NON PHARMACOLOGICAL BEHAVIORAL MANAGEMENT

2. NONPHARMACOLOGICAL
BEHAVIOUR MANAGEMENT

3. CONTENTS
Introduction
Classification of behavior management techniques
Non pharmacological methods of behavior management
Behavior management of : pre - cooperative child
Recent behaviour management techniques
Conclusion
References

4. DEFINITIONS
Behavior: It is defined as any change observed in the functioning of an organism.
Behavioral science: Is the science which deals with the observation of behavioral habits
of man & lower animals in various physical & social environment including behavior
Pedodontics, psychology, sociology & social anthropology

5. Behavioral Pedodontics: Study of science which helps to understand development of fear &
anger as it applies to child in the dental situation.
Behavior shaping: Is the procedure which slowly develops behavior by reinforcing a
successive approximation of the desired behavior until the desired behavior comes in to being.
- MC DONALD

6. Behavior modification: Defined as the attempt to alter human behavior & emotion in
beneficial way & in accordance with laws of learning. - MATHEWSON
Behavior management: The means by which the dental health team effectively & efficiently
performs dental treatment & there by instills a positive dental attitude.
- WRIGHT

7. Wilson’s classification 1933
• Normal/bold: brave enough to face the situation, cooperate & friendly with dentist
• Timid: shy, does not interfere with dental procedures
• Hysterical/ rebellious: influenced by home environment , throws temper tantrum,
rebellious
• Nervous / fearful: tense & anxious, fear of dentistry
CLASSIFICATION OF CHILD BEHAVIOUR

8. Wright classification (1975)
I. Co-operative behavior:
II. Lacking co-operative behavior:
III. Potentially cooperative behavior:

9. III. Potentially cooperative behavior:
1. Uncontrolled behavior:
• 3-6 yrs.
• Temper tantrums
• Tears, loud crying, physical lashing out of the hands & legs
2. Defiant behavior:
• Elementary school group.
• Stubborn or spoilt child

10. 3. Timid behavior:
• Mild but highly anxious
• Shy, whimper, but do not cry hysterically.
• Overprotective in home.
• Needs to gain self confidence.
4. Tense cooperative:
• Extremely tense.
• Border line behavior.
5. Whining behavior:
• Whines through out the procedure
• Extremely frustrate to treat.
• c/o pain even after repeated LA.

11. 6. Stoic behavior:
• Cooperative
• Sits quiet, does not talk readily
• Physically abused child
• Dentist – attentive to other signs , report to the authorities if required.
7. Fearful child:
• Lacks experience in dealing with his environment successfully
• Timid & fearful of the environment, strangers, new experiences.

12. FRANKELS BEHAVIOUR RATING SCALE
• DEFINITELY NEGATIVE
• NEGATIVE
• POSITIVE
• DEFINITELY POSITIVE

13. Lampshire Classification (1970)
1. Co-operative: physically and emotionally relaxed
2. Tense cooperative: tensed, and cooperative at the same time.
3. Outwardly apprehensive: Avoids treatment initially, usually hides behind the mother
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.

14. MATERNAL INFLUENCE ON CHILDREN’S BEHAVIOUR IN THE
DENTAL SITUATION
Mother’s attitudes Child’s behaviour
1. Overprotective - submissive, shy, anxious
2. Overindulgent - aggressive, spoiled, demanding
3. Over-authoritative/ Rejecting - evasive, aggressive, overactive, extreme anxiety
4. Underaffectionate - well behaved but unable to cooperate, cry easily

15. OBJECTIVES
1. Establish effective communication
2. Gain children and parent’s confidence
3. Teach child and parents the positive aspects of preventive dental care.
4. To provide a relaxing and comfortable environment

16. Fundamentals Of Behaviour Management
• Team attitude
• Organisation
• Positive approach
• Truthfulness
• Tolerance
• Flexibility

17. Classification of behaviour management
1. Non pharmacological (psychological) approach
2. Pharmacological approach
Pre medication
Conscious sedation
General anesthesia

18. I.I.
Communication 1.II. Behavior
shaping
(modification)
2.Desensitization
3.Modeling
4.Contingency
management
•III. Behavior
management of
children with
disruptive behaviors:
•Voice control
•Aversive conditioning
•- HOME
•- Physical restraints
1.IV. Other
Behavior
management
techniques :
2.Distraction
3.Audio analgesia
4.Biofeed back
5.Hypnosis
6.Humor
7.Coping
8.Relaxation

19. COMMUNICATION

20. 1. Chambers(1976 ): Verbal communication by speech
2. Nonverbal communication:
• Expression of feelings without speaking
• Body language
• Smiling
• Eye contact
• Showing concern
• By touching
• Giving a hug

22. • Establishing communication
• Message clarity
• Multisensory communication
• Confident communication
• Active listening
• Problem ownership
EFFECTIVE COMMUNICATION

23. Usage of Euphemism or word substitute
Dental terminology Word Substitute
Rubber dam Rain coat
Rubber dam clamp Tooth button
Rubber dam frame Coat rack
Sealant Tooth paint
Topical fluoride gel Cavity fighter
Air syringe Wind gun
Suction Vacuum cleaner
Study models Statues
Alginate Pudding
High speed Whistle
Low speed Motor cycle

24. • Lechner&Wright(1975) : It is that procedure which very slowly develops behavior by
reinforcing successive approximation of the desired behavior until desired behavior is
expressed.
BEHAVIOUR SHAPING

25. Outline for behavior shaping
• State the general goals or task
• Explain the necessity of procedure
• Divide the explanation procedure
• Give explanation at child level
• Reinforce appropriate behavior
• Disregard inappropriate behavior

26. • Joseph Wolpe (1975)
• Teaching the child a competing response such as relaxation and then introducing
progressively more threatening stimuli.
• Systemic desensitization - effective
appropriate / adaptive emotional response (relaxation)
inappropriate or maladaptive response – anxiety.
DESENSITIZATION

28. Addelston (1959)
• Familiarise a patient with a new procedure
• Useful for all patients
• Non-invasive, relatively - easy to implement.
• Used to orient the child - anxiety- provoking stimuli
TELL SHOW DO

29. TELL

30. SHOW

31. DO

32. Objectives:
• To teach & familiarize the patient with dental setting
• To shape the patient responses to various procedures.
Indications:
• First visit
• Above 3 yrs age
• Subsequent visits - new dental procedure.
• Apprehensive child

33. MODELLING
Bandura(1967):
• Imitation, observational learning, identification, iternalization, introjection
“Fearful & avoidant behavior can be extinguished through observation with out any
adverse consequence accruing to the performer”

34. Patient characteristics:
• Wide range of 3-13yrs.
• All types of children
• Ghose et al —previous experience, age of the patient is important for
displaying the behavior

35. Types:
1. Live model: showing another patient undergoing the treatment
Effective – model of same age, sibling.
2. Symbolic model
eg; video tape - child cooperation.
Chambers DW (1970) - both live and filmed modelling are effective in reducing child’ s fear
and anxiety.

36. Steps in modeling :
• Patient attention obtained
• Desired behavior is modeled
• Reinforcement of the guided behavior
Modeling serves as
• Stimulation of the acquisition of new behavior
• Facilitation of behavior already present
• Extinction of fear

37. CONTIGENCY MANAGEMENT
Method of modifying the behavior of children by presentation or withdrawal of
reinforcers.
2types
Positive reinforcers
Negative reinforcers

38. POSITIVE
Reinforcement
( Henry W Fields ,1984)
NEGATIVE reinforcement
( Stokes and Kenndy ,1980).

39. Types of reinforcers
• Social – e.g. , praise , positive facial expression , physical contact by shaking hand ,
hug ,pat on shoulder
• Material - may be given in the form of games ,toys.
• Activity reinforcers – Involving child in some activity like watching TV shows , visit
to park.

40. III. Behavior management of children with disruptive
behaviors:

41. VOICE CONTROL
“ What you say is not as critical as how you say it” – Wright
• Modification of the timbre, intensity and pitch of ones
• For instance – dentist may speak in a loud voice in order to gain child’ s attention /stop
disruptive behaviour
• Once child’ s attention is gained – he may speak in soft voice

42. Objectives:
1. Gain the patient’s attention and compliance;
2. Avert negative or avoidance behavior;
3. Establish appropriate adult-child roles.

43. Dr. Evangeline Jordan 1929
• “If a normal child will not listen but continues to cry and struggle, hold a folded napkin
over the child's mouth and gently but firmly hold his mouth shut, his scream increases his
condition of hysteria, but if the mouth is held closed, there is little sound, and he soon
begins to reason ”.
• McDonald – "If the child is definitely demonstrating a temper tantrum, then the dentist
must demonstrate his authority and mastery of the situation."
HAND OVER MOUTH

44. LEVITAS technique:
• “I place my hand over the child's mouth to muffle the noise .I bring my
face close to him and talk directly into his ear. '"If you want me to take
my hand away. you must stop screaming and listen to me. I only want to
talk to you and look at your teeth." After a few seconds, this is repeated,
and I add, "Are you ready for me to remove my hand",? Almost
invariably there is a nodding of the head. With a final word of caution to
be quiet, the hand is removed.

45. Craig
The purpose of the technique is to gain the attention of the child so that communication
can be established
Other terminologies:
Emotional surprise therapy – Lampshire
Aversion - Crammer

46. Indications:
Children - momentarily hysterical / aggressive / defiant
Contraindications:
Very young
The immature
The frightened
The child with serious physical, mental or emotional handicap.

47. Variations:
• HOME, airway unrestricted
• Hand Over both Nose & mouth , air restricted
• Towel held over mouth only
• Dry towel held over nose &mouth
• Wet towel held over nose mouth

48. Indications:
• Cannot co-operate / due to lack of maturity
• When other behavior management technique have been failed
• When the safety of dental staff & patient would be at risk - with out the use of
protective restraints
Contraindications:
a. Cooperative patient
b. A patient who can’t be mobilized safely because of any systemic or medical
conditions
Physical Restraints

49. Objectives :
To reduce / eliminate the untoward movement
To protect the dental staff, patient from the injury
To render the quality dental treatment in these patients.
Considerations:
Informed consent
Type of restraint
Indication for restraint

50. 1. Oral:
• Mouth props
• Padded wrapped tongue blades
• Rubber bite blocks
2. Body:
• Papoose board
• Triangular sheet
• Pedi wrap
• Bean bag dental chair
• Safety belt
• Extra assistant
3. Extremities:
• Posey straps
• Velcro straps
• Towel & tape
• Extra assistant
4. Head:
• Head positioner
• Plastic bowel
• Extra assistant
TYPES

51. Oral :
• For stubborn child / defiant child
• Mentally handicapped child
• Very young child - cannot keep mouth open period of time.
× In Apprehensive Child -↑ His Fears

53. Body:
•Restrict physical movements
• Pt < 2yrs of age

54. Extremities:
• Attach to the dental unit - restraints a patient at the chest, waist, legs.
• Control the activity of the mentally / physically handicapped .
• Prevent the patient from getting injured himself
• Prevent from interfering in the dental procedure.

55. Head:
Supports the head
Protects the patient from getting injured himself & patient.
Types:
Fore body support
Head protector
Plastic bowel
Extra assistant

56. • White noise
• Gardener, Licklider :1959
• Technique - providing a sound stimulus of such intensity that
patient finds it difficult to attend to anything else.
Audio Analgesia

57. Bio Feedback
• Buonomono - 1979
• Sensors record involuntary responses that tend to increase under stress
• Feedback about these, through the machine, as a visual, auditory or tactile (touch)
• Relaxes senses and reduces pain

58. • Involves the use of certain instrument to detect certain physiological processes associated
with fear.
• Electroencephalographic (EEG) activity, electromyography (EMG) activity- tension
headaches, migraine headaches, heart rate and arrhythmias and blood pressure.

59. Hypnosis
 Franz A Mesmer 1773.
A state of mental relaxation and restricted awareness in which subjects are usually
engrossed in their inner experiences such as imagery, are less analytical and logical
in their thinking and have capacity to respond to suggestions in an automatic and
dissociate manner.

60. Hennon:
• Reduce nervousness and apprehension
• Eliminate defense mechanism that patients use to post pone dental work
• To induce anesthesia
• Prevent oral habits

61. Technique:
• Patient preparation : Children Act (1989)
• Begins with an induction technique
 Aim- relax the patient and encourage them to focus
 Giving repeated instructions suggestive of relaxation and comfort
 Coupling of focusing and suggestion to develop more powerful effect

62. • Stimulus…….. people laugh and feel happy
• Building & maintaining relationships, cognitive function
• Anxiety relief in child, parent and doctor
HUMOR

63. FUNCTIONS
• Social : forming & maintaining relationship.
• Emotional : anxiety relief in child, parent & doctor.
• Informative : transmits the essential information
• Motivation : increases the interest & involvement of the child.
• Cognitive : distraction from fearful stimuli.

64. Lazuae(1980):
• Cognitive and behavioral efforts made by individuals to master, tolerate or reduce stressful
situation.
• Behavioral: physical & verbal activities in which the child engages to over come a stressful
situation
• Cognitive: involving manipulation of emotion
COPING

66. Relaxation
• Mc Ammond : effective in reducing immediate anxiety and fear
• Involves series of basic exercises
• May take several months to learn & practice
• Paul: Relaxation training , hypnosis & a control treatment

67. • Imagery involves concentrating on pictures of
pleasant scenes or events or mentally repeating
positive words or phrases to reduce pain.
• Distraction techniques focus attention away from
negative or painful images .
VISUAL IMAGERY

68. J.F. Roberts Review: Behaviour Management Techniques in Paediatric Dentistry: European
Archives of Paediatric Dentistry (Issue 4). 2010
Universally accepted techniques
• Tell-show-do
• Modelling
• Reinforcement
• Voice control
Controversial Techniques not universally accepted
• Restraints
• HOME
• HOMAR

69. Behavior Management : Pre-Cooperative Child
Pre-cooperative children have immature cognitive skills, highly restricted range
coping with stress.
Prone to mal-adaptive responses to anxiety- provoking situations.
Pre-cooperative child’s perspective:
• Have narrow focus attention
• Exhibits anxiety, frustration - inability to control his / her environment
through resistive or combative behaviors - Unpleasant & traumatic
experiences to dental team.

70. Management techniques:
• Avoid fearful words.
• Patting & stroking behaviors – reduces fear related behaviors in
young children
• Explanation serves children of 3-5yrs.
• Voice control- limited value
• HOME- contraindicated
• Distraction – helpful

71. Behavior management of autistic child
• Gradual & slow exposure to the dental environment with non -threatening contacts
•Parental presence is usually discouraged.
•Treat the patient in quiet , shielded single operatory with reduced decoration & dimmed
lights.
Appointment structure:
•Due to limited span of attention- •Well- organized appointments, should not make the
patients to wait in the waiting room more than 10-15 mins
• dental assistants should minimize the movements- child is easily distracted

72. Management techniques:
• communication: oral commands should be clear, short simple sentences.
•Inappropriate behavior should be ignored
•HOM – not to be applied
Kopel :– •dental procedures into smaller steps
•Rehearsals at home prior to the appointment – helpful to familiarize the treatment.
•Physical restraints- controversial

73. I. Mobile dental app:
• In 2017 - Patil VH
• 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
Recent behaviour management techniques

74. 2. Videogame distraction:
• The use of videogame as a distraction tool is based on the
principles of cognitive- behavioural therapy and neuro feed
back mechanism for children with anxiety disorders.
a. For health promotion: Aljafari A et al 2017 used Oral
health education related videogames for promoting healthy
diet and good oral hygiene for high caries risk children.

75. b. For Management of dental anxiety:
Ko JS et al 2016 used Ipads for reducing anxiety in children during their orthopaedic
visits.
Sil et al 2013 and Wohlheiter KA et al 2013 used videogames to reduce pain perception
during cold-pressor trials.

76. 3. Virtual reality based distraction:
• In 1968, Ivan Sutherland and Bob Sproull invented
virtual reality with a head mounted device that was
connected to a computer.
• Later in Heim(1998) described virtual reality as an
interactive computer based software that can be used to
immerse children in the virtual environment which
completely obstructs the present situation.

77. 4. Audiovisual distraction: • Involves the concept of imagery and distraction delivered via
audiovisual aids, thereby removing the focus on the dental procedures, avoiding anxiety
provoking stimuli and providing a relaxing experience throughout the procedure
GOALS:
a. Imagination
b. Engagement
c. Motivation

78. • Management of dental anxiety: A systematic review by Barreiros D 2018 concluded that
audiovisual distraction is effective in controlling dental anxiety in children
• Management of pain: Oliveira NCAC et al 2016 found audiovisual distraction could reduce
the intensity of pain during painful puncture procedures.

79. 5. Tell- Play- Do
• Tell- Show-Do was modified by Vishwakarma AP as Tell- Play-
Do in 2017 for children aged 5-7 years
• An additional component of allowing the child to play with
dental equipment's was carried in Tell-Play- Do.
• As per the learning theory of Bandura, the child’s anxiety
towards the dental equipments reduces, thereby feels more
comfortable and develops cooperative behavior

80. Conclusion
• Dentistry for children can be demanding and frustrating; at the same time, it can be
enriching, satisfying, and memorable
• Child patient management was a concern 30 years ago as well as today
• Multidisciplinary research that results from combining the wealth of knowledge of both
dentistry and psychology significantly helps in modifying behavior management and child
development

81. References
• Management of dental behaviour in office Wright 2nd edition
• Dentistry for the child and adolescent by McDonald; Avery; Dean : Eight Edition,
• Textbook of pediatric dentistry nikhil marwah: Third edition
• Effect of audiovisual distraction on the management of dental anxiety in children: A
systematic review Yunkun Liu, 26 October 2018
• Efficacy of Non-pharmacological Methods of Pain Management in Children Undergoing
Venipuncture in a Pediatric Outpatient Clinic: A Randomized Controlled Trial of
Audiovisual Distraction and External Cold and Vibration

82. Efficacy of Non-pharmacological Methods of Pain Management in Children Undergoing Venipuncture in a
Pediatric Outpatient Clinic: A Randomized Controlled Trial of Audiovisual Distraction and External Cold
and Vibration
• Purpose : Venipuncture generates anxiety and pain in children. The primary aim of the study was to evaluate two non-
pharmacological techniques, vibration combined with cryotherapeutic topical analgesia by means of the Buzzy® device and
animated cartoons, in terms of pain and anxiety relief during venipuncture in children.
• Designs and Methods : 150 children undergoing venipuncture were randomized into four groups: the ‘no method’ group, the
Buzzy® device group, the animated cartoon group and the combination of Buzzy® and an animated cartoon group. Children's
pain and anxiety levels along with parents' and nurses' anxiety levels were evaluated by means of validated grading scales.
• Results : Overall children's pain increased less in the non-pharmacological intervention groups as compared to the group
without intervention. Notably, the difference was statistically significant in the animated cartoon group for children's perception
of pain. Children's anxiety and parents' anxiety decreased more in non-pharmacological interventions groups as compared to the
group without intervention.
• Conclusions : The study showed the effectiveness of non-pharmacological methods of pain management during venipuncture.
Notably, distraction with animated cartoons was superior in terms of children's perception of pain when compared to Buzzy®,
and to the combination of cartoons and Buzzy®.. Furthermore, nurses' involvement in pediatric care can be enhanced.

83. • The Behavior - management techniques that included in the video were: (1) tell–show–do, (2) nitrous
oxide inhalation sedation, (3) passive restraint by Papoose Board, (4) voice control, (5) hand-over-
mouth, (6) oral sedation, (7) active restraint, (8) general anesthesia and (9) Parental presence/absence
technique.
• The most accepted technique was Tell-Show-Do, and the second preferred technique was Nitrous oxide
inhalation sedation followed by GA and the least preferred was Passive restraint followed by HOM
technique.
• Male parents preferred general anesthesia while the female parents preferred nitrous oxide inhalation
sedation
• Conclusion: Proper assessment of children’s behaviour helps the dentist to plan appointments and render effective
and efficient dental treatment
A Daghamin S, Balharith M, Alhazmi S, AlObaidi F, Kakti A. Behavior Management Techniques in
Pediatric Dentistry: How Well are they Accepted?. Acad J Ped Neonatol. 2017; 5(3)

84. Effect of audiovisual distraction on the management of dental anxiety in children: A
systematic review Yunkun Liu, 26 October 2018
• Aim : Synthesize the available evidences to evaluate the efficacy of audiovisual distraction techniques on the management of dental
anxiety in children.
• Design : Electronic databases (PubMed, Cochrane Central Register of Controlled Trials, and Embase) were searched. We included
randomized controlled trials (RCTs), and methodological quality of included trials was assessed using the Cochrane Collaboration's
criteria. Information on reported anxiety, pain, behaviors, vital signs (including blood pressure, oxygen saturation, and pulse rate),
and children satisfaction was analyzed.
• Results : Nine studies were included for a systematic review, and none of them had low risk of bias. Significant differences in
anxiety were found. According to the study, a majority of results indicated a significant difference in pain and behavior between the
audiovisual and control group. Three studies reported children in the audiovisual group preferred usage of an audiovisual device for
future dental visits. No significant differences could be found regarding blood pressure.
• Conclusions : There is some low-quality evidence suggesting that the usage of audiovisual distraction during dental treatment may
relieve children's dental anxiety.