can have a “no”
answer such as “ Would
you like me to…..?”

15. 15
3- year-old
• Exuberant, independent, imitative of adult behavior, curious,
imaginative
• Gain attention by arousing curiosity, describe procedures to the child
and ask them to add their own description.
• Let them “help”
• Attention span-4-8 minutes
• Favourite word-Why?

16. 16
4-year-old
Dominant, bossy, impatient
Engage the child’s “help”
Grasps simple reasoning Explain simple procedures ( The
filling doesn’t stick if the tooth gets
wet)

17. 17
5-year-old
• Poised, self-confident, aware of rules,
likes to act grown-up, less combative
Accept authority Should be able to use a hand signal
properly
Proud of their
possessions
Show interest in possessions/clothes.
Appeal to their vanity( e.g. “A dirty
tooth….I’ll clean it and put a pretty
filling in it”;”I need you to help me fix
it”

18. 18
Adolescents
• Major emotional, physical and hormonal changes occur during
the teenage years- perplexing
• Moody and sensitive to criticism, so comments about their
dental health need to be delivered with care.

19. CLASSIFICATION OF CHILDREN’S
CO-OPERATIVE BEHAVIOR
• Wilson’s classification
• Frankel’s classification
• Wright’s classification
• Pinkham’s classification
• Lampshire’s classification
19

20. Wilson’s classification (1933)
Behavior Description Attitude towards dental
treatment
Normal or bold Child is confident to face
new situations
Co-operative & friendly
with dentist
Tasteful or timid Child is shy Allows dental treatment
to be performed without
interruption
Hysterical or rebellious Child is rebellious Exhibits temper tantrums
towards dental treatment
Nervous or fearful Child is tense &
extremely anxious
Interrupts dental
treatment
20

21. Frankel’s behavior rating
scale(1962)
21
Behavior Rating Description
Definitely
Negative
Rating no.1 Refuses treatment,cries
forcefully, extremely negative
behavior
Negative Rating no.2 Reluctant to accept
treatment,displays slight
negativism
Positive Rating no.3 Accepts treatment
Definitely
Positive
Rating no.4 Unique behavior,establishes
rapport

22. 22
• Popular research tool
• Shortcoming- does not communicate sufficient clinical
information regarding uncooperative children

23. 23
Modification and adaptation of Frankl’s
Behaviour Rating Scale
Behavior Rating Symbol Description
Definitely
Negative
Rating no.1 (- -) Refuses treatment,cries
forcefully, extremely negative
behavior
Negative Rating no.2 (-) Reluctant to accept
treatment,displays slight
negativism
Positive Rating no.3 (+) Accepts treatment
Definitely
Positive
Rating no.4 (+ +) Unique behavior,establishes
rapport
• In 1975 Wright proposed a modification of Frankl’s Behaviour Rating
Scale.

24. 24
• J. Machen and R. Johnson described an adaptation of Frankl’s Behaviour
Rating Scale (1991).
• New version - two independent raters evaluate children’s behaviour in dental
setting in the range from definitely positive to definitely negative at five
different moments:
 Separation of the child from the parent
 First reaction of the child in dental setting
 Attitude towards the dental staff
 Behaviour during the treatment
 Behaviour after the treatment
Shindova MP, Belcheva AB. Behaviour evaluation scales for pediatric dental patients
review and clinical experience. Folia Med (Plovdiv). 2014;56:264-70

25. Wright’s classification (1975)
1. Cooperative
• Reasonably relaxed, minimal apprehension, enthusiastic
2. Lacking in cooperative ability
• Very young children- communication cannot be
established
• Physically or mentally challenged
3.Potentially cooperative 25

26. 26
3. Potentially cooperative
Uncontrolled or hysterical- temper tantrums, loud cry,
violent movement of extremities
Defiant or obstinate- stubborn, resists treatment
Tense cooperative- agrees to treatment but is tense,
borderline between negative & positive
Whining- receives treatment with continuous complaints
throughout the procedure
Stoic – receives treatment without any expression, physically
abused

27. 27
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.

28. Lampshire’s classification (1970)
Behavior Description
Co-operative Children who remain physically and emotionally
relaxed and cooperative throughout the entire visit,
regardless of treatment undertaken
Tense co-operative Children who are tense but nevertheless cooperative
Outwardly apprehensive Child who hides behind the mother in the waiting
room, uses stalling techniques and avoids talking to the
dentist. These children will eventually accept dental
treatment
Fearful Children who require considerable support in order to
overcome their fear of dental situation. Modeling is
useful for them.
28

29. 29
Behavior Description
Stubborn/
Defiant
Children who passively resist or try to avoid treatment
by using techniques that have been successful for them
in other situations
Hypermotive Children who are agitated and who adopt procedures
such as screaming or kicking as their coping defense
mechanism
Handicapped Children who are physically, mentally or emotionally
handicapped
Emotionally
Immature
This category includes the young children who have not
yet achieved sufficient emotional maturity to
rationalize the need for dental treatment and to cope
with it

30. FEAR AND ANXIETY
• Fear : reaction to known danger
• Anxiety : reaction to unknown anticipated
stimuli
• Fear and anxiety toward the dentist and dental
treatment - avoidance of dental care.
30

31. 31
Dental anxiety
• Anxiety associated with the thought of visiting the
dentist for preventive care and over dental procedures is
referred to as dental anxiety.
• It has been cited as the fifth-most common cause of
anxiety by Agras et al.
• Anxiety is an emotional state that precedes the actual
encounter with the threatening stimuli, which sometimes is
not even identifiable.

32. 32
Fear
• Fear is defined as a painful feeling of impending danger, evil, trouble, etc.
(Delbridge)
• It leads to a fight-or-flight situation.
• Dental fear is a reaction to threatening stimuli in dental situations.
• Phobia is persistent, unrealistic, and intense fear of a specific stimulus,
leading to complete avoidance of the perceived danger.

33. 33
Types of fear :
General
fear
Objective fear
(real or active)
Subjective fear
(Imagined
fear)
Dental fear
Fear of pain
or its
anticipation
Fear of
betrayal
Fear of loss
of control
Fear of
unknown
Fear of
intrusion

34. PSYCHOMETRIC
ASSESSMENT OF DENTAL
FEAR AND ANXIETY
• Corah’s Dental Anxiety Scale (CDAS)
• Modified Dental Anxiety Scale (MDAS),
• Kleinknecht et al’s Dental Fear Survey (DFS)
• Children’s fear survey schedule-dental subscale
(CFSS-DS)
• Visual analog scale.
34

35. 35
• However, none of these existing instruments has been
regarded as a gold standard, as they have their own
limitations.
• The CDAS, MDAS, and DFS are the most commonly
used questionnaires, and have been shown to be reliable and
valid in multiple languages

36. Corah’s dental anxiety Scale (1969)
• The scale consists of four questions about different dental
situations.
• Each question is scored from 1 (not anxious) to 5
(extremely anxious), so the range of possible scores is 4–
20.
• The cutoff point of more than 15 indicates high anxiety
level or possibly phobic. 36

37. 37

38. Modified dental anxiety scale -
Humphris et al (1995)
• In 1995, the Corah dental anxiety scale was modified
by Humphris et al. to overcome its shortcomings
• Humphris et al. added a fifth question relating to
local anesthetics as it is a major cause of anxiety for
many individuals.
38

39. 39

40. Kleinknecht et al’s Dental Fear
Survey (DFS)
• The DFS consists of 20 items concerning avoidance behavior,
physiological fear reactions, and different fear objects concerning
dental appointments and treatment.
• This questionnaire also has five response options, giving summed
scores from a minimum of 20 to a maximum of 100.
• A cutoff point for high dental fear has been suggested at 60.
40

41. 41
• The scale has three dimensions: avoidance of dental
treatment, somatic symptoms of anxiety, and anxiety caused
by dental stimuli.

42. Children’s Fear Survey Schedule
• Developed by Scherer and Nakamura
• Consists of 80-items on a 5-point Likert’s response
• high reliability and validity
• Very cumbersome
• The Dental Subscale of Children’s Fear Survey Schedule (CFSS-DS)
developed by Cuthbert and Malamed consists of 15-items on a 5-point
Likert’s response
• Total range- 15-75
• Score of 38 or more- clinical dental fear
42

43. 43
Venham Picture test
• This scale consists of a series of eight paired
drawings of a child.
• Each pair consists of a child in a nonfearful pose
and a fearful pose (e.g. running away).
• The respondent is asked to indicate, for each
pair, which picture more accurately reflects his or
her feelings at the time.
• Scores are determined by summing the number
of instances in which the child selects the high-
fear stimulus.

44. 44
Facial image scale (FIS)
• Facial image scale (FIS) has a row of five faces ranging
from very happy to very unhappy.
• Children are asked to point at which face they felt most like
at the moment.
• The face is scored by giving a value of one for the most
positive face and five for the most negative face.
• Faces four and five indicate high dental anxiety.

45. VARIABLES INFLUENCING
CHILDREN’S DENTAL BEHAVIOR
1. Sociocultural and developmental
factors
2. Familial factors
3.Factors associated with the
dentist/dental operatory
45

46. Sociocultural and developmental
factors
• Baseline anxiety
• Past medical or dental experience
• School environment and peer influence
• Growth and development
46

47. Baseline anxiety
• Unperturbed initial anxiety of a child before any appointment
• Depends on - psychological strength of child to face new
situations and challenges.
• Efficient parenting -a positive attitude & these children are
confident & have less baseline anxiety.
• High baseline anxiety- overprotected or overindulged children.
• Children born to women with an increased maternal age or
nurtured by a single parent may have high baseline anxiety.
47

48. Past medical or dental
experience
• Any past unpleasant dental experience, prior
hospitalisation, surgical intervention, sickness etc., are
associated with a higher degree of uncooperative
behaviour.
• Therefore the emotional quality of past visits rather
than the number of visits is significant.
48

49. School environment and
peer influence
• Fifty percent of the child’s development is affected by the
school and the remaining 50% by the home environment.
• In school, teachers and peers help to influence the
behaviour of the younger children. Also, seniors become
role models to the juniors.
• A child benefited by school dental health programs will
have a positive approach towards dental treatment.
49

50. Growth and
development
• Physical growth pattern and development are associated
with each other.
• Some derangement in development can leave a negative
attitude in the child’s mind.
• Deficiency in physical growth and development or
congenital malformations, e.g., cleft lip, as awareness of
the deformity increases it leads to psychological trauma
due to rejection by the society.
50

51. Familial factors
51
• Socio-economic factors
• The mother’s presence
• Maternal anxiety
Parental attitude
(Independent
variable)
Child behavior
(Dependent
Variable)

52. Socio-economic factors
• High socioeconomic status child - develop normally because
the family can provide all the necessary requirements to aid in
a normal psychological development
• A low socioeconomic status child - develops resentment and
is tensed as the child gets little attention and is often
neglected.
• It can also directly affect the child’s attitude towards the
value of the dental health.
52

53. The mother’s presence
• Presence of the mother as a passive observer in the operatory
contributes to a greater frequency of positive behavior in
preschool children. [Frankl et al. ,1962]
• It does not enhance the cooperative behaviour of slightly older
children, but neither is it deleterious.
• The mother is usually seated in front and to the right of the dental
chair facing the child. This is a good location, since it will usually
allow the child an unobstructed view of the mother.
53

54. Maternal anxiety
• Primary factor influencing a child’s anxiety in the dental office.
• Highly anxious mother has a negative influence on the child.
• The mother child relationship falls into two broad categories:
 autonomy vs control
 hostility vs love
54

55. Maternal attitude Child’s behavior
Overprotection Submissive, shy, anxious
Overindulgent Aggressive, spoilt, demanding, displays
Temper tantrums
Underaffectionate Usually well behaved, but may be
unable to cooperate, may cry easily
Rejecting Aggressive, overactive, disobedient
Authoritarian Evasive
55
By Bayley & Schaefer :

56. Baumrind Parenting Styles (1973)
56
Viswanath S, Asokan S, Geethapriya PR, Eswara K (2020) Parenting Styles and their
Influence on Child's Dental Behavior and Caries Status: An Analytical Cross-Sectional
Study. Journal of Clinical Pediatric Dentistry 2020; 44(1): 8-14.

57. Factors associated with the
dentist/dental operatory
57
• Dentist attitude and attire
• Dental operatory/ environment
• Length and schedule of the appointment

58. Dentist attitude and attire
• The dentist’s attire should communicate a ‘security’
symbol as well as an authority figure
• The attire should be approachable
• Bizarre and flashy clothes to attract children attention
are absolutely inappropriate
58

59. 59
 Personality of dentist: Should be impressive.
 Dentist’s skill and speed: Dentist should be skilled or he
will loose child’s confidence.
 Dentist’s conversation: Keep talking to the child to gain his
confidence. Use simple words and answer all questions.

60. Dental operatory/ environment
• An ideal pediatric operatory should not look like a
hospital
• It should allay anxiety and assist in obtaining cooperative
behavior
60

61. Length and schedule of the
appointment
• Short appointment- 30 minutes
• Long appointment- 45 minutes
• Early morning appointments - best suited for children as
they tend to be more relaxed and cooperative
61

62. Finn summarized the following factors related to the
dental office which influence child’s behavior:
• Waiting rooms – homely environment
• Comfortable reception room
• Library with books
• Simple but sturdy toys for amusement
• Attractive appointment cards
• Appealing operating room
• Avoid having child patient see adults in pain or sight of
blood on others
62

63. Good morning!
63

64. NON-
PHARMACOLOGICAL
BEHAVIOR
MANAGEMENT
Dr. Pratima Kolekar
MDS II
64

65. CONTENTS
PART I :
• Introduction
• Pedodontic Treatment Triangle
• Pediatric dental patients
• Classification of children’s co-operative behavior
• Fear and Anxiety
• Psychometric Assessment of dental fear and anxiety
• Variables influencing children’s dental behavior
65

66. 66
 PART II
• Definitions
• Fundamentals of behavior guidance
• Behavior guidance techniques
• Pre-appointment behavior shaping
• Basic behavior guidance techniques :
 Communicative management
 Tell-show-do
 Voice control
 Modelling
 Contingency management
 Distractions
 Memory restructuring
 Desensitization

67.  PART III
• Advanced behavior guidance
 Protective stabilization
 Aversive conditioning
• Recent advances in behavior guidance
• Conclusion
• Previous year question papers
• References
67

68. DEFINITIONS
68
Behavior management
means by which the dental health team effectively and
efficiently performs dental treatment and thereby instills a
positive dental attitude. (Wright 1975)
Behavior guidance
is a continuum of individualized interaction involving
the dentist and patient directed toward communication
and education “which ultimately builds trust and allays fear
and anxiety”.

69. 69
Behavior modification
an attempt to alter the human behavior and emotion in a
beneficial way and in accordance with the laws of learning.
(Eysenck,1964).
Behavior shaping
procedure which develops behavior by reinforcing
successive approximations of the desired behavior until
the desired behavior comes into being.

70. FUNDAMENTALS OF
BEHAVIOR MANAGEMENT
1. Positive
approach
2. Team
attitude
3.
Organization
4.
Truthfulness
5. Tolerance 6. Flexibility
70

71. Positive Approach
• Attitude or expectations of the dentist - affect the
outcome of a dental appointment
• Positive statements chances of success with children
• More effective than thoughtless questions or remarks
71

72. Team attitude
• A pleasant smile -tells a child that an adult cares.
• Children can be made comfortable by :
• Casual greeting
• Use of nicknames
• Noting school accomplishments
• Hobbies
• Also helps initiating future conversation .
72

73. Organization
• Each dental office must device its own contingency plans
• The entire staff must know in advance what is expected of
them
• Eg. Who summons the patient? The dentist, the dental
assistant, the dental hygienist, or the receptionist?
• Delays and indecisiveness - apprehension in young
children
73

74. Truthfulness
• Unlike adults, most children see things as either “black”
or “white”
• The shades between are difficult for them to discern
• Truthfulness is extremely important in building trust -
fundamental rule for dealing with children.
74

75. Tolerance
• Dentist’s ability to cope rationally with misbehaviors while
maintaining composure.
• Recognizing individual tolerance levels is especially
important when dealing with children.
75

76. Flexibility
• As children lack maturity -dental team must be prepared to
change its plan at times.
• Treatment of small children may demand a change in
operating position.
• Thus the dental team must be flexible as the situation
demands. 76

77. PRE-APPOINTMENT
BEHAVIOR MODIFICATION
• Anything that is said or done to have a positive influence on the
child’s behavior before the child enters a dental operatory.
• The merit - prepares the pediatric patient and eases the
introduction to dentistry.
77

78. 78
Several methods of preappointment behavior modification
are :
a) Audio-visual aids
• Films or videotapes
• The presentation explains in the way the child can
understand the dental procedures to take place.

79. 79
b) Patient modelling :
• It can be performed with live patient models such as
sibilings, other children or parents

80. 80
• Wright et al (1973) conducted a RCT that
demonstrated the beneficial effect of pre-appointment
letter.
c) Pre-appointment mailings / customized web pages

81. 81
• Preappointment mailings
should be selective.
• The uncomplicated pre-
appointment letter :
 Welcomes the patient
 Spells out the basic, first-
appointment procedure
avoiding dental terminology
 States the philosophy of good
dental health care.

82. 82
• Numerous mailings cause a reversal in parental attitude.
• Overpreparation could confuse a parent or provoke
anxiety.

83. 83
d) Introductory visits –
• Feigal refers to this examination as ‘preconditioning
appointment’
• Oral examination should be done.

84. BEHAVIOR GUIDANCE
TECHNIQUES
• Behavior guidance - not an application of
individual techniques created to deal with children.
• Rather a comprehensive, continuous method meant
to develop and nurture the relationship between the
patient and doctor,which ultimately builds trust
and allays fear and anxiety.
84

85. 85
Basic behavior guidance techniques
Advanced behavior guidance techniques
Recent advances in behavior guidance
technique
AAPD. The reference manual of Pediatric Dentistry. 2012

86. Basic behavior guidance
techniques
86

87. I. Communicative management
• Foundation for all basic behavior guidance
• Prime objective of behavior control.
• It is universally used in pediatric dentistry with both
co-operative and uncooperative child.
87

88. 88
• Initiate conversation with non-dental topics.
{Welbury et al ,2005 }
• Topic of interest to young children -new clothing, pets,
television shows and they like to be asked about it.
• Communication with older children -with reference
to school, play activities, sports and friends.

89. 89
• Ways to establish communication :
Verbal: Spoken language to gain confidence.
Nonverbal: Expression without words like welcome
hand shake, patting, eye contact

90. KEY POINTS FOR
COMMUNICATIVE MANAGEMENT
Establishment of Communication :
• By involving a child in conversation, a dentist
not only learns about the patient, but also
relaxes the youngster.
90

91. 91
 Establishment of the
communicator
• Members of the dental team - be aware of their roles when
communicating with a pediatric patient
• Communication should occur from a single source
• The same holds true when parents are present in the
operatory

92. 92
 Message clarity
• Communication is a complex, multisensory process.
• The message must be understood in the same way by both
the sender and the receiver
Transmitter
Dentist
Medium
Spoken
word
Receiver
Pediatric
patient

93. 93
• Very often, to improve the clarity of messages to young
patients, dentists use euphemisms to explain procedures
 Rubberdam Raincoat
 Airotor Whistle
 Saliva ejector Straw

94. 94
 Tone
• The manner in which something is said is just as
important as what is said.
• For young children, the tone of our voice is what they
hear.
• A soft, reassuring voice is better than a abrupt,
business like voice

95. 95
 Multisensory communication
• Body contact is a form of nonverbal communication
• Simple act of placing hand on a child’s shoulder
conveys a feeling of warmth and friendship

96. 96
• When the dentist talks to children, every effort
should be made not to tower above them
• Sitting and speaking at eye level allow for friendlier
and less authoritative communication

97. 97
 Problem ownership
• In difficult situations , dentist begin sending “you”
messages- “You stop doing that immediately!”
• “You” messages - roadblocks to
communication- undermine rapport, shatter the
child’s self-esteem

98. 98
• “I” messages reflect the practitioner’s
experience and disclose the focus of the
problem- “ I can’t fix your teeth if you don’t
open your mouth wide.”
• They are honest, clear and inarguable

99. 99
 Active listening
• Listening to spoken word - more important to establish
rapport with older children
• Attention to nonverbal behavior is crucial for younger
children
• Sensitivity to the expressed emotions - reassure the child
and encourage genuine communication

100. II. Tell-Show-Do
• HK addelston (1959)
• Desensitizing technique -approach by successive
approximations.
• Attempts made to remove - fear of unknown
100

101. 101
• Objectives:
Teach the patient important aspects of the dental
visit and familiarize the patient with the dental
setting
Shape the patient’s response to procedures

102. 102
o Indications:
 First visit
 Subsequent visits when introducing new dental procedures
 Fearful child
 Apprehensive child because of information received from
parents and peers.
 Effective in children >3 yrs who can understand

103. 103
• The method involves :
• Verbal explanation
Tell
• Demonstrations
Show
• Completion of the
procedure
Do

104. 104
• TSD was the most popular technique for managing
children, which was listed by 87% of pediatric dentists.
{Crossley and Joshi ,2002}
• TSD modifies the behavior of child and aids in achieving
the treatment goals effectively in all age groups. {Sharma
A and Tyagi R, 2011}
Crossley ML, Joshi G. An investigation of paediatric dentists' attitudes towards
parental accompanimentand behavioural management techniques in the UK.
British dental journal. 2002May;192(9):517-21.
Sharma A, Tyagi R. Behavior assessment of children in dental settings: a
retrospective study. Int J Clin Pediatr Dent. 2011;4(1):35-9.

105. Pattern interrupt
• TSD not always easy to practice -when child is crying.
• This stage- ‘pattern interrupt’ plays an important role
• Interrupting behavior by doing the unexpected.
• Eg. Lifting the child at height.
105

106. 106
New alternatives to TSD technique
1. Ask-Tell-Ask :
• ASK : inquiring about patient’s visit & feelings about any
planned procedure
• TELL : Explaining procedures through demonstrations
in non-threatening language appropriate to cognitive
level of the patient
• ASK : inquiring if the patient understands and how she
feels about the impending treatment

107. 107
• Objective:
 Assess anxiety
 Teach the patient about the procedures
 Confirm the patient is comfortable with the treatment
before proceeding.
• Indications: May be used with any patient able to
dialogue.
• Contraindications: None.

108. 108
2. Tell-play-do :
• Performing dental treatment on dental imitating toys
• Child understands the dentist’s frame of reference
• Feels more comfortable & develops cooperative
behavior.

109. III. Voice control
• Given by Pinkham in 1985.
• Voice control is a deliberate
alteration of voice volume, tone or
pace to influence and direct the
patient’s behavior.
109

110. 110
• Objectives :
Gain the patient’s attention and compliance
Avert negative or avoidance behavior
Establish appropriate adult-child roles
• Indications : Uncooperative and inattentive patients
• Contraindications :
Immature children
Physically or mentally challenged children

111. 111
Importantly, the commands should be repeated slowly and
clearly.
The volume may be louder or sometimes reduced to
whisper to get the patients attention
If this request is not honored, the dentist can rephrase it in a
firmer tone
Typically, the dentist makes a request in a normal, positive
tone

112. IV. MODELLING
• Based on Bandura’s social learning theory
• Goal is to reproduce the behavior exhibited by model
112

113. 113
• The merits of modeling procedures, by Rimm and
Masters are as follows:
Stimulation of new behaviors
Facilitation of behavior in a more appropriate
manner
Elimination of avoidance behavior.
Extinction of fears’s

114. 114
• Types of modeling-
1. Audiovisual
2. Live modeling by sibling or parent
• Types of models-
1. Mastery (cooperative patient who enjoys dental
treatment)
2. Coping ( just manages to cope up with the
treatment)

115. V. Contingency
management
• Based on BF Skinner’s operant conditioning
• The presentation of positive reinforcers or
withdrawal of negative reinforcers is termed
contingency management
115

116. 1. Positive reinforcement
• Presentation of the pleasant stimulus and is done to
appreciate the child for good behavior
2. Negative reinforcement
• Withdrawal of the unpleasant stimulus like high
speed handpiece
116

117. 117
3. Time-out or omission
• Withdrawal of the pleasant stimulus to reinforce good
behavior
4. Punishment
• Presentation of unpleasant stimulus to the child eg. Voice
control, HOME

118. Types of reinforcers
• Positive reinforcers- whose presentation
increases the frequency of desired behavior
• Negative reinforcers- whose contingent
withdrawal increases the frequency of
behavior
118

119. 119
• Materials : stickers, pencils, small toys (preferably not
candies and sweets.)
• Rewards are given after dental procedure.
• Bribes given before procedure. Bribes should not be
given in pediatric dental practice

120. 120
• Social praise : Praise, positive facial expression, hand
shake, smile etc. Best kind of positive influencer.
• Activity : opportunity of participating in a preferred
activity like a cartoon show, visit to park.

121. VI. DISTRACTION
• Diverting the patient’s attention from
what may be perceived as an
unpleasant procedure.
• Objective : to relax the patient
121

122. 122
• Commonly used distractors -
magic tricks, toys, cartoons or
movies, music.
• They can be given either in the
waiting room or during dental
treatment.

123. 123
• Types :
 Audio distraction : patient listens
to audio presentation throughout
course of treatment
 Audiovisual distraction : patient is
shown audiovisual presentation
through television during the
entire treatment.

124. VII. MEMORY RESTRUCTURING
• Behavioral approach in which memories associated
with a negative or difficult event (e.g. first dental visit)
are restructured into positive memories using
information suggested after the event has taken place.
124

125. 125
• Restructuring involves four components:
Visual reminders -- photograph of the child smiling
at the initial visit
Positive reinforcement through verbalization--
asking if the child had told her parent what a good
job she had done at the last appointment
Concrete examples to encode sensory details--
praising the child for specific positive behavior
 Sense of accomplishment-- Child then is asked to
demonstrate these behaviors

126. VII.DESENSITIZATION
• Systematic desensitization - technique popularized
by Wolpe.
• Diminishes emotional responsiveness to a negative,
aversive stimulus after progressive exposure to it.
• Helps to reduce maladaptive fear
126

127. 127
The use of systematic desensitization involves three sets of
activities :
Encourage the patients to discuss their status of fear and
anxiety, from the least to the most anxiety-provoking.
Teach the patient relaxation techniques, most commonly
used techniques - breathing and muscle relaxation.
The final step is to gradually expose the patient to these
situations in the hierarchy, from the least to the most
anxiety-promoting

128. VIII. PARENTAL
PRESENCE/ABSENCE
• Can be used to gain cooperation for
treatment
• Pre-cooperative and fearful children, parents be
allowed to be with the child. This prevents
separation anxiety in children.
• A compensatory, overprotective or overindulgent
parent can actually worsen the situation.
128

129. 129
REFERENCES
• Wright GZ, Kupietzky A, editors. Behavior management
in dentistry for children.Wiley Blackwell;2014 Jan 21.
• Dean JA, editor. McDonald and Avery's Dentistry for the Child and
Adolescent-E- Book. Elsevier Health Sciences; 2015 Aug 10.
• Nowak A, Christensen JR, Mabry TR, Townsend JA, Wells MH,
editors. Pediatric Dentistry: Infancy through Adolescence. Elsevier
Health Sciences; 2018 May10.
• Marwah N. Textbook of pediatric dentistry. Jaypee Brothers,
Medical Publishers Pvt. Limited; 2018 Oct 31.

130. 130
• Vishwakarma AP, Bondarde PA, Patil SB, Dodamani AS,
Vishwakarma PY, Mujawar SA. Effectiveness of two different
behavioral modification techniques among 5–7-year-old children: A
randomized controlled trial. J Indian Soc Pedod Prev Dent
2017;35:143-9.
• Salah Adeen Mohammed Alrshah et al. Live Modelling Vs Tell-
Show-Do Technique for Behaviour Management of Children in
the First Dental Visit. Mansoura Journal of Dentistry 2014;1(3):72-
77
• Sharma K, Malik M, Sachdev V. Relative efficacy of tell-show-do
and live modeling techniques on suburban.J Dent
Specialities.2016;4(2):178-182
• Chadwick BL, Hosey MT. Child Taming: How to manage children
in dental practice. Quintessentials, 2003

131. 131

132. Good morning!
132

133. NON-
PHARMACOLOGICAL
BEHAVIOR
MANAGEMENT
Dr. Pratima Kolekar
MDS II
133

134. CONTENTS
PART I :
• Introduction
• Pedodontic Treatment Triangle
• Pediatric dental patients
• Classification of children’s co-operative behavior
• Fear and Anxiety
• Psychometric Assessment of dental fear and anxiety
• Variables influencing children’s dental behavior
134

135. 135
 PART II
• Definitions
• Fundamentals of behavior guidance
• Behavior guidance techniques
• Pre-appointment behavior shaping
• Basic behavior guidance techniques :
 Communicative management
 Tell-show-do
 Voice control
 Modelling
 Contingency management
 Distractions
 Memory restructuring
 Desensitization

136.  PART III
• Advanced behavior guidance
 Protective stabilization
 Aversive conditioning
• Recent advances in behavior guidance
• Other behavior guidance techniques
• Conclusion
• Previous year question papers
• References
136

137. 137
BEHAVIOR
MANAGEMENT
TECHNIQUES
Communicative
management
Behaviour shaping/
modification
Behavior
management/
guidance
• Desensitization
• Modelling
• Contingency
management
• Distraction
• Biofeedback
• Coping
• Hypnosis
• Humor
• Relaxation
• Voice control
• Implosion
therapy
• Aversive
conditioning
Dean JA, editor. McDonald and Avery's Dentistry for
the Child andAdolescent-E- Book. Elsevier Health
Sciences; 2015 Aug 10

138. 138
Beahvior guidance techniques according to Wright :
• Getting to know your patient :
Using paper & pencil questionnaire for parent/caregiver
 Direct interviewing the child and parent.
• Pre-appointment behavior modification :
Preappointment contact and modelling
• Effective communication
• Non-pharmacological clinical strategies :
TSD, Contingency management, modelling, voice control,
densitization, parental presence/absence
• Retraining
HOME, restraints

139. SOCIAL LEARNING THEORY
• Social learning theory was proposed by Albert Bandura
in 1963.
• Bandura believes that behaviour is largely motivated by
social needs.
• Reinforcement is a powerful method for regulating
performance of behaviour but is a relatively ineffective
method for learning behaviour.
139

140. 140
Principles of social learning theory
Observational
learning
acquisition and
later performance
of behaviours
demonstrated by
others
Attention:-
extent to which we
focus on other’s
behaviour
Retention:-
our ability to retain
a representation of
others behaviour in
memory
Production of
processes:- our
ability to actually
perform the
actions we observe
Motivation:-
our need for the
actions we witness;
their usefulness to
us

141. 141
Attention
4 year old child is
made to observe
his other sibling
who behaves well
during dental
treatment
Retention
The child
encodes and
retains desired
behaviour in
dental office
Reproduction
The child
performs the
desired behaviour
at his first dental
operatory
Motivation
The child is
rewarded a small
postoperative gift
for the good
behaviour
The child
becomes a good
dental patient
Observational Learning in Dental
Operatory

142. 142
MODELING
• It is based on Bandura’s social learning theory, which states
that one’s learning or behavior acquisition occurs through
observation of suitable model performing a specific behavior
• Modeling is based on the psychologic principle that much of
one’s learning or behavior acquisition occurs through
observation of a suitable model performing a specific
behavior.

143. 143
• Mother as a live model can be highly effective regimen
while dealing with pediatric patients. (Sharma K ,
Malik Manvi ,2016)
• In comparative efficiency of TSD and live modeling
on children’s heart rates – children receiving live
modeling with mother as model had lower heart rate
than those who received with father as model.
Karan S,Manvi M ,Vinod S.Relative efficacy of TSD and modeling technique
on suburban Indian children during dental treatment based on heart
ratev.clinical study.J Dental Specialities. 2016 ; 4:178-82

144. OPERANT CONDITIONING
• OPERANT:-
• Any active behaviour that operates upon the
environment to generate consequences
• OPERANT CONDITIONING:-
• The behaviour is followed by a consequence, and the
nature of the consequence modifies the organisms
tendency to repeat the behaviour in the future
144

145. • Operant conditioning is a method of learning that
occurs through rewards and punishments for behaviour.
• Through operant conditioning, an association is
made between a behaviour and a consequence for that
behaviour.
145

146. LAW OF EFFECT PRINCIPLE
1. If particular behaviour is powered by desirable
consequences or reward it is more likely to happen
again.
2. If particular behaviour is followed by an undesirable
consequences or punishment that behaviour is less
likely to happen again in the future
146

147. VOICE CONTROL
• It is communicative as well as management
technique
• Sudden and firm commands are used to get
the child’s attention or to stop the her from
whatever she is doing.
• Once the dentist has the child’s attention,
conversation should revert to a quieter tone.
147

148. 148
• Chambers (1976) theorized that voice control is most
effective when used in conjunction with other
communication, such as tapping a child on the chest
or clapping the hands loudly.
• In these cases, it is what is heard that is important
because the dentist is attempting to influence
behavior directly and not through understanding.
• The dentist, however, must realize that this technique
is not acceptable to all parents.

149. ADVANCED BEHAVIOR
GUIDANCE
• For some children, basic behavior guidance is
inadequate to permit safe, high-quality dental
care.
• This may be due to the young age of the child,
special health care needs, extreme defiance or
fearfulness.
149

150. I. PROTECTIVE STABILIZATION
• “Any manual method, physical or mechanical device,
material or equipment that immobilizes or reduces the
ability of a patient to move his or her arms, legs, body or
head freely.”
• It is used to decrease risk of injury during treatment
• Use of technique with parent consent and if done in
positive manner can be very beneficial.
150

151. 151
 Active stabilization :
• The parent, dentist or assistant helps stabilize the patient
• Typically carried out only for a very short period of time
or in times of unexpected, physically uncooperative
behavior.

152. 152
 Passive stabilization :
 It is the use of a device to restrict patient movement
for patient safety.
 Devices used commonly are Papoose Board,
Rainbow Wraps etc.

153. 153
PART AID FEATURE
Mouth Tongue blades
Open wide mouth prop
• Can be used directly to open mouth
• It has a durable foam core on the
outside of a tongue depressor
Molt mouth prop • Very helpful in the management of
a difficult patient for a prolonged
period.
• Disadvantages: possibility of lip
and palatal lacerations and luxation
of teeth if it is not used correctly

154. 154
PART AID FEATURE
Mouth Rubber bite blocks • Available in various sizes to fit
on the occlusal surfaces of
the teeth
• The bite blocks should have
floss attached for easy
retrieval if they become
dislodged in the mouth
Finger guards • Used directly to open mouth

155. 155
PART AID FEATURE
Body Papoose board • Simple to store and use
• Available in areas to hold both large
and small children
• It has attached head stabilizers
• Reusable
• Any restrained patient requires
constant attendance and supervision
Triangular sheets • It allows the patient to upright during
radiographic examinations
• Disadvantages -frequent need for
straps to maintain the patient’s
position in the chair, difficulty of its
use on small patients and the
possibility of airway impingement
• Hyperthermia -during long periods
of immobilization
• Constant supervision required.

156. 156
PART AID FEATURE
Body Pedi wrap • Allows some movement while still
confining the patient
• Its mesh fabric prevents developing
hyperthermia
• Requires straps to maintain body
position in the dental chair
• Constant supervision to prevent the
patient from rolling out of the chair
Bean bag insert • Developed to help comfortably
accommodate hypnotic and severely
spastic persons who need more
support and less immobilization in a
dental environment
• It is reusable
• Many patients with physical
disabilities relax more in this setting

157. 157
PART AID FEATURE
Body Safety belt and extra
assistant
• Useful in controlling
movements
Extremities • Posey straps
• Velcro straps
• Towel and tape
• Extra assistant
• Fasten to the arms of the dental
chair and allow limited
movement frequently prevents
overreaction by resistant or
combative patients
• Helpful for an athetoid-spastic
cerebral palsy patient who tries
desperately, but without success,
to control body movements
Head • Head positioner
• Plastic bowl
• Extra assistant
• Used to stabilize head

158. 158
• Indications
 A patient requires immediate diagnosis and/or limited
treatment and cannot cooperate because of lack of
maturity or mental or physical disability.
 A patient requires diagnosis or treatment and does not
cooperate after other behavior management techniques
have failed.
 The safety of the patient, staff, parent or practitioner
would be at risk without the use of protective
stabilization.

159. 159
• Contraindications
 A cooperative non-sedated patient.
 Patients who cannot be safely stabilized due to medical or
physical conditions.
 Patients who have experienced previous physical or
psychological trauma from protective stabilization (unless
no other alternatives are available).
 Non sedated patients with nonemergent treatment
requiring lengthy appointments.

160. II. AVERSIVE CONDITIONING
• Term aversive conditioning by
Lencher and Wright
• Also known as hand-over-
mouth exercise (HOME) as
described by Dr Evangeline
Jordan (1920)
160

161. 161
• Not used routinely but as method of last resort usually
with children 3 to 6 years of age having appropriate
communicative abilities.
• Technique fits the rules of learning theory:
• Maladaptive acts (screaming, kicking) linked to restraint
(hand over mouth)
• Cooperative behavior is related to removal of the
restriction and the use of positive reinforcement (praise).

162. 162
• Objective :
• To gain child’s attention enabling communication with
dentist so that appropriate behavioral expectation can be
explained.
• To eliminate inappropriate avoidance behavior to dental
treatment and to establish appropriate learned response.
• To increase child’s confidence in coping with anxiety
provoking dental stimuli.
• To assure child safety in delivery of quality dental care.

163. 163
• Technique :
If the child shows negative behavior again the procedure is
repeated.
When child responds, the hand is removed and child’s
appropriate behavior is reinforced
Child is told that the hand will be removed as soon as the
appropriate behavior begins
Hand is placed over child’s mouth and behavioral
expectations are calmly explained

164. 164
• Indication :
A healthy child who is able to understand and cooperate but
who exhibits defiant or hysterical behavior to dental
treatment.
• Contraindication :
Immature child
When it prevents child from breathing
When the dentist is emotionally involved with the child.

165. 165
• Modifications of HOME :
1. Hand over mouth with airway
restricted (HOMAR)
2. Hand over mouth with nose and
airway restricted
3. Towel held over mouth only
4. Dry towel held over nose and
mouth
5. Wet towel hold over nose and
mouth

166. 166
• Legality of home technique
• It has been pointed out that the use of HOME will not
subject the dentist to liability by the patient when it is used
properly with parental consent.
• Use of hand over mouth airway restricted (HOMAR) is
more nearly objectionable legally and may result in liability
of the dentist.

167. RECENT ADVANCES IN
BEHAVIOR GUIDANCE
• The recent technologies such as audiovisual aids,
videogames, mobile apps and virtual reality can be
used as an adjunct for conventional techniques due
to its immersive, interesting and innovational
capability in managing children with behavioral
problems
167

168. 168
I. Mobile Dental App
• In 2017, Patil VH et al. utilized mobile dental app for
reducing fear and anxiety in children in the dental set up.
• An interactive session of using the dental application
during the treatment was allowed and the children were
virtually made dentists and allowed to provide different
treatments through the application.
Patil VH, Vaid K, Gokhale NS, Shah P, Mundada M, Hugar SM. Evaluation of
effectiveness of dental apps in management of child behaviour: A pilot study.
Int J Pedod Rehabil 2017;2:14-8

169. 169
• By this technique, the fear towards different dental
instruments and its use in children could be reduced and
more cooperative behavior could be achieved.

170. 170
II. Videogame Distraction
• Videogame as a distraction tool is based on the principles
of cognitive- behavioral therapy and neurofeedback
mechanism for children with anxiety disorders

171. 171
III. Virtual reality based distraction
• The VR equipment contains head mounted display and
a tracking device.
• The head mounted device contains the display screen
which provides the view of virtual reality environment
in a 360° view.

172. Other Behavior Guidance
Techniques
172

173. HYPNOSIS
173
• It was first suggested by Franz A Mesmer, a physician in
1773
• Hypnosis is a state of mind connected to deep relaxation,
narrowed focus and increased suggestibility.
• When used in dentistry – hypnodontics or suggestion
therapy.

174. 174
• Hypnodontia was first documented in 1829 to facilitate a
dental extraction.
• By 20th century - hypnotic suggestion became regarded by
many dentists as the primary mode of patient management
and control.
• Its relationship with inhalation analgesia began with street
‘professors’, who used to entertain crowds with hypnotic
induction and lectures on the wonders of chemistry; they
would end a show by demonstrating the effects of nitrous
oxide.

175. 175
• One night in 1844, a performance was watched by the
dentist Horace Wells, who observed a volunteer stumbling
around and badly bruising himself after he inhaled nitrous
oxide.
• Afterwards, Mr Wells questioned the volunteer, who said
he felt no pain until the gas wore off.
• The next day, Wells allowed a colleague to extract one of
his own teeth under inhalation anaesthesia with nitrous
oxide, later proclaiming it as “the greatest discovery ever
made!”.

176. 176
• Pharmacological sedation is a temporary respite for a single
procedure.
• Hypnosis can achieve both excellent physiological sedation
and treatment of anxiety and phobias, and reductions in
sedative and analgesic doses.
• Hypnosis is particularly effective in children ages 8–12
years, although as young as children 4 years of age can be
responsive.
Hypnosis in modern dentistry: Challenging Misconceptions faculty Dental
Journal October 2015

177. 177
• Particularly indicated in emotionally disturbed children
who require dental work.
• It is easily accepted by children because they have fewer
misconceptions and preconceived ideas about hypnosis.
• This is because children are often in self-hypnosis state
during imaginary play causing them more susceptible to
hypnosis than adults.

178. 178
• Technique :
1. Patient preparation:
It is important to gain informed consent from the parent and
child in accordance with the Children Act of 1989.
 A simple verbal explanation of hypnosis should be given
and any questions that the parent or child may have are
answered.

179. 179
2. The hypnotic induction :three parts:
Focus the subject’s attention on a stimuli of particular
modality, which may be either visual like a focusing light
held in an out-stretched hand or body sensation like
warmth, cold, tingling.
Giving repeated instructions suggestive of relaxation and
comfort.
The coupling of focussing and suggestion done to develop
more powerful effect, e.g. with every breath you feel more
relaxed.

180. 180
3. Deepening: Deepening the hypnotic state involves the
sequential use of three or four different inductions.
4. Posthypnotic suggestion: These suggestions given by the
clinician during hypnosis are aimed at altering the patient’s
feelings, thoughts and behavior afterwards
5. Altering patient after therapy: This is a process of bringing
the patient out of the hypnotic state and reorienting to
their normal surroundings.

181. 181
Advantages :
• Extremely useful in relaxation of nervous and
excitable patient
• Useful in eliminating fear and tension making long
procedures more tolerable
Disadvantages :
• Time consuming
• Unpredictable level of effectiveness

182. 182
Contraindications and limitations :
• Should not be abused by dentist to probe into
emotional problems of individual
• Should avoid exceeding hisher competence in
using hypnosis for non-dental purposes.

183. 183
COPING
• Coping refers to cognitive and behavioral efforts
made by individuals to master, tolerate or reduce
stressful situations.
• Stress can act to increase pain perception while
coping decrease it by a process called assimilation

184. 184
Coping
strategies
Behavioral
Physical
Verbal
Cognitive
Manipulation
of thoughts

185. 185
• Behavioral coping:
Physical or verbal activities in which the child engages to
deal with stress
Readily visible to dentist
e.g. Inquisitive question about the procedure.

186. 186
• Cognitive coping:
Efforts which involve manipulation of emotions.
Not visible to dentist but play a crucial role in child’s
ability to deal with the treatment as well as forming a
positive outlook for future.
• Children taught coping skills like imagery, relaxation, self
talk demonstrated less stress during treatment.

187. 187
CONCLUSION
• Sheller summarizes - “the task of pediatric dentists is the
same as it was generation ago: to perform precise surgical
procedures on children whose behaviour may range from
cooperative to hostile to defiant’
• Realistically, the complexities of children’s and dentist’s
temperament, parental attitudes, and varying needs make it
clear that there will never be a “one size fits all” technique
• Therefore, the dentist must work towards communication
using the best possible techniques and help develop positive
oral health care habits in the child

188. Previous years question papers
• Discuss in detail the various types of behavior and
their management.
• Describe the various types of children based on
behavior and factors influencing child behavior.
Discuss the management of an emotionally disturbed
and anxious child
• Role of maternal anxiety in he behavior of children
in dental clinic
188

189. 189
• Define behavior management, behavior shaping and
behavior modification. Describe the management of a
preschooler throwing temper tantrums in the dental
office.
• Management of emotionally disturbed child
• Modeling
• Contingency management

190. 190
REFERENCES
• Wright GZ, Kupietzky A, editors. Behavior management
in dentistry for children.Wiley Blackwell;2014 Jan 21.
• Dean JA, editor. McDonald and Avery's Dentistry for the Child and
Adolescent-E- Book. Elsevier Health Sciences; 2015 Aug10.
• Tandon S. Pediatric dentistry.Paras medical publishers;3rd edition.2018
• Marwah N. Textbook of pediatric dentistry. Jaypee Brothers, Medical
Publishers Pvt. Limited; 2018 Oct 31.

191. 191
• Patil VH, Vaid K, Gokhale NS, Shah P, Mundada M, Hugar SM. Evaluation of
effectiveness of dental apps in management of child behaviour: A pilot
study. Int J Pedod Rehabil 2017;2:14-8
• Karan S,Manvi M ,Vinod S.Relative efficacy of TSD and modeling technique
on suburban Indian children during dental treatment based on heart
ratev.clinical study.J Dental Specialities. 2016 ; 4:178-82
• Hypnosis in modern dentistry: Challenging Misconceptions faculty Dental
Journal October 2015

192. 192