Behavior Management Techniques for the Pediatric Dental Practice, Objectives of Behaviour Management Classification of Child Behaviour Factors Effecting Childs’s Behaviour Management Techniques: Pharmacological methods Non-pharmacological methods

1. Behaviour
Management
Dr. Siddharth Dutta (PGT)
Supervised by Dr. Shitanshu Malhotra (Reader)

3. What is Behaviour
Management?
 It is the means by which a dental health team effectively and
efficiently performs treatment for a child and, at the same time,
instils a positive dental attitude.

4. • Objectives of Behaviour Management
• Classification of Child Behaviour
• Factors Effecting Childs’s Behaviour
• Management Techniques
 Pharmacological methods
 Non-pharmacological methods
Contents

5. Objectives of Behavior
Management
Establishes effective communication with the child.
Gains child’s confidence and acceptance of dental treatment.
Provides a comfortable environment for the dental team to work in.

6. Classification of Child
Behaviour in Dental Office

7. LAMPSHIRE’S CLASSIFICATION
Cooperative Tense cooperative Outwardly
apprehensive
Fearful Stubborn
Hypermotive Handicapped
Emotionally
immature

8.  Is it necessary to let the patient cry
throughout the treatment…?

9.  Or subject the patient to general
anaesthesia….?!!

10. Factors Affecting Child’s Behaviour
 Factors involving the child
• Growth and development.
• Past dental experience.
• Social and adaptive skill.
• Position of child in the family.
 Factors involving the parents
• Family influence.
• Parent-child relationship.
• Maternal anxiety.
• Attitude of parents to dentistry.
 Factors involving the dentist
• Appearance of the dental office.
• Personality of the dentist.
• Time and length of appointment.
• Dentist’s skill and speed.
• Use of fear promoting word.
• Use of subtle, flattery, praise and
reward.

11. Behavior Management
Techniques
Non pharmacological methods.
• Psychological Approaches
• Physical Approaches
Pharmacological methods.

12. Non-Pharmacological
Methods

13. • Preappointment Behaviour
Modification
• Communication
• Tell-Show-Do
• Desensitization
• Contingency Management
• Modelling
• Coping
• Hypnosis
Psychological Approaches
• Voice Control
• Audio Analgesia
• Biofeedback
• Humor
• Relaxation Breathing
• Implosion Therapy
• Flooding Technique
• Distraction
• Parental Presence or Absence

14. Physical Approaches
• Hand Over Mouth (HOME)
• Physical Restraints

15. Psychological
Approaches

16. Communication
 Universally used in paediatric dentistry with both co-operative and
uncooperative child.
 Fundamental form of behaviour management.
• Verbal Communication
• Non Verbal Communication
• Both
Types of Communication

17.  What to talk with the patient..?
• Try to call by nick name, give compliments.
• Using animation explain about the procedure briefly (tooth sleeping, worms in tooth).
• Keep the patient occupied in your conversation through out the procedure.

18. Desensitization
 It involves the step by step elimination of the fear, anxiety.
 Desensitization is used to gradually expose the young dental patient to the new dental experience.
 We desensitize the child to the dental experience through a technique of “Tell, Show, Do.” The
child is told and explained as to what is going to happen, shown by demonstration what is going to
happen, and then the dentist or auxiliary does the intended procedure.

19. Modelling
 Based on Bandura’s social learning theory, which states that one’s learning/behaviour acquisition
occurs through observation of suitable model performing a specific behaviour.
 Procedure involves allowing a patient to observe one or more individuals (models) who demonstrate
a positive behaviour in a particular situation.
Types of Modelling
• Audio-visual
• Live modelling by sibling or parent.
Types of Models
• Mastery (cooperative patient who enjoys
dental treatment).
• Coping (just manages to cope up with the
treatment).

20. Patient
Model
(Sibling)
Audio-visual aid
Live modelling

21. Contingency Management
 CM is used to manage variety of behavioural problems, ranging from substance abuse to obesity and
development of brushing habits. In the recent years ethical, legal and safety issues related to invasive
management procedures, such as physical restraint, sedation, and a hand-over-mouth procedure have
encouraged and supported behaviour management using non controversial methods that have a short
learning curve and can help in dispensing dental treatment to children with difficult behaviour more
efficiently and effectively

22. Audio Analgesia
 In this technique, sound in the form of music and masking sound is provided to the subject through
earphones. The masking sound, sometimes called white noise, consists of a mixture of a wide range of
auditory frequencies that produce a roaring noise sometimes described as similar to that of a loud
waterfall or rushing air. The subject is instructed to increase the intensity of the music or masking sound,
or both, when he feels pain. Using this method, successful results in pain management have been
reported by many dentists.

23. Biofeedback
 Biofeedback therapy is a non-drug treatment which is used to control bodily processes that are normally
involuntary, such as muscle tension, blood pressure, or heart rate associated with fear.

24. Voice Control
 Voice control is a punishment technique based on loud commands, has been used widely in paediatric dentistry.
 It is the modification of the intensity and pitch of one’s own voice in an attempt to dominate the interaction
between the child and the dentist. It reminds the child that the dentist is an authority figure to be obeyed.

25. Hypnosis
 Hypnosis, a phenomenon that is referred to as magnetic disharmony/mesmerization.
 During hypnosis, the subject is assisted through a series of instructions to achieve focused attention, dissociate
with the surroundings, absorb inner mental world and maintain non-analytical thinking but have positive outcome
expectancies.
 Occasionally, the dentist may encounter a situation where all behavioural techniques fail, while, for some reason,
premedication or general anaesthesia are contraindicated or rejected by the patient or his/her parents and a
different approach is required. Hypnosis may solve the problem in such cases.

26. Humor
 Dentists use humor in a consistent way in accordance with the systematic desensitization model and
create a playful-humorous atmosphere using verbal and nonverbal cues. They produce humorous
bisociations, incongruities, rhymes, absurdities, exaggerations and puns.
 Humor serves several functions: social, emotional, cognitive, informational, and motivational and is
used to felicitate communication with the patients and parents, alleviate patient anxiety.

27. Coping
 Coping is defines as the cognitive and behavioural efforts made by an individual to master, tolerate or reduce
stressful situations (Lazaue, 1980).
 Coping effect may be of two types :
• Behavioural - are physical and verbal activity in whichthe child engages to overcome a stressful situation .
• Cognitive - Efforts which involves manipulation of emotions .

28. Preappointment Behaviour Modification
 The goal is to establish a good rapport with the patient and to develop positive behaviour.
Done by:
Comic styled email or greetings card conveying the
procedure can alienate some concerns.
• Preappointment mailing
• Audiovisual Modelling
Child sees the video of the treatment prior to the
scheduled appointment date and thus gets
prepared mentally.

29. Tell-Show-Do
 TELL: technique involves verbal explanations of procedures in phrases appropriate to the
developmental level of the patient.
 SHOW: demonstrations for the patient of the visual, auditory, olfactory, and tactile aspects of the
procedure in a carefully defined, non threatening setting.
 DO: and then, without deviating from the explanation and demonstration, completion of the procedure.
• The tell-show-do technique is used with communication skills (verbal and non-
verbal) and positive reinforcement.
Tell Show Do

30. Relaxation Breathing
 This exercise is believed to benefit almost every fearful patient in relaxation through paced breathing.
 The physiologic changes accompanying relaxation or diaphragmatic breathing, effectively forms a counterpart to
the emergency “fight or flight reaction” characterizing an anxious individual.
 It is difficult to be tense and to breathe from your abdomen at the same time and it is believed that it helps in
reducing perceived pain.

31. Implosion Therapy
• Implosive Therapy (IT) is a behaviour modification technique developed by Stampfl (1961) for the treatment of
phobias.
• In implosion therapy anxiety is aroused by only imagining the stimuli (without direct contact). It involves imagined
scenes that are often exaggerated by a therapist and often relate to the child’s most feared fantasy. Finally, the
anxiety that is provoked during implosive therapy is often addressed using psychodynamic approaches (e.g.,
addressing an oral fixation).
• In implosive therapy, you might be asked to imagine the spider entering your mouth as you sleep if that
was an anticipated fantasy aspect of your fear.

32. Flooding Technique
 Flooding is a form of behaviour therapy or exposure therapy based on the principles of respondent
conditioning.
 It is used to treat phobia and anxiety disorders including post-traumatic stress disorder. It works by
exposing the patient to their painful memories,[1] with the goal of reintegrating their repressed emotions with
their current awareness.
 In flooding the child may be asked to picture spider, perhaps at various distances so that he becomes
desensitized to the image.
“Now, Master Jimmy , I’m
going to try a different
approach to treat your
fear of spiders”

33. Distraction
 The patient is distracted from the sound and/or sight ofdental treatment thus reducing anxiety.
 Objective is to relax the patient and to reduce anxietyduring treatment.
 Use stories and fairy tales.
 Types of distraction:
Audio Distraction Audio-Visual Distraction

34. Parental Presence or Absence
 Would or wouldn’t you want the parent watching
over you while you treated their child?????
OR
I told him you were
an ice cream vendor.
You take it from
there.

35. Contd.
Child
Parents Dentist
Paedodontic Treatment Triangle
 Presence could be beneficial or detrimental.

36. Contd.
 This is one of the most controversial issues in paediatric dentistry.
 Generally speaking, paediatric dentists keep them out.
 Generally speaking, paediatricians keep them in.
• Tend to repeat requests
• Become upset if child misbehaves
• Attempt to draw you in conversation
• May “test” you
• Can become a “silent” helper
• Language may be a barrier to
communication with the dentist so
parental presence is needed.
• Good educational tool
 Parent’s absence  Parent’s presence

37. Physical
Approaches

38. Hand Over Mouth (HOME)
 It was introduced by Evangeline Jordan in the year 1920.
 This method is used to establish communication with children who are able to cooperate, but exhibit a hysterical
behavior to avoid treatment.
 A hand placed over the child’s mouth and is told that the hand will be removed as soon as appropriate behavior
begins.
 When the child responds, the hand is removed and the praised for his appropriate behavior.
 Contraindicated in immature frightened, or child with serious physical, mental or emotionally handicapped.

39. Physical Restraints
• Last resort for handling uncooperative/handicapped patients.
• Restraints are usually needed for children who are hypermotive, stubborn or defiant.
• Physical Restraints involve restriction of movement of the child’s head, hands, feet or body.
• Active :-restraints provided by the dentist, staff or parent
without the aid of restraining device
• Passive:-with the aid of restraining device.
 Types of Restraint:

45. Pharmacological
methods

46. Conscious Sedation:
What is C.S ?
• Minimally depressed level of consciousness that retains the patient’s ability to independently and
continuously maintain an airway and respond appropriately to physical stimulation and verbal
command, produced by pharmacologic and non-pharmacologic methods alone or in combination,
(NO LOSS OF CONSCIOUSNESS).

47. Nitrous Oxide
• Oxygen and nitrous oxide is given through a small breathing mask.
• Relaxing, but without putting them to sleep.
• Very safe and effective
• Sometimes called “laughing gas”
• Often given at the dentists office
• Nitrous Oxide is a sweet-smelling, colourless gas.
• It is heavier than air or oxygen
 Nitrous Oxide is a very quick acting inhaled sedation medicine that decreases
discomfort and anxiety.
• Anywhere from a few seconds up to 3-5 minutes
• Crosses the blood-brain barrier rapidly
 Onset

48.  Indications.
• A fearful, anxious patient
• Certain patients with special health care needs.
• A patient whose gag reflex interferes with dental care.
• A patient for whom profound local anaesthesia cannot be obtained.
• A cooperative child undergoing a lengthy dental procedure.
• Some chronic obstructive pulmonary diseases.
• Severe emotional disturbances or drug-related dependencies
• Treatment with bleomycin sulfate.
 Contraindications