1. PATIENT
MANAGEMENT
INDIAN DENTAL ACADEMY
Leader in continuing dental education
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2. •INTRODUCTION
•OFFICE DESIGN & PERSONNEL
•CHILD MANAGEMENT
- FEAR
- MENTALLY CHALLENGED
- PHYSICALLY HANDICAPPED
- BEHAVIOUR MANAGEMENT
•ADULT MANAGEMENT
- PSYCHOLOGY
- ORTHOGNATHIC SURGERIES
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3. PATIENT
MANAGEMENT
DENTAL
OFFICE
PERSONNEL
DOCTOR
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4. Introduction
Doctor patient
relationships have
a significant impact
on successful
treatment in
dentistry.
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5. Various other factors apart from
the doctor patient relationship
play a role to a successful patient
management system.
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6. • The office design of the clinic and a team
approach play a role in the management
of a patient.
• Every individual in the clinic has a
significant role to play in maintaining a
very pleasant and cordial atmosphere.
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7. Office design
• Should be designed functionally to allow
for maximum efficiency in both clinical and
administrative tasks.
• Should be categorized into a clinical area
and administrative area.
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8. Clinical area
• Consists of entrance, waiting room,
adolescent treatment room, adult
treatment room, X- ray room, records
room, wet lab, dry lab and consultation
room.
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9. Administrative area
• Consists of business office, computer
room, postage room, diagnosis room,
doctors private offices.
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10. Personnel
• The members of the office staff are critical
to the performance of the office.
• Anything done by any staff member is a
reflection on the doctor.
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11. Office manager
• Greets the new patients and give new card
to fill.
• Set up records for consultation in exam
room
• Help all the personnel regarding the day
off, vacation time and any other problems.
• Coordinate appointment book with office
personnel & doctor.
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12. Receptionist
• Greets all the patients, attends the
telephone.
• Make all the appointments and keeps all
the patient charts ready for each
appointments.
• Obtain the patients information and keeps
a note on any changes
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13. Chairside assistant
• Maintain patient flow pattern.
• Place separators.
• Fit bands and prepare for bonding.
• Scale cements and helps tie in arch wires.
• Refill and clean sterilizers.
• Check for loose appliances.
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14. A sound Doctor-patient relationship
in orthodontics can positively
influence treatment outcomes by
encouraging the patient to
cooperate in the following
prescribed instructions related to
the particular appliance wear and
maintenance of oral hygiene
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15. • In the practice of orthodontics
today, time should be invested in
creating and maintaining the
important “patient-doctor” bond.
Orthodontist behaviors such as
listening, empathy, and explanation
are important in achieving that
goal.
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16. • The doctor's expression of concern
about the well being of the patient is
also found to be significant in
predicting patient adherence.
• Verbal communication, a calm and
confident manner, and reassurance
increases the patient compliance.
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17. • With better communication, the patient
can relate more information with
greater accuracy, thus improving the
quality of care.
• Patient management can be greatly
enhanced when the patients
“understand” the nature of their
conditions and the proposed treatment
plan or procedure to be performed that
will be used to improve their condition.
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18. Self regulation approach to
orthodontic patient compliance
Recommended
treatment regimen
Motivation Monitor regimen
relevant behaviour
Adjust behaviour
comparator
Error
signal
Lyons &Ramsay
(2000)
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19. Patient centered care Vs
Practitioner centered care
The practitioner prescribes treatment
plans based on individual patient
expectations, priorities and capabilities.
Under this concept would include patient
education, patient empowerment and
contracting procedures.
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20. 1. Patient education
This is very important to success in motivating
the patient.
Patients and parents are unclear about the
treatment modalities.
Various demonstration tools can be used to aid
in the education process.
Study casts and photographs can be used.
Demonstration models and appliances help
Patients to understand different appliances.
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21. 2. Patient empowerment &
contracting procedures
Educating the patient regarding their condition
gives them the tool to make informed decisions.
Individual becomes more involved in the process
of selecting what is most suited for him.
Once decision reached- patient is empowered
and selects a treatment option and the patient is
obliged to comply with an agreement.
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22. Rewarding complaint behaviour
Behaviour modification by the way of a
reward program can be effective in
improving patient compliance to
prescribed instructions.
Rewards becomes a means of positive
feedback for patients in the orthodontic
treatment of malocclusions.
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23. Patient
satisfaction
Parent
satisfaction
Doctor – patient
rapport
Superior treatment
results
Patient compliance
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24. Patient Compliance: A Determinant of
Patient Satisfaction?
Bosa et al ( Angle Orthodontist July 2005)
• The aim of this study was to investigate
whether patient compliance, as noticed and
recorded by the orthodontist during
treatment, can be used as a determinant of
patient’s satisfaction in the long run.
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25. • It was expected that patients who were
rated less compliant by the orthodontist
during treatment would express more
dissatisfaction with the treatment process
and the treatment result.
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26. • The results of the study indicated that
although an orthodontist may judge a patient
to be noncompliant, this judgment did not
seem to affect the satisfaction of the patient
with the treatment process and outcome in
the long run.
• The most important factor contributing to
patient satisfaction was the patient’s
satisfaction with the doctor-patient
relationship.
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27. • Sex was found to be a significant predictor
of the patient’s satisfaction with the doctor-
patient relationship and the situational
aspects of the treatment.
• Female subjects indicated dissatisfaction
with their dentofacial improvement more
often than male subjects
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28. Child management
Extreme care to be taken while managing
a child.
Compliance of the patient has to be
gained by the doctor.
Early treatment would always prove
beneficial as a psychological advantage.
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29. FEAR
DEFINITION: Fear is the
emotional response to a
consciously recognized
and usually external
threat or danger.
It is a primitive
response developed to
protect the individual
from harm and self
destruction.
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30. Classification
Fears can be classified into two
types :
1. Objective fears
2. Subjective fears
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31. Objective fears
• Acquired objectively or are produced
by direct physical stimulation of the
sense organs
• They are not of parental origin, which
are unpleasant and disagreeable in
nature.
• Eg: Fear from unpleasant contact
with dentisty.
Repeated hospitalization
leading to fear of uniforms worn by the
dental team.
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32. Subjective fears
• Acquired based on the feelings and
attitudes suggested to the child by others
without the child personally experiencing
them
• Subjective fears are Imitative, Suggestive
or Imaginative fears.
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33. Suggestive fears
• Acquired by imitation by observation of
others.
• They are generally recurrent, deep
seated and are difficult to eradicate.
• Displayed emotion in parents face
creates more impression than verbal
suggestions.
• These fears also develop from friends,
playmates and media and depend a lot
on repetitionwww.indiandentalacademy.com

34. Imaginative fears
• Imaginative fears are formed as the
child’s imaginative capabilities
develop.
• They become more intense with age
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35. Value of fear
• Fear – lowers pain threshold –hence
pain produced is magnified.
• Fear has a safety value when given a
proper direction and control.
• It is a protective mechanism for self
protection.
• If the child does not fear punishment or
parental disfavour, his behaviour may
become a threatwww.indiandentalacademy.com

36. • The child should not be trained in
the direction of eradicating the fear
but rather should be channeled
towards dangers that really exist
and away from situations where no
danger lies.
• “Dentistry should not be employed
as a threat or punishment”
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37. Fears associated with age
I. Birth to two years
• This is the infancy stage – oral stage of
freud and Erikson’s Trust Vs Mistrust.
• First form of fear or anxiety are seen in
this stage.
• Fear of strangers and also fear developed
from conflict of basic Trust Vs Mistrust
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38. II. Two year old
• Vocabulary is limited to 12 – 1000
words.
• They lack cooperative ability.
• Child will be too young to be reached
with words alone and must touch and
handle objects in order to grasp their
meaning fully.
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39. • Fear and anxiety of this age group is fear
of falling, sudden jerky movements,
bright lights, separation from parents
and fear from strangers
III. Three year old
• Communication is easier.
• Fear of this age group is fear of
strangers
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40. IV. Four year old
• Usually listeners to explanation and are
responsive to verbal directions.
• Very lively and are great talkers
• Increased ability to evaluate fear
producing stimulations.
• Intelligent children display more fear
because of greater awareness of the
danger and reluctance to accept verbal
assurance without proof.
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41. • Fear of this age group includes fear of
falling.
• Fear of bodily injury
• Fear of noise and strangers are reduced.
• Prick of needle and sight of blood can
lead to increased response
disproportionate to that of pain.
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42. V. Five year old
• Age to accept group activities and if
trained properly by the parents there is
little fear of separation.
• Children are proud of their
possessions.
• They will combat on imaginative level,
things they fear in reality.
• This makes the child gain comfort as
well as courage to meet the real
situation.
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43. VI. Six to twelve year old
• Children of this age group learn from the
outside world.
• Become independent of their parents.
• These are important years of learning and
to abide by the rules of the society.
• Children usually can resolve fears of dental
procedures if the dentist explains and
reasons well.
• They also learn to tolerate unpleasant
situations.
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44. VII. Teenage
• Children especially girls tend to become
concerned bout their appearance.
• They like to be as attractive as possible.
• This can lead as a motivational factor for
seeking dental attention.
• To satisfy their ego they will be willing to
cooperate.
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45. PATIENT
MANAGEMENT
PARENT CHILD
DOCTOR
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46. Behaviour management
• Defined as a means by which the
dental health team effectively and
efficiently performs dental treatment
and thereby instills the dental attitude.
( Wright 1975 )
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47. Methods of behaviour management
Mainly includes two methods:
1. Non pharmacological methods.
2. pharmacological methods.
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48. Non pharmacological methods
1. Communication
2. Behaviour shaping( modification )
( a ) Desensitization.
( b ) Modeling.
( c ) Contingency management.
3. Behaviour management.
( a ) Audio analgesic.
( b ) Bio feedback.
( c ) Hypnosis.www.indiandentalacademy.com

49. ( d ) Voice control.
( e ) Humor
( f ) Coping.
( g ) Relaxation.
( h ) Implosion therapy.
( i ) Aversive conditioning
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50. Pharmacological methods
1. Premedication
( a ) Sedative – Hypnosis.
( b ) Anti anxiety.
( c ) Anti histamines.
2. Conscious sedation.
3. General anesthesia.
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51. Intra venous sedation – an alternative
Gozal & Becker ( EJO2002)
• Excellent alternative to GA.
• Need for hospitalization & use of theatre
are eliminated.
• Rx can be carried out in a fully equipped
orthodontic operatory.
• Induction and recovery is rapid.
• Safe level of sedation with minimal side
effects.
• Reduced cost.
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52. Communicative management
•It forms the basis for
re establishing a
relationship with the
child which may allow
a successful
completion of dental
procedure or help the
child to develop
positive attitudes
towards dental care.
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53. Types of communication:
• Verbal communication is by speech.
• Non verbal communication is by :
( a ) Body language
( b ) Smiling
( c ) Eye contact
( d ) Showing concern
( e ) Touching the child
( f ) Expression of feelings without
speaking
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54. • Communication should be relaxed and
comfortable.
• Language should express concern and
friendliness.
• Verbal communication is best for child
more than 3 yrs. Voice should be
constant and gentle.
• Tone of voice can express empathy and
support.
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55. • Content of the conversation with the
child should make the child feel that
the dentist is his well wisher.
• Communication should be from a
single source – B/w dentist and the
child or child and the dental assistant
to avoid confusion.
• Sitting and speaking at the eye level
brings bout a more friendlier
atmosphere.
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56. Euphemisms
• Substitute words which can be used in the
presence of children.
• Effective in communicating with the child.
• Employing certain words that are meaningful
to the child would exhibit a more cooperative
behaviour.
• Word substitutes are more efficiently used
with the preschool children.
• Egs : air – wind , anesthetic – sleepy water, X
ray equipment - camerawww.indiandentalacademy.com

57. Behaviour shaping
• Involves the use of selected reinforces
that being learned will change a child’s
behaviour from an inappropriate to an
appropriate one.
• This is based on the stimulus –
response theory.
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58. • This is a step by step procedure to make
the child involve in the dental therapy.
• These children should be cooperative and
communicative to absorb the information
which may be complex to them.
• The overall procedure should not be
explained with a single explanation
• Childs level of understanding –
euphemism .
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59. Various methods – behaviour shaping
1. Desensitization
• One of the most effective methods for
reducing maladaptive anxiety.
• Teaching a patient to induce a state of
deep muscle relaxation - describing
while in the relaxed state- imaginary
situations relevant to the patient
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60. • Effective in managing a broad spectrum of
phobias including fear of rejection,
physical injury and injections.
• Systemic desensitization requires 15-25
therapy sessions in order to train the
patient properly and reduce anxiety.
• Reciprocal inhibition – inappropriate
response is changed to appropriate
response
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61. Tell show do technique
• Introduced by Addleson
in the year 1959.
• Dentist uses the
language
understandable to the
child and tells the
patient what is to be
done.
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62. • Dentist demonstrates the procedures to child
using a model or himself and is done slowly
• The dentist proceeds to do the treatment
exactly as described.
• This procedure should be continuous from
the child’s entry into the clinic through all
procedures involved in the treatment.
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63. 2. Modeling
• Introduced by Bandura ( 1969 ).
• Involves allowing patient to observe one or
more individuals who demonstrate a
positive behaviour in a particular situation.
• Patient will frequently initiate the models
behaviour when placed in a similar
situation.
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64. Advantages
Patients attention is obtained.
Desired behaviour is modeled.
Reinforcement of the guided behaviour
may be provided.
Fear is eliminated.
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65. Contingency management
• Method of modifying behaviour by
presentation or withdrawal of reinforcers.
• Reinforces increases the frequency of
behaviour.
• Two types – 1.positive
2.Negative.
• Negative reinforcer is usually the termination
of an aversive stimulus.
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66. • Types of reinforcements may be :
Social reinforcements
Material reinforcements
Activity reinforcements
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67. Aversive conditioning
• One mode of behaviour management.
• Two common methods used are the
HOME and PHYSICAL RESTRAINT.
HOME
• Termed Hand over mouth technique.
• Introduced by Evangeline Jordan in the
year 1920.
• Purpose is to gain the attention of the
child.
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68. Technique
• Technique
• Once the child cooperates ,he should be
complimented.
• Childs airway should not be restricted
• Procedure should not last more than 20 to
30 sec
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69. Indications
• Healthy child who can understand but
exhibit defiance and hysterical behaviour
during treatment.
• 3- 6 yrs
• Child who understands simple verbal
words.
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70. Contra indications
• Child below 3 yrs old.
• Handicapped child/ immature child.
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71. Physical restraints
• Last effort for handling stubborn or defiant
children.
Types of restraint :
• Body : Pedi wrap
Bean bag with straps
Towel and tapes.
Papoose board
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72. • Extremities : Velcro straps
Posey Straps.
• Head : Head Positioner.
Extra assistant.
• Mouth : Mouth Props
Bite blocks
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73. Papoose board
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74. Orthodontic management of an
autistic child ( JCO FEB 2005 )
• Autism is an organic disorder
characterized by abnormalities in the brain
especially the limbic function and
cerebellum, it is manifested in an impaired
capacity for communication and social
interaction and in repetition of actions and
behaviour.
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75. Characteristics of autistic child
• No imaginative capacity.
• Speak a fluent unintelligible jargon called
“delayed echolalia”-bits and pieces of
memorized dialogue.
• They echo the speech of others or
produce meaningless words.
• Repetition of stereotyped movements.
• Unusual tolerance for monotony.
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76. • Management of an autistic child is a
challenge to the orthodontist.
• Thorough understanding is required of these
special need patients.
• They have better non verbal (visual – spatial
) than auditory- verbal skills.
• Dental care for autistic children are provided
generally under General anesthesia.
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77. • Autistic children responds well to visual
pedagogy.
• Rehearsals employed by the parent at home to
help condition the child prior to his clinic visit.
• Repetitions should be used to help child learn
bout each procedure.
• Exposure to the dental environment should be a
gradual and slow process with non threatening
contacts.
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78. • Autistic children follow routines strictly and resist
changes in their daily life.
• Cooperative behavior by the child should always
be rewarded.
• “show-tell-do technique” is employed rather than
the traditional tell-show-do technique as they
lack imagination.
• Brackets should be told as “silver earrings” that
would be stuck to the teeth..
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79. • Attention span of an autistic child is short
and hence the duration of a particular
treatment is very crucial.
• Amount of work to be performed at each
appointment must be carefully considered.
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80. Adult management
• Management techniques vary from that of the child.
• Major motivation for child- parents.
• Adults seeks treatment because of the need for that
“something” which is not clearly expressed.
• Important to identify why the patients seeks treatment.
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81. • Most adult patient understand why they
need treatment and have a better positive
self image.
• Two types of motivation :
1.External motivation
2.Internal motivation
( Edgerton and Knorr AJO 1982)
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82. • Internal motivation better cooperative.
• Should be asked the question “ why now?”.
• Adult patients always require a
considerable degree of explanation so that
they will be compliant.
• They can be less tolerant to discomfort and
pain and hence additional chair side
time should be anticipated.
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83. • Open area of room is better than a
separate adult room –gives them a
positive influence in patient adaptation to
treatment.
• If expectations of both the doc and the
patient are realistic then comprehensive
Rx for adults can be a rewarding
experience for both.
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84. Conclusion
• Patient management is an important criteria
in achieving clinical results
• Efficient patient management helps to
cultivate a good patient doctor rapport which
is an incentive for the patient always to get
back to the doctor ~ practice management
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