Non pharmacological means of behaviour management

1. NON-
PHARMACOLOGICAL
BEHAVIOUR
MANAGEMENT
Dr.Rishabh Kapoor
READER
Department of Pedodontics & Preventive Dentistry
17.04.2023
BDS IV year

2. OBJECTIVES
◦ To establishes effective communication with the child.
◦ Gaining child’s confidence and acceptance of dental treatment.
◦ Providing a comfortable environment for the dental team to work in.

3. CONTENTS
◦ Objectives
◦ Questions
◦ Introduction
◦ Non- Pharmacological behaviour management techniques
◦ Behaviour Shaping
Modelling
Contingency Management
◦ Behaviour Management
Audio analgesia Biofeedback
Voice control Hypnosis
Humor Coping
Relaxation Implosion therapy Distraction
Aversive conditioning
◦ Conclusion
◦ References
◦ Suggested Reading

5. Introduction to behaviour
management
◦ It is a comprehensive methodology meant to develop a relationship
between the child patient and the dentist and builds trust and diminishes
fear and anxiety.

6. Non-pharmacological method
of behavior management:
1) Communication
- Verbal - Non verbal
2) Behaviour shaping (Modification)
- Desensitization - Modelling
- Contingency management
3) Behaviour management
- Audio analgesia - Biofeedback
- Voice control - Hypnosis
- Humor - Coping
- Relaxation - Implosion therapy
- Aversive conditioning

7. MODELLING AND SUPPORT:
• Introduced by Bandura
(1969)
• This procedure involves
allowing a patient to
observe one or more
individual (models) who
demonstrate a positive
behaviour modeling can be
done by
• Live models
• Filmed models
• Posters
• Audiovisual aids

8. An ideal modeling tape should include
 Proper response to an injection (using a gentle
technique with topical anesthetic).
 Dentist explaining the procedure including the sounds
and feelings associated with it.
 Patient raising his or her hand for a rest stop.
 Proper response to discomfort.
 Successful completion of the dental procedure with
dentist praising co-operative behaviour.

9. EDUCATIVE PAMPHLETS

10. CONTINGENCY MANAGEMENT:
Method of modifying the behaviour of children by
presentation or withdrawal of reinforces.
Reinforces can be
- Positive - Negative
Positive Reinforces  Presentation of which increases
the frequency of desired behavior.
It can be in the form of
Material  Eg: candy gums, cookies

11. Social reinforces  Through praising,
positive facial expression. Or
Activity reinforces  Eg: Involving the child
in some activity like watching a TV show / special
programmes with him.
Social reinforces are the most effective ones as with
their use, anxious patients can be reassured, co-operative
patients can be encouraged and motivated.
Negative reinforces:
Withdrawal of which increases the frequency of desired
behavior. Eg: withdrawal of mother during treatment.

12. Parental presence / Absence
This technique involves using presence or absence of
parent to gain co-operation for treatment.
Objectives:
- To gain patient’s attention and compliance.
- To avert negative or avoidance behavior.
- To enhance the communication environment.
Contingent Escape:
- Escape from the dental treatment is a powerful motivation.
- Allowing the child to stop treatment gives him a sense of
control. Eg: raising hand when he wants to stop.

13. Example:
Tell the child that you will need him to let you work
on his teeth for a count of 10 and then stop and allow
him to rest for a while since getting out of a surgery is
a powerful motivation, the dentist must impress that he
will be allowed to go as soon as work is done.

14. Other methods of behaviour management:
Audio analgesia:
- Or “White Nose” is a method of reducing pain.
This technique consists of providing a sound stimulus
of such intensity that the patient finds it difficult to
attend to anything else.
- Auditory stimulus such as pleasant music has been
used to reduce stress and also reduce the reaction
to pain.

15. Biofeedback:
Involves the use of certain instruments to detect certain
physiological processes associated with fear.
For example:
If blood pressure is high, the instrument gives stimulation
and the subject is taught to control the signals. therefore it
is useful in anxiety and stress related disorders.
- Electroencephalogram
- Electromyography

16. HUMOR:
Helps to elevate the mood of the child, which helps the
child to relax.
Functions of humor:
Social: Forming and maintaining a relationship.
Emotional: Anxiety relief in the child, parent and doctor.
Informative: Transmits essential information, in a non-
threatening way.
Motivation: It increases the interest and involvement of the
child.
Cognitive: Distraction from fearful stimuli.

18. COPING: It is the mechanism by which the child copes up with
the dental treatment. It is defined as the cognitive and
behavioural efforts made by an individual to master, tolerate
or reduce stressful situations.
COGNITIVE:
- The child may be silent and thinking in his mind to keep calm.
- Maintain realistic perspective on the events at hand (Reality-
oriented working).
- Perceive the situation as less threatening (Cognitive
reappraisal).
- Calms and reassures themselves that everything will be all
right.

19. Voice Control:
- Sometimes it is unnecessary for the dentist to raise
his or her voice level and assert their authority over a
misbehaving child.
- Make sure not to convey that you are angry with the
child, but that you can’t accept the behavior.
- As soon as the child’s attention is captured, the
dentist should immediately change back to a normal,
soft-voice.
- Give positive reinforcement to get the child’s mind
back on a positive track.

20. RELAXATION AND HYPNOSIS:
Deep Breathing:
- It helps the patient to calm
down.
- Encourage the patient to breathe deeply from the
abdominal area.
- Ten to twenty deep, slow breathe gives the
patient more time to think about the fact they
are in good hands and that the treatment is for
their benefit.

21. DISTRACTION
◦ This is a technique to divert patient’s attention during unpleasant
procedures

22. AVERSIVE CONDITIONING:
It is a safe and effective method of managing extremely
negative behaviour. Those dentists who contemplate using it
should obtain parental consent prior to its use.
- Home
- Physical restraint
HOME (HAND OVER MOUTH EXERCISE)
Purpose:
To gain the attention of a child so that communication can
be achieved.

23. Indications:
- A healthy child who can understand but who exhibits
defiance and hysterical behavior during treatment.
- 3-6 years old.
- A child who can understand simple verbal commands.
- Children displaying uncontrollable behavior.
Contraindications:
- Child under 3 years of age
- Handicapped child/immature child frightened child.
- Physical, mental and emotional handicap.

24. Precaution:
- Child’s airway not be restricted.
- Procedure should not last for more than 20-30 sec.
Several Variations of home:
- Hand over mouth with the airway unrestricted.
- Hand over mouth and the nose and the airway
restricted.
- Towel held over the mouth only.
- Dry towel held over the nose and mouth.
- Wet towel held over the nose and mouth.

25. HOMAR (AIRWAY RESTRICTED)
The advantage behind airway restriction is that the child
will be so as to breathe and the screaming will decrease so
that the doctor can proceed. Together with hand over mouth
nostrils are pinched for 15 secs.
Disadvantage
Airway restriction was the critical element and it should
be avoided.
PHYSICAL RESTRAINTS:
It is the last report for handling uncooperative patients or
handicapped patients.

26. The Decision to use restraint must take into consideration:
- Other alternative behavior modalities.
- Dental needs of the patient.
- Quality of dental care.
- Patient’s emotional development.
- Patient’s physical considerations.
“The following must be included in patient’s record”
- Informed consent
- Type of restraint
- Indication for restraint

27. Objectives:
- To reduce or eliminate untoward movement.
- To protect the patient and dental staff from injury.
- To facilitate delivery of quality dental treatment.
Indication:
- A patient who requires diagnosis and/or treatment
and cannot co-operate due to lack of maturity.
- Mental or physically handicapped patient who does
not cooperate.
- Where all other behaviour management techniques
have failed.

28. Restraints are of the following types:
ORAL
- Mouth props
- Padded wrapped tongue blades
- Rubber bite blocks.
BODY
- Papoose board
- Triangular sheet
- Pedi-wrap
- Safety belt
- Extra assistant

29. EXTREMITIES
- Posey straps
- Velco straps
- Towel and tape
HEAD
- Forearm body support
- Plastic bowl
- Extra assistant

30. CONCLUSION:
The study of human behaviour does not lend itself easily
to randomized controlled clinical trials. We are not able to
say which technique is more effective than the other. Rather
we have to choose behaviour management techniques by
experience.
Behavior management, when used judiciously can result in
the most satisfying of all results.
“A child should be eager to return to the dental operatory
for his next appointment”.

31. video
◦ https://www.youtube.com/watch?v=dY6dxeZ1YxM&authuser=0

32. References
◦ McDonalds , Avery, Dean Dentistry for the Child and
Adolescent.8th edition; 2004; Mosby Publications
◦ Pinkham, Casamassimo, Fields, Mc Tigue, Nowak, Pediatric
Dentistry. Infancy through adolescense. 4th edition;2005;
Saunders Company.
◦ Richard R Welbury, Monty S. Duggal and Marie- Therese
Hosey, Pediatric Dentistry, 3rd edition;2005;Oxford.
◦ Shobha Tondon. Textbook of Pedodontics. 1st edition;2001;
Paras Publications.
◦ Sidney B.Finn. Clinical Pedodontics. 4th edition;2004;
Saunders Company.

33. Suggested Reading

34. QUESTIONS
◦ Discuss various behaviour management techniques
◦ What are positive and negative reinforces?
◦ What is aversive conditioning?

35. MCQs
◦ Name two techniques under contigency management?
◦ HOM technique is contraindicated under
a) >3yrs b) >4
c) >4yrs c) >6yrs
◦ Most widely use BMT?
a) Desensitization b) voice control
c) Aversive conditioning d) hypnosis

36. ◦Which of the following is not non-
pharmacological BMT?
a) Conscious sedation b) HOM
c) tell-show-do d) Hypnosis

37. THANKYOU