pedo

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PEDO. 5TH Y.2016- 2017 Lec. -3-
Dr. Sami MalikAbdulhameed
BEHAVIOUR MANAGEMENT IN PEDIATRIC DENTISTRY
“One of the essential qualities of the clinician is interest in humanity, for the
secret in the care of the patient is in the caring for the patient.”
Objectives of behavior management
-Psychology and Dentistry: Mental Health Aspects of Patient Care is a practical guide to
an often-neglected aspectof dentistry-the contributions of the behavioral sciences to dental
research and practice. All children should be able to expect painless, high quality dental
care. There are many different techniques which can help people overcome their dental
phobia or fears. They are sometimes referred to as "behavior management". Should you
come across this terminology, relax - it doesn'tmean you'll be handcuffed to the chair. AS
we know PAIN , FEAR AND ANXIETY terms associated with dental treatment
specifically with children.
CHILD DEVELOPMENT
Child development involves the study of all areas of human development from
conception through young adulthood. It implies a sequential unfolding that
may involve changes in size, shape, function. structure, or skill. the broad area
of physical development involves changes that occur children`s size, strength,
motor coordination, functioning of body systems, and SO forth thus the child's
total physical growth and efficiency from the moment of conception until
adulthood is termed physical development.
No two children, even in the same family, develop exactly along the same
pattern, the child may have the definite chronologic age, but psychologically
he may he plus or minus several years of age. Another area that has received
great attention from psychologists is the socialization of children. As with
physical development, age-specific skills have been derived for social
development; these take ln to account both interpersonal relationships and
independent functioning skills.

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Intellectual Development
 Developed by Piaget.
 Known Piaget’s 4 stages of Intellectual Development:
– Stage one: sensorimotor period (0-2 years)
– Stage two: preoperational period (2-7 years)
– Stage three: concrete operational period (7-11 years)
– Stage four: formal operational period (11-15 years)
 Implications to dentists:
– Understanding the intellectual development of child aids effective
communication.
– As dentists to realize that there is sequential unfolding of
capabilities of children.
Intellectual development is probably the area most comprehensively studied,
beginning in the early 1900s with the work of Alfred Binet. The method that
he employed quantified mental abilities in relation to chronologic age. lt led
to the conception of the I Q (intelligence Quotient )
Intelligence Quotient {IQ}
ClassificationGuide General Consideration % of population
IQ RANGE
140 andup verysuperior 0.5
120-139 superior 2.5
110-119 Highaverage 14
90- 109 Average 60
80- 89 Low average 12
70-79 Border line 7
69 and below Mentallydisabled 4

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The IQ formula used by Binat is:
Mental Age
IQ = ------------------------- x 100
Chronologic Age
Child Temperaments
 Studies have shownthat childrenenter the worldwithcharacteristic
temperaments/personality whichstays for the rest of their lives.
 Thomas & Chess (1977) suggested3 basic temperaments:
– Easy temperament
– Difficult temperament
– Slow towarm temperament
 Implications todentists:
– Must use different approaches &techniques depending onpersonality
type.
– Eg: Easy temperament:flexibleenough quick changes toplans
– Slow towarm up needs a long time to adjust
– Difficult temperament wouldrespondtoadentist whoprovides clear
instructions &encouragement.
Developmental Milestones
 Dentists shouldbe aware of children’s abilitiesat various ages
 So that communicationcan occur at the appropriate levels.
 Dentists have appropriate expectations for aparticular childin the dental
surgery.
 Variability among childrenregarding the ages at whichthese milestones are met.

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Three Points toRemember
 1-Dentistry canbe scary to the child
 2- It’s Important toKnow What You Are Doing
 3- It is the dentist’s responsibility tomanage his or her childpatients
Child behavior
 Behaviour: Is an observableact, which can be described in similar ways by more
than one person.
”Itis defined as any change observed in the functioning of the organism.”
Behavioural pedodontics:- Itis a study of science which helps to understand
development of fear, anxiety and anger as it applies to child in the dental situations
Emotion is a state of mental excitement characterized by physiological, behavioral
changes and alterations of feelings.
 Between Parentand Child
“When children are in the midst of strong emotions, they cannotlisten to
anyone…they wantusto understand whatis going on inside of them—whatthey
are feeling at that particular moment. Only when children feelrightcan they think
clearly and act right. Strong feelingsdo not vanish by being banished.”
Commonly seen emotions in a child
*Cry (Elsbach1963)
 Obstinate cry,
 Frightenedcry ,
 Hurt cry,
 Compensatory cry
* Anger
*Fear

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 Itmay be defined as an unpleasantemotion or effect consisting of psycho-
physiologicalchanges in responseto realistic threat or danger to one's own
experience.
 Innatefear
 Subjective fear
 Objective fear:
Fear Evoking Dental Stimuli…
 FactorsCausing Dental Fear
 1. Fear of pain or its anticipation.
 2. A lack of trustor fear of betrayal.
 3. Fear of.1oss of control.
 4. Fear of the unknown.
 5. Fear of intrusion.
Anxiety*
Is an emotion similar to fear arising withoutany objective sourceof danger. Is a reaction
to unknown danger.
 Itis often been defined as a state of unpleasant feeling combined with an
associated feeling of impending doom or danger from within rather than from
without.
 Itis a learned process being in responseto one's environment. As anxiety depends
on the ability to imagine, it develops later than fear.
Types of anxiety
 Trait anxietytemperamentfeature. These children are generally jittery,
hypersensitiveto stimuli.
 Free floating anxiety- persistently anxious mood
 Situational anxiety- Seen only to specific situations or objects.
 Stateanxiety-

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 General anxiety -a chronic pervasivefeeling of anxiousness whatever the external
circumstances.
Phobia:*
 Defined as persistent, excessive, unreasonablefear of a specific object, activity or
situation that results in a compelling desire to avoid the dreaded object.
 Simple
 Situational
 Social
Common phobic presentations…
- Badly broken down teeth
- Often will have very high tolerances to pain
- Multiple dental visits withouttreatment
- Reported fainting at the dental office after injections
- Supposed allergic reactions to “all dental anesthetics!”
- Difficulty in getting completely numb or takesa lot of anesthetic to get numb
- Hyperactivegag reflex
Behavior management
 Behavior management is the means by which the dental health team effectively
and efficiently performs treatmentfor a child and, at the same time, instillsa
positivedental attitude.
 The fundamentalsof behavior management center on theattitudeand integrity
of the entiredental team.
FUNDAMENTALS OF BEHAVIOR MANAGEMENT
 Positive approach- Positive statements
 Team attitude- Friendly and caring
 Organization- Well organized dental team and treatment

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 Truthfulness- Black or White ,nothing gray
 Tolerance- Ability to rationally cope with the misbehaviors
 Flexibility-as situation demands
CLASSIFYING CHILDREN'S BEHAVIOR
Wright's clinical classification (1975)
Cooperative
Lacking in cooperativeability
Potentially cooperative
Potentially cooperative
 Uncontrolled/Hysterical,
 Defiant/obstinate,
 Tense-cooperative,
 Timid/shy,
 Whining
Frankel’s Behavioral Rating Scale. (1962)
 Rating 1: Definitely Negative. Refusal of treatment, forceful crying, fearfulness, or any other
overt evidence of extreme negativism.
 Rating 2: Negative. Reluctance to accept treatment, uncooperativeness, some evidence of
negative attitude but not pronounced.
 Rating 3: Positive. Acceptance of treatment; cautious behavior at times; willingness to comply
with the dentist, at times with reservation, but patient follows the dentist's directions
cooperatively.
 Rating 4: Definitely Positive. Good rapport with the dentist, interest in the dental procedures,
laughter and enjoyment.
Lampshire Classification(1970)
1-Co-operative: The child is physically and emotionally relaxed. Is cooprative throughout the entire
procedure
2. Tense cooperative: The child is tensed, and cooperative at the same time.

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3. Outwardly apprehensive: Avoids treatment initially, . usually hides behind the mother, avoids
looking or talking tothe dentist. Eventually accepts dental treatment.
4. Fearful: Requires considerable support so as to overcome the fears of dental treatment.
5. Stubborn/Defiant: Passively resists treatment by using techniques that have been successful in
other situations.
6. Hypermotive: The child is acutely agitated and resorts to screaming kicking etc.
7. Handicapped: Physically/mentally, emotionally handicapped.
8. Emotionally immature
Factors affecting Childs behavior
 Under the control of dentist
 Under the control of parents
– Maternal anxiety and attitudes [Overprotective, Overindulgent, Under
affectionate, Rejecting, authoritarian]
 Others [socioeconomic status, nutritional,pastdental experience]
Variables Influencing Behavior
 Age
 Dentist
 Maternal Anxiety
 PastMedical History
 Time and Length of Appointment
 Patient Awareness of Problems
 Parents (later in lecture)
Age
 < 2 years of age
 2 years of age
 wide varianceon ability to communicate

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 use TSD
 parent present(separation anxiety)
 3 - 7 years of age
 8 years of age and older
Under The Control of The Dentist
• Dental office
• Dentist’s attitude
• Dentist attire
• Presence or absence of parents
• Presence of older sibling
Dental Setting
 Everyonein the setting should be transmitting positive, comforting,expectations to
the child.
 Use of stimulating visualdistracters in the surgery.
 Having age appropriate materials in the waiting areas.
 Greet child in waiting roompreferably without masks, coats etc.
 Pace procedures according to child’s capabilities ( not rushing or getting the child
bored)
Factors influencing behaviour in dental setting

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Emotions of staff
 Parents, dental auxillary staff may transmitfear & anxiety to the child.
 Hence dental staff need to be:
– Calm
– Confident
– Use humour
– Promote positiveexperiences to the child
PhysicalContact
 Initially work fromin front.
 At eye level.
 Proximity of ‘intimate zone’ (45cm) usually invaded by dentists hence frequent
stopping during procedureallows sometime for coping.
Dentist-PatientRelation
Straightforward ‘one to one’ relationship in most adult dentistry.
The situation is more complexin children’s dentistry.The dentist(and other members
of the dental team)mustalso communicate with the parent(s) and the child may
receive information from more than one source.

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Communication
Talking with Parents
 Dentists shouldalways have positive relationshipwithparent &child.
 Keepboth well informed.
 Always toinvolve childrenindiscussions.

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 To separate the childfromthe parent to discuss sensitiveissues.
Dealing with Parents/ Family Members
 Appropriate for parents tobe present togive support totheir childrenduring
treatment.
 If parents are not helping withmanagement of childthey should be informedof
your expectations:
 Clear
 Polite/professional
 Parental access shouldnever be denied.
Other family members who readily cope withdental treatment usedas models.
Maternal Anxiety
Patient Awareness of Problems
Past Medical History
Time and Length of Appointment
Timing
 Introduced at appropriate rate.
 Conducting less invasive procedures will be more tolerable.
Children early in the morning
*1st
visit simple and quick exam.
• Length of Appointment should be short
• Appointment time should be early
• Avoid nap time.