excellent lectures by our teacher professor hasham khan

1. Dr. Hasham Khan
Professor of Paediatric Dentistry
Khyber College of Dentistry
Peshawar

2. Recommended Book
A Manual of Paediatric Dentistry
By Andlaw & Rock

3. Paediatric Dentistry
 Paediatric dentistry is synonymous with dentistry for children.
It includes preventive dentistry, operative dentistry, oral surgery,
preventive and interceptive orthodontics, prosthodontics,
periodontal therapy and the treatment of oral diseases in children.
 Concomitant with above is the understanding of the child emotional
and psychological needs and the process of social maturation.
 In addition, to be really knowledgeable about the best needs of
child patients, the paedodontist needs to know about growth and
development and should know certain basics in paediatric medicine.
 Paedodontist is also one of the members of the cleft lip and cleft
palate team.

4. According to the American Association of
Paediatric Dentistry(1999):
“Paediatric dentistry is an age defined specialty that
provides both primary and specialty, comprehensive,
preventive and therapeutic oral health care for infants
and children through adolescence including those with
special health care needs”.

5.  The first textbook on dentistry for children was
written by Hogeboom in 1924.
 The Council on Dental Education of the American
Dental Association included paedodontics in the
dental school curriculum in 1941.
 The American Academy of Paediatric Dentistry
was formed in 1948 and the British Society of
Paediatric Dentistry was founded in 1968.
 The American Board of Paedodontics held its first
certification examination in 1949.

7. Child Management
in
Dental Practice

8. Behaviour Management
(called Behaviour Guidance by AAPD since 2003)
Aim:
The aim of behaviour guidance or management is to
carry out the dental treatment of the child effectively,
efficiently and safely and at the same time encourage a
positive attitude so that the child is willing to return for
further treatment and will look after his / her dentition at
home.

9. Paedodontic Treatment Triangle
The main difference between dentistry for children and adult dentistry is
that it is a three-way relationship, i.e;
• The child
• The parent
• The dentist
Called Paedodontic Treatment Triangle. The child is put at the apex
of the triangle which shows that child should be the center of
attention.
Child
Parent Dentist
→
→

10. General Principals in Child Management
OR Fundamentals of Behaviour Guidance or Management
1. Establish communication (by showing interest in the child).
2. Always explain to the child why, how and when.
3. Be truthful (never lie to the child).
4. Have a positive approach:
• Avoid giving choice which you can’t afford.
• Do not use words which create fear.
• Before starting a procedure, you may tell the child how he would feel.
5. Praise good behaviour and ignore bad.
6. Talk to the child at his level, i.e; use child-size words.
7. Be flexible and adoptive:
• Show flexibility in your plan.
• Don’t create fuss for things which are not important.

11. Continues
8. Keep calm when the child is behaving badly. Don’t show your anger.
9. Get the child involved in treatment, e.g.; holding saliva ejector.
10. Give the child some control over the situation. e.g.; ask the child to
raise your left hand if you want me to stop for some reason.
11. Don’t deny child’s fear.
12. The appointment:
• Should be kept short especially for apprehensive children.
• Should be booked close.
• Time depends upon the child and the dentist.
• Anxious child should not be kept waiting for too long before appointment.
13. Lastly use behaviour management technique which will suite
the child.

12. Techniques of Behaviour Guidance or Management
Non-Pharmacological Techniques
1. Behaviour shaping
2. Tell - show – do
3. Desensitization
4. Modeling
5. Re-enforcement
6. Voice Control
7. Retraining
8. Protective Stabilization (Restraint techniques)
I. Papoose board ii. Pediwrap
iii. Hand-over-mouth (HOM)
9. Hypnosis
Pharmacological Techniques
1. Sedation
I. Oral sedation
II. I.V sedation
III. I.M sedation
IV. Rectal sedation
V. Inhalation sedation (I.S)
2. G.A

13. Behaviour Shaping
• Behaviour shaping means to start from simple (do simple or show
simple) and then proceed to difficult, i.e.; planning the treatment in
such a way that it is carried out in small steps from simple to more
complicated procedures.
• We encourage the child to behave in a way we want.
• Repeat things if the child is not going to cope.

14. Tell-Show-Do
• Corner stone of behaviour management.
• Self explanatory,i,e; you have to tell the child what you
are going to do and with what. Then you have to show the
child how it works and then you have to do the procedure.
• Praise the child at intervals during the treatment.
• While telling the child, use language the child will
understand.

15. Desensitization
• Used in children with pre-existing fears, e.g needle phobia
drill phobia etc.
• It involves helping the patient to relax in the dental
environment, and then constructing a hierarchy of fearful
stimuli for that patient. These stimuli are introduced to the
child gradually, with progression onto the next only when
the child is able to cope with the previous situation.
• It is important to know the basis of the child’s fear.

16. Modeling
• Used for children who are apprehensive and have little
or no previous dental experience.
• The child is encouraged to watch other children of a
similar age or siblings receiving dental treatment happily
and getting rewards. The child then try to mimic
behaviour of the model and get the same results.
• Parents can also be used as a model.
• Other methods of modeling may be watching video or a
programme on T.V.

17. Reinforcement
• A method where good behaviour is rewarded by showing approval
and by praising the child. It is expected that the show of approval
and praise will reinforce the good behaviour, thus increasing the
probability of it being repeated in the subsequent treatment. It is
important that the child is praised frequently during the treatment.
• Another form of reward is a present given at the end of the
appointment such as a badge, sticker etc.
• Do not immediately abandon the session if a child become
uncooperative during treatment.
• The dentist should not ridicule the child for his poor behaviour, or
show his anger; only disappointment may be shown.

18. Voice Control
 In voice control technique, the dentist show more authority and
confidence in his or her communication with the child. The tone of the
dentist’s voice and the facial expression of the dentist must also mirror his
/her attitude of confidence. Sudden and firm commands may be used to
get the child’s attention or to stop the child from disruptive behaviour.
 Mostly used for managing the behaviour of preschool children. This
technique is extremely effective at intercepting inappropriate behaviours
at their start and moderately effective at intercepting them after they are
full blown. Voice control is an all-important factor in management of the
child patients.
Nonverbal Advantage: In this technique, voice control is used and the
whole body (instead of only facial expression) talks including posture,
breathing, action of limbs, walking, concentration and emotions. All this
demonstrate the dentist’s confidence and authority to the child and affect
the child behaviour.
“A downward & forward position in front of the child while simultaneously
establishing eye contact .” This is how most clinicians find the nonverbal
advantage.

19. Retraining
• Children who require retraining are apprehensive or show negative
behaviour.
• Apprehension or negative behaviour may be the result of a previous
dental visit or improper parental or peer orientation.
• The dentist need to determine the source of the problem so as to avoid
the problem through another technique, de-emphasis or distraction.
• Retraining eventually leads to behaviour shaping.
• “The stimulus must be altered to elicit a change in the response”. When
retraining a child with negative behaviour, the dentist need to build a
new series of associations in the child’s mind so that the child develops a
new perception of the dental surgery and a new relationship to
dentistry. The previously learned unacceptable behaviour must be
extinguished.
• If the new stimulus is similar to the previous stimulus, then the response
will be similar (called stimulus generalization). To avoid generalization by
the child, the dentist and his team must show a “difference”.
• The use of Nitrous Oxide – Oxygen sedation offers a difference.

20. Protective Stabilization
(Advanced Behaviour Guidance)
(Formerly referred to as Restraint Techniques or Medical Immobilization)
These techniques rely on restraining the child patient so that undesirable
behaviours such as kicking, arm thrashing and head-rolling are strictly
controlled.
Techniques used are:
• Papoose Boards
• Pediwrap
• Hand-over-mouth (HOM) or Aversive Conditioning
HOM technique is used only to establish communication. The child is
told that the hand will be removed as soon as he stops crying.

21. Hypnosis
“ Hypnosis may be defined as a particular state of mind in which
suggestions are more readily accepted and acted upon and it is usually
induced in one person by another.”
• Hypnosis produces a state of altered consciousness and relaxation.
• Can only be induced in individuals who wish to cooperate. To induce a
hypnotic trance requires time and special training.
• It has a part to play in helping children overcome their fear of dental
treatment. It may provide an alternative to other techniques based on
the use of drugs.

22. Sedation
• Indicated for children who are genuinely anxious or
frightened but who understand the need for treatment
and wishes to cooperate.
• It is important that the sedated patient is conscious and
in command of all normal protective reflexes, including
the cough reflex.

23. Oral Sedation
• Very easy and convenient to administer a drug orally.
• Less predictable because of many factors that influence its absorption.
• Not a very satisfactory method to be used in children. However it may
help in some children.
• Important to gain the trust and confidence of the child before
prescribing a sedative drug. The child should be told that the drug
will help him feel more relaxed during the treatment.
• Drugs commonly used include chloral hydrate, promethazine, diazepam
etc.

24. I.V Sedation
• For I.V sedation, the child must be cooperative enough to accept I.V
injection.
• Advantages include a very rapid effect and that the dose can be
given in increments until the desired level of sedation is achieved.
• Usually it is very difficult to determine the correct dose and the
recovery may be long. There is also danger of lingual obstruction
of airway in some patients.
• This method of sedation may work for some children but it is rarely
used.
• Drug used commonly is diazepam (now replaced by midazolam).
Midazolam : Trade name Dermicum

25. I.M Sedation
• Used in USA for young children.
• Advantages include rapid and predictable effects.
• Disadvantage is that it is very difficult to give I.M
injection to a nervous child.
• Drugs used include a combination of Promethazine Hcl
and Pethidine.
• Rarely used in other countries and such patients are
usually treated under G.A.

26. Rectal Sedation
• Popular only in some Scandinavian countries.
• It can’t be used in our country because of social values.

27. Inhalation Sedation
• Most popular technique of sedation for use in children.
• Indicated for the anxious child who wants to cooperate but who is
overwhelmed by fear.
• It also demand a certain degree of cooperation.
• Nitrous oxide (N2O) and Oxygen (O2 ) mixture is used to produce
sedation, previously called relative analgesia RA).
• A special apparatus is used for the administration of inhalation
sedation.
• Contra-indicated in upper airway obstruction, e.g. common cold,
pulmonary disease, mentally handicapped and very young children
(below 3 years). There are also some other contra-indications.

29. G.A
• Allows dental rehabilitation to be achieved at one visit.
• Suitable for very young and uncooperative children and for
the handicapped.
• Also indicated when extensive work has to be done, e.g;
multiple extractions.
• Conservative work can also be done if the child has to
undergo GA for surgical procedures. GA for conservative
treatment alone is rarely justified.

30. Other Behaviour Guidance or Management
Techniques
• Distraction (contingent) : This approach aims to shift the
patient’s attention from the dental setting to some other situation
or from a potentially unpleasant procedure to some other action.
• Changing Control / Temporary Escape (contingent)
• Memory Restructuring: Memory restructuring is a technique
which aims to help children develop positive memories of their
dental treatment and as such may be effective in reducing fear and
improving behaviour. The technique is useful for all patients who
can verbally communicate.

31. Techniques Included in Advanced
Behaviour Guidance
• Protective Stabilization (Formerly referred to as Restraint
Techniques or Medical Immobilization)
• Sedation
• General Anaesthesia (GA)

32. Classification of Children’s Behaviour
• Frankl’s behaviour rating scale (1962).
• Wright’s classification (1975).
• Lampshire’s classification.
• Kopel’s classification.

33. Frankl’s behaviour rating scale
Frankl’s behaviour rating scale Wright modification
Rating No. 1Definitely negative (- -)
» Refuses treatment
Immature, Uncontrollable and Defiant behaviour
» Cries forcefully
» Extremely negative
Rating No. 2Negative ( - )
» Reluctance to accept treatment
Uncooperative and withdrawn
Immature, Timid, Whining and influenced behaviour
» Slightly negative
Rating No. 3Positive ( + )
» Accepts treatment but may be cautious or reserved.,
follows directions.
Tense cooperative, Concertive, Whining and Timid
behaviour
Rating No. 4Definitely Positive (+ +)
» Unique behaviour
Good rapport, interested in dental procedures, laughs
and enjoys.

34. STAGES OF DEVELOPMENT

35. The Infant
• Child is the centre of attention.
• Encounter with the outside world is very defined and small.
• Oral experimentation by putting everything in mouth.
• No rational response should be expected.

36. The 2-year-old
• The child starts moving from totally depended stage to self control.
• Can be extremely possessive.
• The child wish to touch and handle objects to grasp their meaning fully.
• The attention span is very limited and dental procedures should be
accomplished as efficiently as possible.
• Crying during dental examination common, negatively react to sudden
noises and positively to bright colours.

37. The 3-year-old
• Semi-independent, a good self control and can rationalize.
• Communication in the dental surgery can be achieved as vocabulary
is greatly improved.
• The 3-year-old can be successfully managed through a positive
approach because there is a desire to be praised, please others and
conform.
• The attention span is greater, provided the child is occupied with
something of interest.
• Lesser degree of fear, child can be separated from parents.

38. The 4-year-old
• A complex age. The child attempt to get his or her own way.
• Good ability to respond to verbal directions but repeated firmness may
be used intelligently to establish proper guidelines.
• A 4-year-old child is dogmatic as compared to compliant 3-year-old. The
child may be termed “spoiled” by the parents wrongly.
• At this age child is at the peak of fears. The child should be handled very
carefully as mishandling can have a long term effects on dental attitudes.

39. The 5-year-old
• This is an ideal age. Fears have usually diminished.
• Take pride in accomplishment and of their possessions.
Respond very well to praise.
• The 5-year-olds are usually pleasant and like comments
about personal appearance.
• They can communicate well, understand most instructions
and are very conforming in behavioral patterns.

40. The 6-year-old
• A critical age in the life of a child, school is on full time basis in grade-1.
• Dependency on parents is reduced.
• Age of considerable anxiety and fear of injury to the body.
• There may be outbursts of violent temper tantrums or striking
at parents or dentist due to peak of tensions.
• May be very anxious. However , the 6-year-olds respond satisfactorily
to “tell, show, and do” approach.

41. The 7-12 year-old
• Children of this age prefer the company of others of similar age and sex.
• The child try to learn and develop in the world of reality through play.
• The child like identification by adults other than parents.
• Big questions are posed quite casually and the child may do everything
to cover up insecurity and uncertainty.
• It is important to treat each child according to his or her age.

42. The teen-ager
• A social transition period from childhood to adulthood.
• Popularity is a very important desire.
• Teen-agers experience great physiologic and social changes and
personalities vary widely with differing moods.
• Behaviour vary from one visit to another, flexibility should exist to
accommodate differences in moods.
• Dependency on parents decline and importance of peers escalates.
Great concern with acceptance by peers (important social agents).
• Frequently very hungry because of rapid growth. Frequent snacking
― a period of accelerated dental decay.

43. Factors Influencing the Child's Behaviour
1. Fear and anxiety.
2. Age of the child (stage of development).
3. Past medical and dental history.
4. Influence of siblings, friends and peers.
5. Influence of parents.
6. Presence of parent, brother or sister in the dental surgery.
7. Social class.
8. Personality and upbringing.
9. Intelligence and intellectual maturity.
10. Family position and rank.

44. Factors Related to Dentist
11. Time and length of appointment.
12. Environment.
13. Rewards and gifts.
14. Dress.

45. Pre-appointment Behaviour Modification
The methods employed include:
1. Audiovisual modeling.
2. Patient modeling.
3. Pre-appointment mailings.
4. Introductory appointments.

46. Managing Child Behaviour at the
Appointment
1. Communication
• Verbal communication
• Non-verbal communication
– Body contact
– Eye contact
– Facial expression
• Communication environment
2. Behaviour shaping
3. Tell - Show - Do
4. Rewards and appraisal
5. Be confident

47. Parents of the Child Patient
While dealing with the parents of the child patient, the
following differences has to be taken into
consideration:
1. Socioeconomic differences
2. Cultural differences
3. Ethnic differences

48. Different Parental Attitudes (Abnormal)
1. Overprotective or over-controlling parents
2. Manipulative or demanding parents
3. Neglecting parents
4. Hostile or mistrusting parents
5. Parents of the handicapped child

49. Advantages and Disadvantages of the
Presence of Parents in the Dental Surgery
Advantages:
1. Represents security.
2. Parent can aid in reinforcement.
3. Dentist can give preventive advice.
Disadvantages:
1. Communicates his/her own anxiety to the child.
2. May Interfere with dentist-child relationship by
talking inappropriately.
3. Child may get negative reinforcement if parent too
sympathetic.