health

1. 1
BEHAVIOR MANAGEMENT -
Non pharmacological methods
Dr Prabha Devi .C. Maganur
post graduate student
Dept of Pedodontics
BDCH

2. 2
“Although the operative dentistry may be perfect,
the appointment is a failure if the child departs in
tears”
Mc Elory (1895)

3. 3
contents
Terminologies used
Learning & development of behavior
Normal behavior of children & adolescent
Fear
Child cry in the dentistry
Children misbehavior classification- pinkham
Behavioral patterns in children

4. 4
Behavior rating scales
Anxiety rating scales
Children attitudes towards dentistry
Factors affecting behavior
Pedodontic triangle
Procedures & skills for behavior guidance
Main areas to be focused
Behavior management objectives

5. 5
Fundamentals of behavior management
Classification of behavior management techniques
Non pharmacological methods of BM
Behavior management:
1. pre - cooperative child
2. autistic child
3. cancer patient
Conclusion
References

6. 6
Terminologies used
Behavior: deportment or conduct; any or all of a person’s total
activity, especially that which is externally observable.
(oxford dictionary)
Behavior: is an observable act. It is defined as any change
observed in the functioning of an organism. Learning as related to
behavior is a process in which past experience or practice results
in relatively permanent changes in an individual’s behavior.
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

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

8. 8
psychologists - 3 distinct mechanisms
(1) classical conditioning ------ Ivan Pavlov
(2) operant conditioning ------ B.F skinner
(3) observational learning (modeling) ------
Learning & development of behavior

9. 9
Russian physiologist Ivan Pavlov (19th century) – “apparently
unassociated stimuli could produce reflexive behavior.”
Pavlov's classic experiment:
Food to hungry animal ------ sight, smell elicit salivation.
Food + ringing of the bell each time ----- salivation
Ringing of the bell ----- salivation
(conditioned stimulus) (response)
classical conditioning --- Ivan Pavlov

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Even at the early age – child experiences with medical personals

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•The association between a conditioned and an unconditioned stimulus
is strengthened every time they occur together ----
REINFORCEMENT
Reinforcement:
Conditioned stimulus unconditioned stimulus
Sign of white coat Pain of injection
Sign of white coat Pain of injection
Sign of white coat Pain of injection
Sign of white coat Pain of injection

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Association b /n conditioned & unconditioned stimulus not
reinforced
Less strong & conditioned response will no longer occur.
“Extinction of the conditioned behavior”.
Generalization: similar office settings condition the stimulus to
greater extent
Discrimination ----The opposite of generalization of a conditioned
stimulus

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operant conditioning --- B.F skinner
 basic principle ---- “the consequence of a behavior is in itself a
stimulus that can affect future behavior”
Stimulus Response
Consequence

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four basic types of operant conditioning- distinguished by the
nature of the consequence :
1. positive reinforcement.
2. negative reinforcement
3. Omission
4. punishment

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observational learning (modeling)
2 distinct stages:
 acquisition of the
behavior --- by observing it
 the actual performance
of that behavior.
*

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Stone & church (1975): child development into 5 stages:
Infant
Toddler
Preschooler
Middle-yrs child
Adolescent
Normal behavior of children &adolescent

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Infant:(0 - 15 mons) :
•6mons—1st experiences fear, stranger anxiety,
•Displays apprehension
•If needs not met -- -ve experiences remains as fear & distrust
Toddler (15 mons- 2yrs) :
•Displays ambulant nature
•Do not understand why dental procedures has to be done.
•Not cooperative for radiographs
•May tolerate prophylactic measures.
•Deep carious lesions– extensive R/ are beyond the normal
behavior capabilities
•May require conscious sedation.

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Preshooler(2-6 yrs):
•Play the role modeling
•Fantasy world, dramatic
•Likes to verbalize with dentist during R/
•Require euphemistic descriptions.
•Self aware of pain & bleeding avoid such actions, words
Middle yrs child (6-12 yrs):
•Time for independent identity
•Understands what is seen.
•Anxiety can be dealt with in a reasonably way by staff.
Adolescent: (11-15 yrs)
•Cooperative behavior.
•Influence of peer is most.

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Sydney Finn --“It is primary emotion acquired soon after birth".
Fischer – “fear is an emotion occurring in situations of stress and
uncertainty where in the person experiencing it sees himself
as threatened or helpless and whose reaction is to resist or flee
situation out anticipation of pain, distress, or distraction ”
Types:
 Objective fear
 Subjective fear
Fear, Changes in Fear Perception with Age:

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OBJECTIVE FEAR:
produced by direct physical stimulation of the sense organs
Not of parental origin.
Eg: unpleasant nature of past dental experience.
may be associated with unrelated experiences. *
smell of certain drugs or chemicals**
lowers the threshold of pain**

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SUBJECTIVE FEAR:
Are those based on feelings and attitudes that have been suggested to
the child by others about him without the child having had the
experience personally .
A young child is prone to suggestion. *
Shoban and Borland --- fear of dentistry in adults was based more on
what they heard about dentistry from their parents than on
anything else.
In children, the greatest producer of fear : hearing of unpleasant
dental experience from parents or friends.
2 sub types:
1. suggestive
2. imaginative

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Suggestive fears :
may be acquired by imitation. *
generally recurrent fears ,more deep seated and difficult to
eradicate.
acquired from friends or from materials --- books, periodicals,
cartoons, radio, television
fearful' child is fearful of everyone and every thing.
Imaginary fear:
imagine fearful things & feared.

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 Sleepy child ----↑ fear and irritation than the widely awake child
(bcoz of lower tolerance to discomfort.)
 A physically healthy child ----respond more actively than the ill
child
 A mentally alert child --- respond more intelligently and rapidly
than the mentally retarded
0-1 yr:
Appropriate time to introduce the child to dentistry.
Fear of stranger,↑ in anxiety
2-3 Years :
Noise of the instruments and the vibration of the drill may frighten
the very young child.
Changes in Fear Perception with Age:

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3-4 Years (preschooler):
Fear of separation from parents.
Feel dentistry as a mode of punishment.
Benefited - by the presence of the mother in the operatory
Intelligent children -- more fear because of their greater
awareness. of danger and reluctance to accept verbal assurance.
Fantasy plays a role, and gains comfort and the courage to meet
the real situation.

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Frankl studies----
1. Children > 4 years of age no difference in behavior whether the
mother was present or absent from the operatory.
2. At 4 years of age, the peak of definite fears is reached
3. 4-6 years - gradual decline in the earliest fears such as those of
falling of noise, etc.
The ↓ fear: due to
1. Realization that there is nothing to fear.
2. Social pressure to conceal fear.
3. Social limitation.
4. Adult guidance

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At 7 Years:
•Tries to resolve real fears.
•Family support is imp in understanding & overcoming his fears.
•Can reason and convey to the dentist when pain is being inflicted by
gesture.
8-14 Years:
•Learns to tolerate unpleasant situation
•Marked desire to be obedient.
•Develops considerable emotional control.
Teenage:
•Can control the fear
•Concerned about their appearance.
•The dentist can use this interest in cosmetic effect.

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Child cry in the dentistry
Elsbach ---1963 has described four types of children's cries.
1. The obstinate cry
2. The frightened cry
3. The hurt cry
4. The compensatory cry
OBSTINATE CRY:
 made by an obstinate child.
 characterized by loud crying
 temper tantrum - kicking, biting etc

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FRIGHTENED CRY:
profusion of tears & constant wailing sound.
Crying due to fear
confidence is lacking, not the discipline.
HURT CRY:
tears are the only manifestation.
simply reacting to stimulus of pain
making a valiant attempt to cooperate at the expense of his own
comfort
COMPENSATORY CRY:
not really a cry at all.
sound that the pt. makes with drill, when the drill stops the cry stops.
no tears, no sobs-- just a constant whining noise.

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Category I: The Emotionally Compromised Child:
Category II: the shy, introverted:
Category III :The Frightened Child
Category IV : the child who is adverse to authority
Children misbehavior classification

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Category I: The Emotionally Compromised Child:
 Not Large group
 Dentistry or other challenges are difficult – psycho emotional
problems
 Emotional illness--- broken families, poverty, unfortunate
parenting, abused & neglected children (high incidence)
 Little success- treating such children

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Category II: the shy, introverted:
• “SHY BIRDS”
•very young children
•Poorly socialized children
• afraid of social challenges including with going to the dentist
•Rarely display aggressive avoidance behavior like tantrum.
•Praise and the tell-show-do technique---really work
•When they open up, - become fantastic patients

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Category III :The Frightened Child:
• Very frightened
• Fear of needles is 90%
• Fear ranges from, needle --- bodily harm----fear of unknown.
1. Chronologic age
2. Emotional upsets in the life ( abused, separation of parents,
grieving due to loss of grandparents , health problems)
3. Acquired fears: ( by peers, siblings or parents )
4. learned fears: previous difficult or painful experience at a
physician's or dentist's office or at a hospital.

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Category IV : the child who is adverse to authority:
(Pinkham, 1983) -- cannot follow adult directives well
Spoiled children
Incorrigible
Overindulged children
Defiant children.
Dentist
Reason - these children have an aversion to authority.
Stimulate worst behavior

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Adler, 1958 & Dreikurs1964:
• 4 potential misdirected goals in the life of a child
• seep into the personality of the child, & subtly satisfy the
strong human craving for superiority, main force that drives all
human behavior.
I) Undue attention:
make sure that parents pay attention to them any time they want
them to.
Behavioral characteristics: Annoying, irritating, teasing, disruptive.
II) Struggle for power: prepared to have a power struggle with
parents for getting attention.
Behavioral characteristics: Argues and contradicts, does the
opposite of instructions, makes people angry, throws temper
tantrums.

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III) Retaliation and revenge:
children will get even with parents and will punish them.
will not let them without hurting them back”
Behavioral characteristics: Displays violent temper, says things that
hurt people, seeks revenge, gets even.
IV) Inadequacy: convince themselves that they are special in the
worst sort of way.
totally unable to grow up, unable to achieve, and in fact
They plan to do nothing at all for either themselves, parents, or
anyone else on the this earth”
Behavioral characteristics: Gives up easily, rarely participates, acts as
if he or she is incapable, displays inadequacy.

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Behavioral patterns in children
Wilson’s classification
Wright classification
Lamp shire classification
Classification of child’s behavior observed in the dental office
Kopel’ s classification

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Wilson’s classification
 Normal/bold: brave enough to face the situation, cooperate &
friendly with dentist
 Tasteful/ 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

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Wright classification (1975)
I. Co-operative behavior:
 Relaxed, minimal apprehension, can be R/ by behavior
shaping
 Develop good rapport, interested in the dental procedure
 Laugh & enjoy the situation
 Allow the dental to function efficiently & effectively
II. Lacking co-operative behavior:
 Contrast to co-operative child
 Includes very young child < 2 ½ yrs.
 major behavior problems

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III. Potentially cooperative behavior:
1. Uncontrolled behavior:
• 3-6 yrs.
• Temper tantrums even in the reception area.
• Incorrigible.
• Tears, loud crying, physical lashing out flailing of the hands
& legs
2. Defiant behavior:
• Elementary school group.
• Stubborn or spoilt child
• highly cooperative – once won over.

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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 behavior
• Extremely frustrate to treat.
• Elbash : characterized -----as a compensatory behavior.
• c/o pain even after repeated LA.

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6. Stoic behavior:
• Cooperative
• Sits quiet ,passively receives R/ including LA.
• Does not talk readily
• Physically abused child
• Dentist – attentive to other signs , report to the authorities if
required.
7. Fearful child:
• Does not offer resistance to R/
• Uses delay tactics : question everything to postpone R/
• Lacks experience in dealing with his environment successfully
• Timid & fearful of the environment strangers new experiences.

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Lampshire classification
1. Cooperative: physically , mentally relaxed, cooperative
2. Tense cooperative:
3. Outwardly apprehensive: R/ avoids talking / eyes contact .
Eventually accepts R/
4. Fearful: requires considerable support to over come the fear
5. Stubborn / defiant: passively resists.
6. Hyper motive: acutely agitated, resorts screaming, kicking etc
7. Handicapped:
8. Emotionally immature:

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Classification of child’s behavior observed in
the dental office
Cooperative behavior:
1. Positive
2. Potentially cooperative
3. Cooperative with reservation
Lacking Cooperative:
1. Disabled physically
2. Medically compromised
3. Mentally disabled

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Disruptive Cooperative:
1. Seductive/ demanding
2. Obsessive / resistant
3. Angry / aggressive
4. Somatizing
5. Dissolution / psychotic
6. Depressed
7. Addictive( adolescent)
i) drug abuse
ii) eating disorder
***

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Kopel ’s classification(1959)
 Very young patient
 Emotionally disturb pt such as
 Child from a broken / poor family
 Pampered/ spoiled child
 neurotic child
 excessively fearful child
 Hyperactive child
 Physically handicapped
 Mentally handicapped child
 Child with previous untoward medical or dental experience

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Behavior rating scales
 Frankl’s behavior rating scale
 Saranat & coworkers classification
 Houpt scale
 Global rating scale
 Co-operative behavior rating

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Frankl’s behavior rating scale
Rating 1: definitively negative(--)
1. Refusal of R/
2. Crying forcefully, fearful / any other overt evidence of
extreme negativism
Rating 2 : negative(-)
1. Reluctant to R/
2. Un cooperative , evidence of negative attitude, not pronounced

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Rating 3 : positive(+)
 Accept R/ at time cautious
 willingness to comply with the dentist , at times with
reservation but follows the dentist direction cooperatively
Rating 4 definitively positive(++)
 Good rapport with dentist ,
 interested in the dental procedures laughing & enjoying
***

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Saranat & coworkers classification
Active cooperation: (1)
 Smiles offers information, initiates the conversation, gives
the positive information
Passive cooperation: (2):
 indifferent but obedient , follows instruction quiet.
Neutral (3):
 Needs convincing mild crying follows the instruction
forcefully.

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opposed(4):
 Disturb the work, seizes dentist hands not relaxed , sits
& stands alternatively
Completely uncooperatively, strongly
opposed(5):
 Cries refuses to sit or to enter the room.
****

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Houpt scale (categorical rating scale)
Crying :
1. Screaming
2. Continuous crying
3. Mild intermittent crying
4. No crying
IJPD 1995;5: 87-95
Cooperation:
1. Violently resists/ disrupts
the treatment
2. Movements makes the
treatment difficult
3. Minor movement/
intermittent
4. No movement

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 Sleep:
1. Fully awake
2. drowsy
3. Asleep/ intermittent
4. Sound sleep
Apprehension
1. Hysterical/ disobeys all
instruction.
2. Extremely anxious /
disobeys some instruction
delays R/
3. Mildly anxious / complies
with support
4. Calm/ relaxed / follows
instruction
***

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Global rating scale
 5: excellent
 4: very good
 3: good
 2: fair
 1: poor/ aborted
IJPD 1995;5:87-95

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Co-operative behavior rating
0 ------- total cooperation best possible working conditions no
crying or physical protest
1------- mild soft verbal protest. Crying - signal of discomfort but
does not obstruct procedure
2------ protest more prominent & vigorous both crying hand signals.
Protest more distracting & trouble some. However, child still
complies with requests to cooperate

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3 -------protest present , real problem to dentist. Complies with
demands reluctantly, requiring extra effort by dentist
4 ----- protest disrupts procedure, requires that all the dentist’s
attention be directed toward the child behavior compliance
eventually effort by dentist, but with physical restraint.
5 -------general protestant, no compliance or cooperation. Physical
restraint required

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Anxiety rating scales
2 types of measurement technique :
 Technique that rely on the observation of reactions of child by
others.
Eg: behavioral & physiological measurements
 Technique that rely on some form of verbal – cognitive self
report.
Eg: questionnaires.

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Types:
Venham picture test
children’ fear survey schedule –dental subscale (CFSS-DS)
Clinical anxiety rating scale
Corah’s dental anxiety scale (DAS)
Visual analogue scale

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Venham picture test
 Self report instrument using a picture technique for answering
 measure of the change in dental anxiety as a consequence of
presence / absence of parent in the dental treatment.
 consists of 8 items measuring situational / state of anxiety
 8 pictures of children , exhibiting various emotions
 Child’s the best reflects his own
 scores = 0-8
 Easy to administer
 Best suited for the children
JDC 1998:252-8

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Venham picture test

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children’ fear survey schedule –dental
subscale (CFSS-DS) JDC 1998:252-8
 Revised form of the fear survey schedule for children (FSC-FC)
 Consists of 15 items each item covering a different aspect dental
situation
 Subject rate their level of anxiety on a 5 point scale ranging from
1------ not afraid
2------ a little afraid
3------- a fair amount afraid
4-------- pretty much afraid
5------ very afraid
 Total scores range ----15 – 75 .

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Not
afraid
at all
A
little
afraid
A fair
amount
afraid
Pretty
much
afraid
Very
afraid
Dentists
Doctors
Injections
Having somebody
examine ur mouth
Having open to ur mouth
Having stranger to touch
ur mouth
Having some body to look
at u
Children’s fear survey schedule – dental subscale

62. 62
The dentist drilling
The sight of the dentist
drilling
the noise of the
drilling
having someone to put
instrument in ur mouth
Choking
Having going to the
hospital
People in white
uniforms
Having the nurse clean
ur teeth

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Clinical anxiety rating scale JDC 1999 :36-41
0-----relaxed, smiling, willing able to converse.
Best possible working conditions. displays the behavior
desired by the dentist spontaneously or immediately upon
being asked
1------uneasy concerned.
During stressful procedure may protest briefly & quietly to
indicate discomfort. Hands remain down / partially raised to
signal discomfort. Child willing & able to interpret experience
as requested . Tense facial expression. Breathing is held in
(high chest) capable of co-operate well with treatment

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2----- tense
Tone of voice , q & ans reflect anxiety. during stressful procedure,
verbal protest (quiet ) crying, hand tense & raised but not interfering
much. Child interprets situation with reasonable accuracy &
continuous to work to cope with his/ her anxiety. Protest more
distracting & troublesome. Child still complies with request to co-
operate. Continuity is disturb
3------relectant to accept in any situation:
Difficult in assessing situation threat. Pronounced verbal
protest, crying using hands to try to stop procedure. Protest out
of proportion to threat or it is expressed well before the threat.
Copes with situation with great reluctance. Treatment proceeds
with difficult

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4 ------interference of anxiety & ability to assess situation:
General crying not related to R/ . Prominent body movements ,
sometimes needing physical restraint. Child can be reached
through verbal communication & eventually with reluctance &
great effort begins to work to cope. Protest disrupts procedure.
5 -------out of contact with the reality of the threat .
Hard loud crying, screaming, swearing unable to listen to verbal
communication. Regardless of age, reverts to primitive flight
responses. Actively involved in escape behavior. Physical
restraint is required

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Corah’s dental anxiety scale (DAS)
 Originally developed to measure dental anxiety & fear in adult
dental pt
 questionnaires – 4 items with 5 ans alternatives each
 scores are individually added --------total scores that can range
from
4 ----- not anxious
20 ------extrmely anxious
 Not routinely in children
 Applied to older children
JDC 1998 : 252-8

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68. 68
Visual analogue scale IJPD 1995;5: 87-95
Measure of anxiety.
Rater mark a point on the 10cm line to respond to the perceived
level of anxiety
Then measured using a ruler to give a score to the nearest mm.
High low
l_________________________________l

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Children attitudes towards dentistry:
Attitude: "a readiness, inclination or tendency to act toward
inner or external elements in accordance with the individuals
acquaintance with them
depends upon both the individuals interpretation of a situation
and his emotional reaction to it.
Mc Dermoh ---- largely shaped by the emotional meaning of
the event to the child & will vary according to the child's stage
of emotional development

70. 70
Stricker and Howitt---in a study of 88 preschool and kindergarten
children ,
half of them----- had a previous dental experience
only 14 of them (16%) to be mildly apprehensive.
Likes:
Interesting wait room , including comic & story books, magazines
Background music
The dentist to talk while working
To be called by first name
Explanations of dental procedure
To watch in mirror as the dentist works
To have a signal to for the dentist to stop drilling
To be hold he / She has been a good patient
A postoperative gift

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Dislikes:
Being kept wait
an attractive waiting area
The smell of the dentist office
Cotton rolls
Drilling
Operating light to the eyes
Untruthfulness about a painful procedure
Being made fun off
 scold by the dentist
Being asked questions when mouth is full
Being compared to other children
Uncomplimentary reports to parents

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Children reaction towards first visit
 Ripa: first dental visit be made at no later than three or four
years of age.
 degree of cooperation exhibited by preschool children at
their first appointment is high.
 the first visit------ only an examination, radiographic
evaluation, and possibly a prophylaxis and topical fluoride
treatment.
 Most children - accept their first oral examination
 highest rates of uncooperative behavior ---separation from
his mother and during the taking of radiographs.
-- discomfort of the procedure.

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The untoward behavior during separation may be due to:
1. A fear of abandonment, common < 4yrs, if separated from his
parent in the waiting room.
2. Fear of the unknown -- subjective fears , acquired from older
members of the family.
3. ↑ maternal anxiety.,----- child overtly anxious or exhibit some
degree of uncooperative behavior in the dental chair.
4. child's awareness towards dental problem requiring R/ --- more
anxious than a child who is not aware of the R/

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Children reaction towards sequential visit
Koenigsberg and Johnson----
 to determine the extent to which the children's responses
changed as more definitive R/ was performed.
 The children ---3-7 yrs never been to a dentist previously.
 behavior of app 60% to 65% of the 61 children remained
unchanged as care progressed from the examination to the
restorative phase of R/
 App 20% - deterioration in behavior while another 20% showed
improvement.
 majority of behavioral responses - +ve at all 3 appointments.

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Children reaction towards injection
 L A Inj highest incidence of disruptive behavior in children.
 Frankl and co-workers –
highest incidence of uncooperative behavior of preschool children
occurred during the injection phase of restorative treatment.
 Myers and co-workers, monitored children pulse rates during a
restorative visit, -----
1. pulse rate was elevated immediately before and during the
injection indicating a higher state of anxiety than at other phases
of the restorative visit.

76. 76
Kassowitz:
•observed 133 children, 6 mons -12yrs yrs of age received a total
of 328 injections.
•evaluated degree of apprehension immediately before the
injection and their attitude during its administration.
Results:
•complete lack of emotional control - < 4yrs age.
•↑ toward self-control and mastery of the situation as the age ↑.
•8yrs--- outward manifestations of fear or self-pity or a physically
disruptive response to the injection, were infrequent.
“the ability to cope with painful but necessary experiences is
suggested as an index of emotional maturity in the growing child”

77. 77
Children reaction towards exodontia
more anxiety-provoking dental procedures.
Trieger and Bernstein - case histories of several children on whom
they have performed exodontia.
1. Cooperative behavior was identified when a child showed anxiety
and communicated it clearly but was able to demonstrate
acceptable patterns of behavior .
2. some --- regressed to behavior more appropriate for
younger age: some cried & others refused to talk after Xn.
3. While individual children reacted differently, there was more
overt anxiety and defensiveness in 3-4yrs, while5-7yrs exhibited
more cooperative behavior.

78. 78
Baldwin "Draw-a-Person" test:
• children who required dental Xn were asked to draw a picture of
a person at. several different states of treatment.
• The standing heights of the human figure drawings were
measured, & ↓ in height was considered a sign of stress.
Test was administered to the children at specific intervals:
a) before they were informed that a dental Xn was required,
b) after they were informed of the impending procedure,
c) at the time of extraction, and during the post Xn and recovery
period.
d) In the postoperative period the test was administered at thirty
minutes, seven days, and one month or one year following the
extraction.

79. 79
Results: the figures drawn
1. after they were informed that a dental Xn was required, ----↓
‘size’ compared to the original figures.
2. at the time of surgery --- also reduced in size.
3. Postoperatively ---- gradual return to the original size of the
figures.
finding is empirically related to the stress of the dental extraction”

80. 80
group results
Group 1 informed about need for
extraction & the extraction
appointment.
4-7 day waiting period b/ n
the visit
decreased less in
height after surgery
and recovered to the
baseline height sooner
Group 2 no significant waiting period. Increased less in height
after surgery &
recovered later
Baldwin : to asses the ability of the children to cope with Xn

81. 81
waiting period allows children to psychologically prepare for the Xn
Recommended: dentist must prepare the child for exodontia by
informing him that an Xn is planned for a future appointment.

82. 82

83. 83
Factors affecting behavior of children
Under the control of the parents:
1. Maternal influence on the personality
2. Effect of maternal attitude
a) mother child behavior interaction
i) overprotection
ii) overindulgent
iii) under affectionate
iv) rejecting
v) authoritarian
3. Effect of maternal anxiety
4. Effect of mothers presence in the operatory

84. 84
Under the control of dentist:
1. Effect of the dentist activity & attitude
2. Effect of the dentist attire
3. Effect of the length of the time of day of appointment
4. Effect of dental environment
5. Pre appointment preparation
6. Effect of another presence in the operatory
a) mother's presence
b) an older sibling presence
Other variables:
1. Growth & development
2. Nutritional factor
3. Past dental experience
4. Genetics
5. School environment , socioeconomic status

85. 85
I Under the control of the parents:
Maternal influence on the personality
 research into parent-child relationships:
1. the parent as the independent variable
2. child as the dependent one.
Bell termed “one-tailed,”
 parental characteristics ---have a unilateral influence on
developing in the child.
 Acc to the "one-tailed" theory,
 child's characteristics,--- his personality, behavior, and
reaction to stressful situations-- are α maternal characteristics.
 Bayley and Schaefer --- mother-child relationships
1. autonomy vs. control.
2. hostility vs. love.

86. 86
Schaefer model of maternal behavior

87. 87
Berkeley Growth Study:
•“The behavior of mothers rated according to the attitudes depicted
in the Schaefer model.”
•The mothers' attitudes were then correlated with the behavior of
their sons.
• Autonomy mothers -sons were friendly, cooperative, and
attentive.
•punitive mothers and those who ignored their children ---sons
uncooperative, timid, non attentive

88. 88
Effect of maternal attitude: Mother- child behavior
interactions:
Mother’s behavior Child’s behavior
Over protective
1.Dominant
2. overindulgent
Submissive, shy
anxious, aggressive, demanding,
overindulgent Aggressive, spoiled, demanding; displays
temper
Under affectionate Usually well behaved, but may be unable
to cooperate: shy, may cry easily
Rejecting Aggressive, overactive, disobedient
authoritarian Evasive & dawdling

89. 95
Under the control of the parents:
Effect of maternal anxiety
Shoben &Borland --"the problem of dental fear is not specific to
the dental situation. Rather it is closely bound up with attitudinal
transmission of anxiety through the child's interactions with
significant figures in his social environment.
Johnson and Baldwin :
 evaluated the behavior of children: 1st dental visit for an Xn.
 in second study -evaluated children's behavior during a dental
visit for an examination and dental prophylaxis.
 Results: Behavior of children α his mother's level of anxiety.
Mothers with ↑ anxiety levels – children exhibited ↑ -ve &
uncooperative behavior

90. 97
Under the control of the parents:
Effect of mothers presence in the operatory
 children behave satisfactorily
without a parent present.
 older children prefer their
parent remain in the waiting
room.
 In uncooperative behavior--
parent presence support to
behavior can limit the range
of behavior control techniques
of the dentist.

91. 98
Frankl and co-workers ---
the presence of the mother can be a positive influence on the
behavior of young children undergoing their first dental visit.
The mother's presence - reduce the fears of the young child
and can offer emotional support during this experience.
Older children do not exhibit significant differences in
behavior according to the mother's presence or absence.
*Croxton --- final visit 93% of the children exhibited a
positive response.

92. 99
II )Under the control of dentist:
Effect of the dentist activity & attitude
Jenks --- six categories of activities by which dentists can foster
or enhance cooperative behavior in children.
 data gathering and observation,
 structuring,
 externalization,
 empathy and support,
 flexible authority
 education and training

93. 100
I. Data gathering and observation:
Data gathering -- collecting the type of information about a child
and his parents that can be obtained by a formal or informal
office interview or by a written questionnaire.
Observation --perceiving overt and subtle behavioral
characteristics of a child which provide clues as to how he
should be approached by the dentist and his staff.
* Jenks:
1. How does the child approach the dental situation? Is he
cooperative, interested, bored, apathetic, or fearful?
2. Does the child exhibit spontaneity and initiative with the dentist
and his staff, or is he submissive?

94. 101
3. How. does the interpersonal relationship between the dentist
and child develop with time? Does the child respond to the
dentist's attempt at friendliness or does he remain impersonal,
aloof, or resistant?
4. What emotions does the child display? Is he lively and
responsive, or is he serious, moody, or emotionally inert?
5.Does the child exhibit independence in the dental chair
commensurate with his age, or is he overly dependent on
emotional support from his parent, the dentist, or staff?
6.Does the child exhibit signs of discomfort or distress through
words or bodily movements?

95. 102
II. Structuring:
the establishment of guidelines of behavior which are communicated
by the dentist and his staff to the child.
The dentist:
1. Explains the purpose of the dental R/ , elaborates the specific
goals
2. Communicate in understandable language to the child
3. Prepares the child for each phase of treatment by describing it
in advance.
4. Separates each procedure into stages.
therapy is identified----the procedure is described---- the child is
told when a stage is completed.

96. 103
5. Prepares the child for each change in sensation before he will
experience it.:
a. altering of chair position,
b. possible pain and subsequent numbness associated with the LA
c. the vibration of the slow-speed handpiece,
d. the whine of the airotar handpiece
6. Informs about the next appointment and what will be done then.

97. 104
III. Externalization:
process by which the child's attention is focused away from the
sensations associated with the dental treatment.
Eg: while securing LA
states – “the objective is to interest and involve the child, but
without over stimulating him into verbal or motor discharges
which might interfere with the necessary procedures”
Jenks - two components
•Distraction
•Involvement Involvement:

98. 105
Empathy and Support:
capacity to understand and to experience the feelings of another
without losing one's objectivity.
Dentist should:
1. Permit children to express feelings of fear or anger, and desires,
without rejecting them. not allow to act out certain feelings by
kicking or fighting.
2. Communicate with the children to understand their reactions to
the R/
Eg: during the cavity preparation dentist may say, "This is
noisy, isn't it? It sounds like aloud whistle and sometimes bothers
your ears. It bothers mine, too. I'll finish as soon as possible.”

99. 106
3. Comfort the children when it is appropriate. :
done by a careful choice of words, by the tone of the voice or by
touching the child and giving him a reassuring pat or hug.
4. Encourage child when they show acceptable behavior.
5. Listening to children's comments when they wish to talk.
But should not be allowed to use verbal communication as a ploy to
delay treatment.
6. Provide a structured situation in which children can feel secure.

100. 107
Flexible Authority:
•must control dentist-patient interaction,
•must be tempered with a degree of flexibility or compromise in
order to meet the needs of the particular patient or situation.
If dental visit deteriorates --- the dentist must consider:
• whether the behavior is due to the child's personality or
• lack of maturity, or
•whether he himself has contributed to the situation by his approach
to the child.
If so , the dentist's attitude should be sufficiently flexible to allow
him to modify his tactics at the same or at future visits

101. 108
Education and Training:
dentist –
should educate children and their parents.
The educational message should be a practical and realistic.
Eg : recommend non cariogenic snack substitutes like
popcorn, potato chips, peanuts, or sucrose-free chewing gum.

102. 109
Effect of the dentist attire
•So far no study.*
•If undue past experience with white uniforms or doctors—
association of fear is more.
•Cohen - that the type of attire that a dentist wears probably is
not a significant factor influencing the behavior of most
children in the dental situation;

103. 110
Effect of the length of the time of day of
appointment
Lenchner- evaluated the effect of appointment length on children:
No significant difference - between children's behavior during
long or short appointments.
deterioration of behavior during long appointments.
early morning appointments - young children
appointment scheduling --- more dependent on convenience than
on the possible effect scheduling might have on children's behavior.

104. 111
Effect of dental environment
 Swallow and co-worker ---- effect on children's anxiety of the
environment in which the dental interview and treatment were
performed. 100 pts
Group results
1st pastel colored carpeted, easy chairs, small
nursery chair. Examn, R/ std operatory.
lowest anxiety
levels.
2nd Examination & R/ -dental chair, the
operator's stool, a chair for parent
the highest
anxiety levels
3rd interviews, examinations& R/ - std
operatory
the highest
anxiety levels
4th procedures - modified operatory the highest
anxiety levels

105. 112
Pre appointment preparation
Wright and co-workers :
 the pre appointment letter ↓ mother's anxiety about the child's first
dental visit.
Pinkham and Fields – “effects of pre appointment preparation on
maternal anxiety and child behavior”
 lower anxiety scores for mothers who participated in the
preoperative preparation program compared to mothers who did
not.
 no significant difference between the behavior of the participating
and the nonparticipating children at their first visits.
Still studies are required to support

106. 113
The ADA ---- pamphlet,
"Your Child's First
Visit to the Dentist,"
The pre appointment
contact should be:
1. a form of welcome to
the parent and child,
1. should describe the
first visit, and
2. should explain how
parents can prepare
their children for a
dental appointment

107. 114
Effect of another presence in the operatory
a) mother's presence
b) an older sibling presence
mother's presence:
an older sibling presence:
 an older sibling serves as a role
model.
 Ghose et al--
Positive behavior in the younger
child if accompanied by the older
sibling,
if the older sibling was in the
operatory when the younger
was being treated

108. 115
Other variables
 Growth & development
 Nutritional factors
 Past dental experience
 Genetics
 School environment
 socio economic status

109. 116
Growth & development :
Congenital malformations: cleft lip & palate ---psychological trauma
Mental retardation , epilepsy, cerebral palsy– cannot react to the
requirements of the mother & society
Failure of the cognitive development ---variables in the behavior are
encountered
Nutritional factors:
Studies----increase consumption of sugars causes irritable behavior
Skipping breakfast --------- an impaired performance
Nutritional deficiency ----milestones of biological & cognitive
development

110. 117
Past medical & dental experience:
positive past medical experience --- more cooperative dental pts.
Emotional quality --imp than no visits
Any previous pain -----critical in misbehavior in children.
Genetics:
Modified by the environment,
Constant interaction b/ n genetic programme of the child &
environment for the psychological development of the child

111. 118
School environment:
50% attitude of the child is influenced by the peer in the
school
Seniors – role model
Peer dental experience.
Socioeconomic status:
High socio economic status child--- normal behavior but may
be spoilt
Behavior if he gets what he wants always.
Low socio economic status---develops resentment, tensed due
to little attention & neglected

112. 119
Pedodontic triangle
R/ of child—1:2 relationship.
1. Child pt
2. Parents
3. Dentist
Communication is reciprocal
Recently:
Society in the centre.
Management technique should be
acceptable
litigiousness factors are
considered during R/ child

113. 120
Behavior management objectives
 To render R/ effectively & efficiently.
 To instill a positive attitude in the child & parent towards
preventive dental care
 To establish effective communication with child & parent
 to gain confidence of both child & parent & acceptance of
the R/
 To provide relaxing a comfortable environment for the dental
team to work in while treating child

114. 121
Procedures & skills for behavior guidance
Initial contact & appointment scheduling:
1. Patient's name (and nickname, if any)
2. Parent's name
3. Address
4. Telephone number (business and home)
5. Patient's age
6. Referring individual (if another dentist, ask why referred)
7. Grade in school and progression (an indication as to whether
or not you are dealing with a retarded child)

115. 122
PREVISIT LETTER:
1. A confirmation of the appointment date and time
2. An expression of appreciation for the confidence that the patient
has demonstrated in you by scheduling an appointment
3. An outline of what will be accomplished the first visit and how
4. Educational material to prepare the child for the dental visit
Any other specific information pertinent to the situation

116. 123
.
Advantages:
1. useful for education in communities where Pedodontics is not
readily accepted.
2. The parent is told exactly how to prepare the child.
3. indirectly informs the parent that the initial visit is diagnostic and
corrects any erroneous impression that the child will receive
treatment for a particular tooth.
4. confirms the day and time of the appointment.
5. gives specific information such as fee and whether or not the
parent is permitted in treatment area and the like, thus preventing
any misunderstanding

117. 124
Parent & child separation:
Bechler(1898): excluding the parent from the operating room –
contribute to the positive behavior of the child.
Starkey(1970): suggested for Parent & child separation :
1. The parent injects orders, becoming a barrier to the
development of rapport between the dentist and child.
2. The dentist is unable to use voice intonation in the presence of
the parent because the parent is offended.

118. 125
3. The parent often repeats
orders, creating an annoyance
for both the dentist and child.
4. The child divides attention
between parent and dentist.

119. 126
5. The dentist divides
attention between the
parent and child
Some exceptions:
•Age: if the child is below the age of 4 yrs
•Disabled child: parent cooperation is necessary in the operatory.

120. 127
GREETING THE CHILD :
Receptionist:
• should walk into the reception area to greet the child.
• Use the child's preferred name to greet him/her
• Should not employ baby talk or be overly friendly.
• Speak with the child on his or her level verbally and
physically.
• Avoid sudden movements, which sometimes frighten or
startle a child.

121. 128
If the child is separated from the parent in the reception
area, the assistant should respond as follows:
• Maintain a positive communication with the child.
• Make body contact with the child before suggesting that it
is now time to see the dentist.
• Be prepared to bodily remove the child to the operatory
(unnecessary with older children. )

122. 129
Dental assistant should provide following instructions:
1. Provide children with constant and repeated instruction.
2. Instruct the child exactly where to sit.
3. Avoid any sudden movements.
4. Maintain positive communication with the child
5. Do not show the instruments to any apprehensive child.
6. Do not tell the child it will not hurt.
7. If asked about procedures, explain that “Dr._____ will tell you
everything to be done.”

123. 130
After the dentist is present and when treatment is being
rendered, the assistant should respond as follows:
1. Remain silent, allowing the dentist to explain the treatment.
2. Not permit the child to touch the equipment without the
dentist's permission.

124. 131
SEQUENCING OF APPOINTMENTS:
•Diagnostic appointment – introduction to dentistry in a
favorable manner.
•No overt procedures are performed, and no painful procedure
In 1st appointment.
•At the consultation appointment:
The case should be presented to parents without the child being
present, except for the very young child.

125. 132
TREATMENT APPOINTMENTS:
1. The receptionist arranges a sequence of appointments
2. The quadrant dentistry should be followed
3. Weekly appointment --minimal opportunity to become overly
anxious between visits.
4. Formerly naptime appointments were inappropriate,
recent thinking naptimes - not a problem.
5. At the completion of each visit, the parent should be greeted in
the consultation area by the dentist escorting the child.
6. The parent should be told in the child's presence of some
positive aspects of behavior to reinforce good behavior.

126. 133
RECOGNITION FOR CHILDREN:
1. Limited only by the creative imagination of the practitioner.
2. Gift giving - -- standard practice among dentists.
3. Gifts --never be used as a bribe, "If you sit real still and open
your mouth wide, I'll give you a prize!"
4. Gifts -- tokens of affection and friendship.
5. The sending of birthday cards to children is a laudable practice
with tangible rewards for the dentist.

127. 137
Fundamentals of behavior management
1. Positive approach:
 + ve statement-- ↑chances of success of R/ , more effective than
thoughtless Q or remarks.
2. Team attitude:
 Pleasant smile of receptionist, dentist —child to feel comfortable
 pts hobbies---initiates future conversations, friendly atmosphere,
caring attitude to the child
3. Organization:
 Must devise its own contingency plans.
 Entire team------ R/ procedure well in advance
 Written plan --- available to each of dental team
 Delay in R/ --- apprehension in the young child

128. 138
4. Truthfulness:
 Dental team- truthful to build trust in young child.
 Fundamental rule in treating children
5. Tolerance:
 Dentist -be tolerant while R/ children.
 Child tolerance power should be assessed properly
 dentist - assess his coping abilities with children with
behavior problems,
6. Flexibility:
 Dental team- prepared to change the plans
 Incase child is fatigue-- R/ may have to be shortened.
 Dentist should be ready for change in the operating position
if required

129. 139
Classification of behavior management
Non pharmacological (psychological) approach
Pharmacological approach
Non pharmacological approach ( psychological )
I. Communication
II. Behavior shaping (modification)
1. Desensitization
2. Modeling
3. Contingency management

130. 140
IV. Other Behavior management techniques :
1. Distraction
2. Audio analgesia
3. Biofeed back
4. Hypnosis
5. Humor
6. Coping
7. Relaxation
8. Implosion theory
III. Behavior management of children with disruptive behaviors:
1. Voice control
2. Aversive conditioning
a) HOME
b) Physical restraints

131. 141
AAPD classification:
Pediatr dent1994;16:13-17
10 behavior managements:
I )communication management
techniques:
5 techniques
 Voice control
 TSD
 Positive reinforcement
 Distraction
 Nonverbal communication
III) HOM technique
III) Physical restraint
IV) Pharmacological methods
 Conscious sedation
 Nitrous oxide
 General anesthesia

132. 142
Patient management by domain
 Dr David chambers (1977)- psychologist labeled the
available ways to dentist to manage the children –
“embarrassment of riches”
Five basic domains:
1. Physical domain
2. Pharmacological domain
3. Aversive domain
4. Reward oriented domain
5. Linguistic domain

133. 143
Physical domain:
 Useful in treating emergencies on hysterical children &
children who cannot be reached in language due to their age
 Developmental disabled children
 Ranges from – use of hand restraint to physical restraint like
Pedi wrap etc
 Mouth prop- physical domain
 Explanation to parents, guardians or caretakers—must with
informed consent.

134. 144
Pharmacological domain:
•Use conscious sedation
•Parental consent – required
•Choice of drug – careful
• last resort
•Smaller the child –more the danger
•Appropriate monitoring technique- required
Aversive domain:
• HOME
•Practiced aversively to quiet a crying or screaming child
•Informed consent required

135. 145
Reward oriented domain:
•Used to secure the cooperation of child
•Use of rewards by parents– negative effect.
•Reward should come as an surprise after the treatment- eg: ice cream
at end of the appointment.
Linguistic domain:
•Communication techniques that involve the conversation of the
dentist with child & vice versa
• demands dentist as communicator, dentist will be coach, a rewarder,
psychologist, a distracter.

136. 146
Non pharmacological methods of BM
1. Communication
•Chambers (1976): Universally used in pediatric dentistry
•Fundamental form of BM
•Establishing a relationship with the child
•Allow a successful completion of dental procedure &
•Help child to develop +ve attitudes toward dental care.

137. 147
Types :
1. Verbal communication by speech
2. Nonverbal communication:
• Body language
• Smiling
• Eye contact
• Expression of feelings without speaking
• Showing concern
• By touching
• Giving him a pat
• Giving a hug
3. Both verbal & non verbal

138. 148
Key point of communicative technique:
1. Establishing of communication:
• First objective
• conversation with child :- enables dentist to learn about pt
• Relaxes the young child.
• Differs with the age.
• Vocabulary of the child –imp
Smith (1920):
• 12 mons- 3 words
• 15 mons-19 words
• 18 mons- 22 words
• 21 mons- 118 words
• 2yrs--- 272 words
• 3 yrs- 896 words
• 4 yr- 1540 words
• 5 yr --- >2000 words.

139. 149
•Grammar acquisition – imp.
•Brown & Fraser – 2-3 yr old kids had acquired the
fundamental grammatical rules.
•Musser et al– age of 4 fundamental grammar is acquired.
HONESTY OF APPROACH ---very imp
•Treated as imp person
•Should not be “talk down to” but talked to his own level.
•Verbal communication with children :
•best initiated with complementary comments Q & ans

140. 150
2. Establishment of the communicator:
• Dental team- aware of their roles
• at the reception area- dental assistant should speak.
• When dentist arrives – dental assistant should be passive.
• communication should occur from single source
3. Message clarity::
Communication – multi sensory process
North western university conference of pedodontic teachers (1971):
communication includes 3 aspects
Transmitter—dental health team
Medium – spoken word
Receiver –patient
Careful in selecting word

141. 151
Usage of euphemism or word substitute:
Dental terminology Word substitute
Rubber dam Rain coat
Rubber dam clamp Tooth button
R D frame Coat rack
Sealant Tooth paint
Topical fluoride gel Cavity fighter
Air syringe Wind gun
Suction Vacuum cleaner
Study models Statues
Alginate Pudding
High speeds Whistle
Low sped Motor cycle

142. 152
4. Multisensory communication:
•Focus on what to say or hw to say.
•Placing a hand on child’s shoulder- feeling of warmth, friendship
•Sitting and speaking at eye level – friendlier, less authoritative
communication.
•Avoidance of Eye contact– child is not prepared to cooperate.

143. 153
5. Problem ownership:
 Avoidance of “You messages”.:
 -ve messages
 Undermine the rapport b/ n dentist & patient.
 Eg: you must sit still.
 “I messages”. :
 establishes the focus of the problem
 Eg: I cant fix ur teeth if u don’t open ur mouth wide.
Wepman & sonnenberg: well suited to ↑ flow of information b/ n
dentist & child pt

144. 154
6. Active listening:
•imp in older children than young child
•Wepman & sonnenberg :2nd step in encouraging the kind of
genuine communication.
7. Appropriate responses:
•Very imp
Depends on :
•Extent & nature of the relationship of child
•Age of the child
•Evaluation of the motivation of child’s behavior

145. 155
JADA 1977:329-334
QI 20001:135-141
Ped dent 1994:13-17
Behavior shaping (modification)
Desensitization
•Tell Show Do Technique( TSD): Addelston (1959)
• one of the desensitization procedure which can be used in dental
settings.
•Cornerstone of behavior management.
•Foremost efficient, noninvasive, relatively, easy to implant.
•Used to orient the child gradually to anxiety- provoking stimuli in a
such a way that she / he will be able to cope with the situation

146. 156
Components:
Tell:
Show:
Do:

147. 157
Objectives:
•To teach the pt imp aspect of the dental visit & familiarize the pt
with dental setting
•To shape the pt responses to procedures through desensitization &
well described expectation.
Indications:
•first visit
•Above 3 yrs age
•Subsequent visit when introducing new dental procedure.
•Apprehensive child
Uses:
•Grants the pt ability to learn new & more pleasant association with
the anxiety- provoking stimuli.
•Creates friendliness, makes visit enjoyable

148. 158
Modeling
 Bandura(1967): “fearful & avoidant behavior can be
extinguished vicariously through observation with out any
adverse consequence accruing to the performer”
 Provides a promising tool for prevention as well as the
reduction of dental fear.
Patient characteristics:
 Wide range of 3-13yrs.
 All types of children
 Ghose et al —previous experience , age of the pt is imp for
displaying the behavior
JADA 1977:329—334
DCNA 1988:693-704
Ped dent 1994:13-17
QI 2001:135-141

149. 159
Types:
1. Live model: showing another pt undergoing the R/
Effective – model of same age, sibling.
2. Symbolic or vicarious model
Eg; video tape showing child cooperation.

150. 160
Outlines:
•Pt attention obtained
•Desired behavior is modeled.
•Physical guidance of the desired behavior may be necessary
when the pt is initially expected to mimic the modeled behavior.
Functions:
•Stimulation of the acquisition of new behaviors
•Facilitation of behavior already in the pt’s repertoire in more
appropriate manner or time
•Disinhibition of behavior avoided bcoz of fear
•Extinction of fear

151. 161
Ghose et al :
•“Study to test whether modeling reduces fearful & uncooperative
behavior in child pts”
•75 children 3-5 yrs age.
Results:
•Children who saw their older sibling exhibited more positive
behavior than who did not.
•Children with exposure to modeling --- + ve behavior even in the
2nd appointment where in actual R/ procedure conducted, including
LA

152. 162
Contingency management
 Method of modifying the behavior of children by presentation
or withdrawal of reinforcers.
2types:
 Positive reinforcers: is one whose contingent withdrawal
increase the frequency of behavior.
 Negative reinforcers: is one whose contingent withdrawal
increase the frequency of behavior.
JADA 1977:324-
Ped Dent 1994: 13-17

153. 163
Reinforcers: classified as
1. Material reinforcers
2. Social reinforcers
3. Activity reinforcers
Material reinforcers:
 Effective for children & frequently are baneful to oral health.
 Eg: candy, gum, cookies
Social reinforcers:
 majority of all reinforcing events affecting human behavior.
 Should be dispensed throughout the each visit .
 pt should never be neglected ,on completion R/ .
 Can shape the behavior of the hesitant & inexperienced pt
 Anxious pt can be reassured
 Encouragement & motivation to new heights of interest ---
Cooperative pt

154. 164

155. 165

156. 166
Activity reinforcers:
•Involve the opportunity /privilege of participating in a preferred
activity after performance of a less preferred behavior
•Little Application in operatory dentistry
•Successful in the home programs- plaque control, habit breaking
therapies.

157. 167

158. 168
Voice control
 Dr Brauer: --voice control of the child patient
 “ voice control by the practitioners is an imp factor in
management of the patient . The tone & emphasis employed in
talking with child produce favorable & unfavorable reactions.
while many dentist have recognized the value of voice control &
have mastered satisfactory voice techniques, additional research is
warranted in this area”
 Abrupt & emphatic change in the dentist’s tone of voice-----
emphasize his displeasure with the child’s in attention.
 Wright says “what u say is not critical as how u say”
 As soon the child complies ---dentist should complement him on
his resultant excellent behavior
JDC 1985; 199- 202

159. 169
Dr Bruer: “ the voice , certain qualities under control, has
motivated nations in peace as well as war , has captured
audiences at all ages ; & it can have a profound influence in the
behavior pattern of the individual. It is a powerful instrument
employed in too few instances in child behavior problems. The
profession must learn more of the positive value of this technique
Pinkham: “facial expression imp as tone of the voice”
Facial expression of the dentist conveys the child the dentist is
serious & in control

160. 170
HOME
 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 finally hold
his mouth shut. His screams increase his condition of
hysteria, but if the mouth is held dosed, 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."
JDC 1974:178 - 182

161. 171
Rand and Associates' suggested rules for obtaining obedience in
the dental office, “The first rule is to gain the child's attention.
….to make sure he hears words' of command”.
•McBride put it bluntly. "In my office, I'll tell you what's going to
be done. Now you sit there and let's not hear one word from you.
I'll tell you what to do”.
•Samson ------- “the child must understand quite clearly what is to
be done-if old enough, why it is to be done. and certainly that, at
all costs, it is going to be done”
•Craig ----- “The purpose of the technique is to gain the attention
of the child so that communication can be established and his
cooperation obtained for a ,a safe course of treatment.”

162. 172
Indications:
children who are momentarily hysterical, belligerent or defiant
Contraindications:
Very young
The immature
The frightened
The child with serious physical, mental or emotional handicap.
Mandatory:
The that this technique only be used on children with sufficient
maturity to understand simple verbal commands

163. 173
Details of the technique:
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.

164. 174

165. 175
As it leaves the face, there may be another wail with the garbled
request, "1 want my mommy." immediately the hand is replaced.
The admonition to stop screaming is repeated, and I add, "You want
your mommy"? Once again the head nods And then I say, "All
right, but you must be quiet, and I will bring her in as soon as I am
finished. O.K."? Again. the nod ------and the hand is slowly
lowered. My assistant is always present during HOME to help
restrain flailing arms and legs so that no one is physically injured.
By restraining the child he can be made aware of the fact that his
undesirable coping strategies' are not necessary or useful.

166. 176
While the child is composing himself. I begin to talk about his
clothes, about his freckles, about his pets, about almost anything,
and no reference is made to what has gone before. As far as I am
concerned. that is done and over. If there is an attempt on the part
of the child to start again, a gentle but firm reminder that the hand
will be replaced is usually enough to make him reconsider. It is
sometimes difficult to convey HOME with the written word, for
voice control and modulation are essential for HOME to be most
effective”.

167. 177
Child Gains Confidence:
From examination ---prophylaxis measures– radiographs ---- is a
process of confidence building.
At the end of the treatment :
Eg:
"Johnny, I want to thank you for helping me today. I want you to
do me two favors, O.K.? (Once again the head nods). T want you
to come see me again, O.K.? (And still another nod). Fine. And I
want you to tell your daddy tonight that I said you were an
excellent patient 'Bye."
Praise the positive attitude of the child in front of mother.

168. 178
Parental Consent:
•“I give consent to needed dental services and of proper and
acceptable methods to complete same for ______” with sign & dated
•Craig “ when consent has been obtained to treat the parental
objection to the technique should be of no more concern than a
parent's objection to any other procedure normally used in the office”.
Popularity of the Technique:
Results 1967 poll by the Association of Pedodontic Diplomats ----
“95 % --- accepted the use of physical restraints in some occasions.

169. 179
•Dr. Herbcrt Goldstein, formerly of the Georgia Institute of
Mental Health, --- "an act of punishment which improves
behavior is, in fact. an act of love.”
• Dr. J. Cottner Hirschberg, child psychiatrist at the Menninger
Foundation, - "For a child to develop a sense of self reliance and
adequacy, . . . it is necessary that he be permitted to gradual1y
and frequently make the choices be is ready to make, but also
learn to accept and tolerate restrictions where necessary

170. 180
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
• RIPA-----Child’s airway should never be restricted

171. 181
Physical restraints
Objectives :
 To reduce / eliminate the untoward movement
 To protect the dental staff, pt from the injury
 to render the quality dental treatment in these pts.
Indications:
 cannot co-operate due to lack of maturity
 does not co-operate due to mental/ physical handicap
 When other behavior management technique have been failed
 When the safety of dental staff & or pt would be at risk with
out the use of protective restraints

172. 182
Contraindications:
•Cooperative pt
Considerations:
•Informed consent
•Type of restraint used
•Indication for restraint

173. 183
Types:
1. Oral:
• Mouth props
• Padded wrapped tongue
blades
• Rubber bite blocks
2. Body:
• Papoose board
• Triangular sheet
• Pedi wrap
• Bean bag dental chair
insert
• Safety belt
• Extra assistant
3. Extremities:
• Posey straps
• Velcro straps
• Towel & tape
• Extra assistant
4. Head:
• Fore body support
• Head protector
• Plastic bowel
• Extra assistant

174. 184
Oral :
At the time of injection
•For stubborn child/ defiant
child
•Mentally handicapped child
•Very young child who
cannot keep its mouth open
for extended period of time.
•NOT IN APREHENSIVE
CHILD---↑ HIS FEARS

175. 185
Body:
•Restrict the pt movements
•Used frequently in pt <
2yrs of age
•Types:
•Papoose board
•Triangular sheet
•Pedi wrap
•Bean bag dental chair
insert
•Safety belt
•Extra assistant
Papoose board
•Pedi wrap

176. 186
Extremities:
•Attach to the dental unit restraint a pt at the chest waist,
legs.
•To control the activity of the mentally / physically
handicapped pt who cannot control his own movements.
•Prevent the pt from getting injured himself
•Prevent from interfering in the dental procedure.
Extremities:
•Posey straps
•Velcro straps
•Towel & tape
•Extra assistant

177. 187
Velcro straps
Posey straps

178. 188
 Head:
 Supports the head
 Protects the pt from
getting injured himself &
pt.
Types:
 Fore body support
 Head protector
 Plastic bowel
 Extra assistant

179. 189
Other Behavior management techniques:
distraction
 Newer technique:
2 types:
 Audio
 Audio visual

180. 190
Audio analgesia
 Audio analgesia, or "white noise," is another method of pain
reduction.
 Technique--- consists of providing a sound stimulus of such
intensity that the patient finds it difficult to attend to
anything else.
 The effect seems to result from stimulus distraction,
displacement of attention, and a positive feeling on the part
of the dentist that it can help.
 Gardner et al - completely effective in 65% of 1,000 patients
who previously required nitrous oxide or local anesthetics to
accomplish comparable procedures.

181. 191
• Schermer - effective in 76% of 1,200 dental patients during
cavity preparation or scaling of teeth. In addition, extractions
were performed on 115 children and 200 adults' with the aid of
topical anesthesia and audioanalgesia.
• Burt and Korn - 60% of obstetrical patients experienced good to
excellent results when audioanalgesia was administered.
• Morosko' ana Simmons varied both The amount. of noise and
the degree of suggestibility.
found ---latter had no effect but that pain threshold and tolerance
were both significantly altered by audioanalgesia
• Melzack and co-workers -claimed that auditory stimulation is
effective only for slowly rising pain, where the level tolerated is
a function of expectation.

182. 192
Howitt --studied the effects of audioanalgesia in dental environment on
over 100 children.
children - several groups,
-control, stereophonic music group, a. white sound group, and a total
audioanalgesia (music and white sound) group.
The level at which the children first felt pain (clinical response
threshold) and the level at which they refused to tolerate further
discomfort (highest tolerance threshold) were recorded.
Results-
1. clinical response threshold was the same regardless of the type of
intervention.
2. tolerance thresholds varied markedly according to the
audioanalgesia technique used,
3. total audio analgesia group exhibiting the highest tolerance.

183. 193
Biofeed back
 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.
 Barber et al : the physiologic function to be controlled must be
sufficiently sensitive to detect momentary changes, which are
instantly fed back to the subject
 humans - achieved by means of a visual or auditory signal
 yet to be fully realized, but appears to be especially useful in
anxiety and stress-related disorders.

184. 194
Hypnosis
 most effective in the presence of anxiety.
 differs from relaxation procedures by its greater reliance on
the role, skill, and training of the operator.
 Not all patients can be hypnotized.
 Barber -technique is effective in at least ⅓ of all patients,
 basic mechanism - relief of pain

185. 196
placebo
 The placebo effect --- as one which is not due to the specific
pharmacologic properties of an administered substance.
 with hypnotic technique, placebos are generally more effective
Beecher reports:
 52% of his surgical patients with severe postoperative pain
accompanied by a great deal of anxiety obtained relief
following injection with morphine, 40% found relief with
placebos.
 when pain and anxiety were not as great, the same dose of
morphine brought relief to 89% and placebos to only 26%.,

186. 197
Hill and co-workers -- morphine does not interfere with the
assessment of pain but that it reduces anxiety and overestimation
of pain.
Feather et al ---placebos do not affect sensitivity to pain but do
significantly reduce the willingness of subjects to report pain

187. 198
Humor
 Helps to elevate the mood of the pt.
 acts as:
 Social- forming & maintaining the relationship
 Emotional: anxiety relief in child, parent & doctor.
 Informative; transmits the essential information in the
nonthreatening way.
 Motivation: increases the interest & involvement of the child.
 Cognitive: distraction from fearful stimuli.

188. 199
Coping
 Mechanism by which the child copes with the dental treatment.
 Lazuae(1980): the cognitive & behavioral efforts made by the
individual to master, tolerate or to reduce stressful situations.
 Opton E.M: Patients differ not only in their perception and
response to pain but also in their, ways of dealing, or coping,
with the stress associated with painful experiences.
2types:
 Behavioral
 cognitive

189. 200
• Behavioral: physical & verbal activities in which the child engages
to over come a stressful situation
• Cognitive: child may be silent & thinking in his mind to keep calm.
Can enable the children to :
a) To maintain the realistic perspective on the events at hand ( reality
oriented working).
b) Perceive the stimulation as less threatening
c) Calms & reassure themselves that everything will be alright( the
emotional regulating mechanisms)
Friendliness ,support & reassurance – imp ways of enhancing trust and
affiliation

190. 201
Relaxation
•Preliminary data by Mc Ammond et al --- effective in reducing
immediate anxiety and fear while the patient is receiving an LA.
•involves a series of basic exercises.
•several months to learn and which require the patient to practice at
home for at least fifteen minutes each day.
•Autogenic training: a technique similar to Jacobson's relaxation
training, --- two or three months' instruction followed by a period of
continuing practice.

191. 202
•Bobey and Davidson: compared subjects receiving either brief
relaxation training, anxiety arousal, cognitive rehearsal, or control
treatment in their reactions to radiant heat and pressure algometer
stimulation.
•Results: The relaxation group showed the highest pain tolerance
scores.
•Paul compared the relative effectiveness of brief relaxation
training, hypnosis, and a control treatment in reducing subjective
stress, distress, and physiologic arousal and found that both
relaxation training and hypnosis were effective

192. 203
Behavior management in pre- cooperative child
Definition: pre-cooperative children have immature cognitive
skills, highly restricted range coping with stress.
Prone to maladaptive responses to anxiety- provoking
situations.
Pre cooperative child’s perspective:
Have narrow focus attention
typically exhibits anxiety , frustration inability to control his or
her environment through resistive or combative behaviors–
unpleasant & traumatic experiences to dental team.
DCNA;1995:789-816

193. 204
Parent expectation for child & dentist behavior:
Their child will be introduced to treatment in as pleasant a manner
as possible with compassion, understanding, tolerance & patience.
All problems , treatment recommendations & available alternatives
will be reasonably presented
Quality treatment will be performed in an efficient & timely
manner
Costs will appropriate & identified in advance where ever possible
Parent presence during examination treatment:
•Controversy.
•Some prefer parent presence ----provides opportunity for the
reluctant, timid or apprehensive child

194. 205
Dentists expectations for the pre cooperative child:
•Some clinicians- authoritarian, often disciplinary
•Others- passive or tolerant manner
•Too high expectations- frustrations & exasperation
Management techniques:
•Avoid fearful words.
•Patting & stroking behaviors – effective in reducing fear related
behaviors of young children
•Explanation serves – interruption of procedures in children of 3-5yrs.
•Use of voice control- limited value
•HOM- contraindicated without exception.
•Distraction – helpful
Pharmacological management – last approach, but needed at times

195. 206
Behavior management of autistic child
Dental environment:
•Gradual & slow exposure to the dental environment with non -
threatening contacts
•Parental presence is usually discouraged.
•Treat the pt in quiet , shielded single operatory vs. an open bay
arrangement, with reduced decoration & dimmed lights.
Appointment structure:
•Due to limited span of attention-
•Well- organized appointments, should not make the pts to wait
in the waiting room more than 10-15 mins
• dental assistants should minimize the movements- child is
easily distracted
Ped dent 1998:312-17

196. 207
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

197. 208
Behavior management of cancer patient
Behavior problems & cancer:
 Depending on the age of the p t& physical condition, problems
range --- extreme anxiety reactions to medical & dental
procedures, to regressive acting - out excessive demands on
family & staff.
Fear of dental procedures:
 Severe & debilitating in young children
 Child with repeated bone marrow aspirations– must be
physically restrained sometimes----such pt are very anxious
from fear from anticipated dental procedure & fear of physical
discomfort
J of Pedo 1987:1-6

198. 209
Behavior management --
•Controlling pain, anxiety associated with dental procedures
•Desensitization , positive reinforcement –useful
Recommendations for treatment:
•Identify whether the pt s fearful in the first appointment
•Meet the pt in the unthreatening environment
•Interact with pt well before of treatment starts
•During the treatment appointment– encourage pt to request
breaks during the R/
•Should emphasize to the pt that she/he must relax
•Breathing – in deeply & then slowly exhaling – release some
tension
•Breathing exercise – distraction for child, give him/her sense of
control over pain & anxiety

199. 210
Prescription for treatment: (OARIONA LOWE)
•Meet pt in unthreatened environment
•Discuss & explain the anticipated dental procedures
•Encourage relaxation techniques before & during the procedure
•Do not undertake extensive restorative work /extraction when
the pt has had a heavy dose of chemotherapy , spinal tap, or
various blood tests
• be sure the pt is comfortable
•Frequently check to see how the pt is doing . Do not rush
through procedure.

200. 211
Conclusion

201. 212
References
1. Stewart
2. Mc Donald
3. Stephen Wei
4. Mathewson
5. pinkham
6. Shobha Tandon
7. Zerald Wright
8. Ripa
9. Profitt
1. Ped dent 1992:376-
2. JDC 1999:36-
3. IJPD 1995: 87-95
4. Ped dent:2004
5. DCNA 2000:
6. DCNA1988:735- ,647- , 667-
7. DCNA 1995; 737- 769
8. JDC1976:39-45
9. J DC 1983:437-
10. JDC 1982:266-
11. JDC1990:31-37, 38-45
12. JDC1993:169-174
13. JDC1991:303- 305
14. JDC1988: 17-24
15. AAPD 2002:41-
16. JADA1977 :329-
17. QI;2001:135-141
18. Ped dent1994:13-17
19. JDC1974:31-
20. JDC1977:30-
21. JDC1988:269- 272