non pharmacological behavior management techniques

NON PHARMACOLOGICAL
BEHAVIOUR MANAGEMENT
Presented by: Anukrati Doneria

• Introduction
• Definition
• Classification of children’s behavior observed in
dental clinic
• Factors affecting behavior of children in dental
office
• Effects of parenting styles on children’s bahaviour
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CONTENTS

• Non-Pharmacological behavior management Techniques
• Recent non-pharmacological behavior management
techniques
• Conclusion
• References
3
CONTENTS

INTRODUCTION
• Wright suggested that a “positive dental attitude” should be the aim
of behavior management.
• It does not imply just the behavior necessary to complete a given
task but includes creating a long-term interest on the patient’s part
for ongoing prevention and improved dental health in the future.
• To do this the dentist must establish a relationship based on trust
with the child and accompanying adult to ensure compliance with
preventive regimes and allow treatment to occur.
• Behavior management methods are about communication and
education.
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INTRODUCTION
• The relationship between child, dentist and family may start before
the patient arrives in the surgery and can involve written
information as well as dialogue, voice tone, facial expression, body
language and touch.
• No one method will be applicable in all situations, rather the
appropriate management technique(s) should be chosen based on the
individual child’s requirements.
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Child
Dentist
Parents and
family
The relationship between the child, the child’s family and
the dental team is a dynamic process.

Pedodontic triangle
• Main difference between treating a child
and an adult is the involvement of 1:2
relationship which is shown as pedodontic
triangle.
• The triangle indicates:
• 1. The child is the focus of attention both for
the dentist and parents.
• 2. The arrows show that the relationship
should be reciprocal.
• 3. The dentist has to communicate with the
child as well as the parents whereas in case
of adults, a direct communication (1:1) is
possible.
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• Ideal triangle: when an early
foundation of a healthy, stable and
harmonious pediatric dental triangle is
set.
• Pediatric triangle at an emergency first
time visit.
• Different parenting styles also alters
the pediatric triangle.
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Pedodontic triangle
Dental team

Behavior is any change observed in the functioning of an organism.
Behavioral science is the science which deals with the observation of
behavioral habits of man and lower animals in various physical and social
environments, including behavior Pedodontics, psychology, sociology and
social anthropology.
Behavioral Pedodontics is a study of science which helps to understand
development of fear, anxiety and anger as it applies to child in the dental
institution.
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DEFINITIONS

Behavior shaping: is the procedure which slowly develops behavior
by reinforcing a successive approximation of the desired behavior
until the desired behavior comes into being (Mc Donald)
Behavior modification: is defined as the attempt to alter human
behavior and emotion in a beneficial way and in accordance with the
laws of learning. (Mathewson)
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DEFINITIONS

CLASSIFICATION
OF BEHAVIOR OF
CHILD
IN DENTAL
CLINIC

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I. Wilson (1933)
• Normal or bold: The child is brave enough to face new situations, is co-
operative, and friendly with the dentist.
• Tasteful or timid: The child is shy,but does not interfere with the dental
procedures.
• Hysterical or rebellious: Child is influenced by home environment, throws
temper-tantrums and is rebellious
• Nervous or fearful: The child is tense and anxious, fears dentistry.

II) According to age
(a) Pre-cooperative stage- less than 2 years
(b) Cooperative stage- above 2 years
Following are the characteristics of children in the ages between 2-5 years:
A. 2-year-olds
– Geared to gross motor skills like jumping, running etc.
– Likes to see and touch
– Very much attached to parents
– Involved in solitary play
– Limited vocabulary, early sentence formation.
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B. 3-year-olds
– Less egocentric, likes to please
– Have active imagination
– Likes stories
– Attached to parents
C. 4-year-olds
– Tries to impose powers
– Participate in social groups
– Knows “thank you” and “please”
– Learn self-help skills
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D. 5-year-olds
– Period of consolidation
– Take pride in possessions
– Play cooperatively with peers

III. Clinical classification of behavior patterns
(a) Cooperative- potentially cooperative, cooperative with reservation
(b) Lacking cooperative ability – physically or mentally disabled patients. Or
medically compromised patient.
(c) Disruptive cooperative- demanding, resistant, aggressive, depressed, somatizing.
IV. Frankl behavior rating scale (1962)
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BEHAVIOUR PATTERNS OF A CHILD

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1. Definitely
negative(--)
1. Refuses treatment:
• Immature behavior – can’t cope with situation e.g. toddler, special child
• Uncontrolled behavior – temper tantrum suggestive of extreme anxiety e.g. pre-schooler
• Defiant behavior – exhibits resistance e.g. spoiled, stubborn child, middle school years
2. Cries forcefully: Uncontrollable behavior e.g. late pre-school going child or middle school
years.
3. Extreme negative behavior associated with fear:
• Uncontrollable behavior – exhibited in older children possessing deep rooted problems.
• Defiant behavior – includes passive resistance in individuals approaching adolescence.
2. Negative(-) 1. Reluctant to accept treatment:
• Immature behavior – toddler or pre-schooler.
• Timid behavior – overprotected or dominated children.
• Influenced behavior – family or peer pressure.
2. Displays evidence of slight negativism:
• Timid behavior
• Whining behavior

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3. Positive(+) Accepts treatment
• Tense cooperative – follows dentists directions, but resistant and
cautious all the time.
• Conservative behavior – responds harmoniously.
• Timid behavior – follows directions in shy, quite manner but can become
uncooperative due to any bad experience during treatment.
4. Definitely
positive(++)
Unique behavior- looks forward to understand the importance of good
preventive care and establishes a good rapport.

V. Lamp shire’s classification
i) Cooperative- physically and emotionally,
regardless of treatment.
ii) Tense cooperative: cooperative but tensed;
tension may be unnoticed.
iii) Outwardly apprehensive- hide behind
mother, avoids looking or talking to dentist but
eventually accepts treatment.
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iv) Fearful: requires considerable support. Modeling,
desensitization and other behavior modifications become
necessary.
v) Stubborn or defiant-resists or tries to avoid treatment.
vi) Hyperactive- agitated, screams and starts fighting.
vii) Handicapped
viii) Emotionally immature
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VI. Houpt Behavior Rating Scale – grades Childs behavior during treatment.
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1. Aborted, no treatment rendered
2. Poor, treatment interrupted, only partial treatment completed
3. Fair, treatment interrupted but eventually completed
4. Good, Difficult but all the treatment will be completed.
5. Very good, some limited crying and movement
6. Excellent, no crying or movement
VII. Pinkham’s classification
Category I – Emotionally compromised child.
Category II – Shy, introvert child.
Category III – Frightened child.
Category IV – Child who is adverse to authority

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VIII. Sarnat’s behavior rating scale
Active cooperation A smile, offers information, initiates
light conversation, and gives positive
responses.
Passive cooperation Indifferent but obedient, follows
instructions quietly.
Neutral, Indifferent Needs convincing, mild crying, follows
instructions under pressure.
Opposed, disturbs work Seizes hands of dentist, not relaxed, sits
& stands alternatively.
Completely uncooperative,
Strongly opposed
Cries, refuses to sit or enter dental
office.

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IX. Wright (1975)
• Cooperative Behavior - Child is cooperative, relaxed with minimal apprehension.
• Lacking cooperative ability- Usually seen in young child (0-3 years), disabled child,
physical and mental handicap.
• Potentially cooperative- Has potential to cooperate, because of the inherent fears
the child does not cooperate. Has 5 sub-categories:
a. Uncontrolled/Hysterical/Incorrigible - Preschool children at their first dental visit.
Temper tantrums, i.e., physical lashing out of legs and arms, loud crying and refuses
to cooperate
b. Defiant behavior/obstinate behavior- can be seen in any age group. Usually in spoilt
or stubborn children. can be made cooperative

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c. Tense cooperative- Borderline between positive and negative
behavior.
Does not resist treatment but the child is tensed at mind.
d. Timid behavior/shy- Usually seen in an overprotective child at the
first visit. , shy but cooperative
e. Whining type: Complaining type of behavior; allows treatment, but
complains throughout the procedure.
f. Stotic behavior: Seen in physically abused children. They are
cooperative and passively accept all treatment without any facial
expression.

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X. Garcia – Godoy (1986)
• Fearful: resists entering treatment room, cries, screams. Could be passive, accepting
treatment but will state his fear to treatment.
• Timid: enters cautiously, thoughtful with eyes on floor. Does not look at professional staff
when talked to.
• Spoiled: enters clinic with arrogant and proud behavior. Neglects treatment and states
preferences or treatment, gives order.
• Aggressive: screams, does not open mouth, kicks. Sits on dental chair and neglects
treatment.
• Adopted: combination of spoiled and fearful behavior. Could present with timid
characteristics.
• Handicapped: all children with mental or physical handicapping conditions; will need
special care and this will manifest in behavior.
• Cooperative: cooperative with treatment.

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Factors Affecting Child’s
Reaction to
Dental Treatment

A wide variety of factors have been observed to contribute to
children’s reaction in the dental office. These variables are of two
types:
1. Major variables
2. Minor variables
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Factors Affecting Child’s Reaction to
Dental Treatment

1. MAJOR VARIABLE
a. Past medical history
b. Awareness of dental problems
2. MINOR VARIABLES
a. Stories and experiences narrated to children by adults or siblings
regarding painful experiences.
b. Effect of dental pain
c. Parents’ prediction of children’s behavior
d. Contemporary influences
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FACTORS WHICH AFFECT CHILD’S BEHAVIOR IN
THE DENTAL OFFICE
A. Under the control of the Dentist
1. Dental clinic
• Should be warm and simulate a homely environment. A pleasant environment
helps the children to be relieved of anxiety about the dental situation.
• Healthy communication with the child should be established.
• The operating posters, TV and videogames and a separate waiting room for the
children is necessary and this should contain toys, for all age groups, story books
and comics.
• Dental auxiliary should be kind to the children and should greet with a smile.
• Appointment time should always be short

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DESIGN OF A CHILD-
FRIENDLY DENTAL
CLINIC
• Playful environment
• Fresh, bright and bold colors like
red, yellow, orange
• Open spaces to move around
• Asked not to touch here and there
• Humor
• Cartoon films, magic shows,
advertisements on TV
• Instrument tray with minimum
things on it; only 1-2 mouth
mirrors for initial examination

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2. Personality of the Dentist
• The approach should be casual, confident and friendly towards the child.
• The dentist must be in command of the situation and modify any behavior that
interferes with treatment.
• Should never lose temper.
• Always call by nick name or at least first name. All conversation should be
directed towards him.
The dentist can help the child to display good behavior by-
• Gaining the confidence of the child that they are there to help
• Permitting children to express their feeling and being a good listener
• Comforting children when it is appropriate
• Encouraging children when they show acceptable behavior.

3. Effect of dentist’s activity and attitudes
Jenks (1964) has described six categories of activities by which the dentist can foster or
enhance cooperation in children.
a. Data gathering and observation
• This involves 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 includes noting the behavior of the child as he steps into the dental office
during history taking and while the dental procedure is being carried out.
b. Structuring
• Refers to establishing certain guidelines of behavior set by the dentist and his team to
the child so that the child knows what to expect and how to react.

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c. Externalization:
process by which the child’s attention is focused away from the sensations
associated with the dental treatment.
• Distraction
• Involvement
The objective is to interest and involve the child but at the same time not to let
him into verbal or motor discharges which might interfere with the necessary
procedure.
d. Empathy and support:
• Empathy is the capacity to understand and to experience the feeling of
another without losing one’s own objectivity. Dentists should not be totally
engrossed in the technical aspect of therapy.
e. Flexible authority:
• This includes compromises made by the dentist to meet the needs of the
particular patient.

f. Education and training:
• The dentist should implement a program which educates children and their
parents as to what constitutes good dental health and stimulates them to
make the behavioral changes necessary to achieve these goals.
4. Effect of dentist’s attire:
If a child has previously experienced a stressful situation which includes the
presence of someone in white attire such as a physician, the mere presence of
a white clothed individual would be sufficient to evoke a negative behavior.
5. Presence or absence of parents in the operatory:
This depends on the behavior of the child, parent and dentist. Mother’s
presence is essential for a preschool child, handicapped child etc. An older
child does not require mother’s presence because of emotional in dependence
of these children as they grow older. Dentists are usually comfortable and
relaxed when parents are in the reception room.

The father and the mother both play an important role in child’s
psychological development; but maternal influence is more important
because:
i) Mother-child relationship is more intimate.
ii) Maternal influence on child’s mental, physiological and emotional
development begins even before birth. Mother’s nutritional status,
physical health, emotional state may affect the foetus through
changes in mother’s neuro-hormonal system.
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PARENTAL INFLUENCES ON
CHILD’S BEHAVIOUR

Bell has termed parent-child relationship as
being “one-tailed” where parent is an
independent variable and child is the dependent
one.
Parental attitudes and it’s effects:
Parental attitudes can be of the following nature
1. Overprotection i.e. exaggeration of love and
affection. Factors responsible for overprotection
can be:
i) History of previous miscarriage or a period of
sterility before the child’s birth.
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ii) Death of a sibling or if the mother cannot
bear more children.
iii) Family’s financial status.
iv) Absence of either parent
v) Illness or physical handicap in the child.
2. Overindulgence
Parents give children whatever they want
without any restraint. The child becomes spoilt
and is accustomed to getting his own way.
In the dental clinic, the children may show
temper tantrums when they cannot control
situations.
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PARENTAL INFLUENCES ON CHILD’S
BEHAVIOUR
3. Under affection- It may manifest as:
i) Mild detachment
ii) Indifference
iii) Neglect
This can be due to the parents having little time
and concern for the children; or if child is unwanted
due to some reason.
In dental clinic: The children are usually well-
behaved; shy and indecisive. They cry easily, but
respond well when treated with a little affection.
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4. Rejection: The causes of rejection are
i) Unwanted child
ii) Unhappy marriage
iii) Birth of the child not anticipated
iv) If child’s presence interferes with parental careers or ambitions.
v) If mother herself is immature or emotionally unstable.
These children lack the feeling of belonging. They are anxious, aggressive,
overactive, disobedient and ‘attention seekers’.
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CHILD’S BEHAVIOUR

PARENTAL INFLUENCES ON CHILD’S BEHAVIOUR
5. Authoritarianism
• Parents induce discipline in the form
of physical punishment or verbal
ridicule. They insist that the child
should follow their set of norms and
extend many efforts to train the child
as per their expectations. The
parents are non-love oriented.
• The children are submissive with
heightened avoidance gradient. They
delay response and exhibit evasive
behavior.
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6. Identification
• Parents try to re-live their lives through their children. In doing so, they give
children everything that had been denied to them. If the children do not respond
favorably, parents display overt disappointment.
• The children carry a sense of guilt which is mirrored in shyness, retirement and
unsure. They are generally good dental patients but need to be handled with
kindness and consideration.
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CHILD’S BEHAVIOUR

Effects of parental anxiety
• Children respond with tension and fear primarily because of the way dental
experiences have been described to them.
• The problem of dental fear is not specific to dental situations or procedure. The
behavior of a child is found to be directly proportional to the level of maternal
anxiety.
• Children of mothers with high anxiety levels exhibit more negative and
uncooperative behavior.
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CHILD’S BEHAVIOUR

Effects of parent’s presence in the operatory
• Dentists generally prefer to have parents outside the operating room because
most children behave satisfactorily in the absence of parents.
• If the child is uncooperative, parent’s presence may support his behavior and
limit the range of behavior control techniques of the dentist.
• In some cases, parent’s presence may be desirable:
i) Children of 1-3 years of age
ii) Children during their first dental visit.
iii) Handicapped children.
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CHILD’S BEHAVIOUR

For obtaining desirable behaviour from children; following instructions should be
given to parents:
1. Do not express your fears in front of children.
2. Never use dentistry as a threat or punishment.
3. Familiarize the child with dentistry by taking him to a dentist to become
accustomed to dental office.
4. Expressing occasional display of courage builds courage in the child’s mind.
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CHILD’S BEHAVIOUR

5. Advise and instruct your children about regular care.
6. Never scold the children to overcome the fear of dental treatment.
7. Never bribe your children to go to a dentist.
8. Never promise the children what the dentist is not going to do.
9. Carry the child to the dentist in a casual manner without being over- sympathetic.
10. Do not enter the operatory unless desired.
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CHILD’S BEHAVIOUR

B. Out of Control of the Dentist
I. Growth and development
• Both proceed in a relatively predictable logical step like sequential order.
Influenced by genetic, familial, cultural, interpersonal and psychic
factors.
• Most children demonstrate emotional maturation along with physical
growth.
• If there is a deficiency in physical growth and development or congenital
malformations, e.g.cleft lip, as awareness of the deformity increases it
leads to psychological trauma due to rejection by the society.
• Mental retardation, epilepsy, cerebral palsy etc., make the child mentally
handicapped. Here, the child cannot react to the requirements of the
mother and the expectations of the society. Hence, there is a failure of
cognitive development and variations in the behavior.

II. IQ of the Child
• Intelligent quotient (IQ) is the method of quantifying the mental ability in relation to
chronological age formulated by Alfred Binet in the early 1900’s.
Mental age
Formula – IQ = _____________________ × 100
Chronological age
• Positive relationship exists between IQ and acceptance of dental treatment.
III. Nutritional factors
• Studies have shown that an increase intake of sugar causes an irritable behavior.
• Skipping breakfast leads to an impaired performance.
• Nutritional deficiency also affects biological and cognitive development.

IV. Past medical and dental experience
Any past unpleasant dental experience, prior hospitalization, sickness, etc., are
associated with uncooperative behavior.
V. Genetics
• There should be a constant interaction between genetic programme of the child and
environment for the psychological development of the child.
VI. School environment
• 50% of the child’s development is affected by school and the remaining 50% by the
home environment.
VII. Socioeconomic status
• High socioeconomic status child may develop normally because the family can provide
all the necessary requirements to aid in a normal psychologic development. On the
other hand, this child may also become spoilt if he always gets what he wants.
• A low socioeconomic status child develops resentment and is tensed as the child gets
little attention often neglected. can directly affect the child’s attitude towards the
value of dental health.

VIII. Position of the Child in the Family and Child’s Behavior (Ordinal –
Position Syndrome)
• First child: Uncertainty, mistrustfulness, insecurity, shrewdness, stinginess,
dependence, responsibility, authoritarianism, jealousy, sensitive.
• Second child: Independence, aggressive, extravert, funloving, adventuresome
• Middle child: Aggressiveness, easily distracted, inferiority and prone for behavior
disorders.
• Last child: Secure, confident, immature, envy, irresponsible, spontaneous good and
bad behavior

C. Under the Control of the Parents
I. Home environment
The home is the first school where a child learns to behave. All the home individuals
influence the child’s behavior but none so much as the mother. E.g., in case of a
broken home, the child may feel insecure, inferior, apathic and depressed.Mother
child relationship has been described as one tailed.
II. Family development and peer influences:
• Position of the child, status of the child in the family, parental attitudes can influence
the child’s behavior.
III. Maternal behavior
• Maternal influence on the children’s mental, physical and emotional development begins
even before birth.
• Neurohormonal system of mother transfers emotion to the fetus.
• Postnatal behavior of the child is linked to prenatal emotional status of the expectant
mother, e.g., emotional stress during pregnancy can lead to an excessively active and
irritable infant.

Classification of maternal behavior
in dental clinic
• Most of the characters of child like behavior, personality, anxiety and
reaction to stress are influenced by both mother and father’s
characters but mother plays an important role in child’s psychologic
development because mother generally have the intimate contact
with the child since pre-natal period.
• Mother child relationship falls into two categories:
• Bayley and Schaefer summarized maternal attitude as:
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Autonomy/freedom vs
control
Hostility vs love

Maternal
attitude
Features Child behavior
Over-protective • Excessive care for children in terms of feeding,
dressing, bathing even after a certain age.
• Excessive concern about routine dental check-
up/condition
• May not allow the child to participate in risk
involving activities
• Constantly involved in his daily activities
• Aggressive
• Shy
• Submissive
• Demanding
• throwing
tantrums.
Overindulgence • Parents/relatives give whatever they want
• Emotional development is impeded
• Crying and temper tantrums is the way of
demanding whatever they want
• Aggressive
• Spoiled
• Demanding
• Throwing
tantrums
Under
affectionate
• Less emotionally supportive mother
• Mild detachment to neglect
• Making emotional contact with such child is difficult.
• In dental setting these child may cry easily, unable to
or not willing to cooperate
• Respond well on giving emotional support
• Well behaved
• Shy
• Unable to
cooperate
• Lack of decision
making
capacity
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Maternal
attitude
Features Child behavior
Rejecting • If child is unwanted
• Usually overt
• Mother neglects child, severe punishment,
nagging, resistant to spend time and money on
child.
• Both physical and emotional abuse can be seen
• Extreme anxiety
• Aggressive
• Obedient
• overactive
Authoritarian • Non love oriented behavior controlling technique
of child’s behavior.
• Discipline often takes the form of punishment or
verbal ridicule.
• Mother has her own set of norms for child which
she wants to be followed.
• Authoritarian mother is usually a product of
authoritarian upbringing.
• Evasive
• Resentment
• Child doesn’t disobey
the mother directly
but he has
heightened
avoidance gradient.
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BEHAVIOR
MANAGEMENT
IN
CHILDREN
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• Behavior management is the means by which the dental health team effectively
and efficiently performs treatment for a child and at the same time, instills a
positive dental attitude. (G. Z. Wright, 1975)
• Behavior management is a continuum of interaction with the child, directed
towards communication and education in an endeavour, to allay anxiety and fear
and to promote an understanding of the need for good oral health and the process
by which it is achieved.
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BEHAVIOUR MANAGEMENT

What is ‘child management in dentistry’?
The ‘child management in dentistry’ means:
• Guiding children through their dental experiences
• Instilling in children a positive attitude towards dentistry
• Controlling and modifying child behavior effectively while rendering treatment for
the children in an efficient and comfortable manner.
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Objectives of behavior management
1. Establish effective communication with child and parent.
2. Gain children and parent’s confidence and acceptance of dental treatment.
3. Teach child and parents the positive aspects of preventive dental care.
4. To provide a relaxing and comfortable environment for the dental team to work in,
while treating the child.
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Fundamentals of Behavior Management
1. Positive approach
2. Team attitude - the team should have interest, friendly and caring attitude
3. Organization - effective planning without delay or indecisiveness
4. Truthfulness
5. Tolerance - rationally coping with child’s behavior
6. Flexibility - if necessary, altering the treatment plans wisely.
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Questions to assess child behavior in the dental clinic
1. Does the child have an eye-to-eye contact as he/she enters the clinic?
2. Does the child answer the initial questions such as his/her name/ school name?
3. Does he/she have a smile on face, a ‘neutral’ look or scared/crying expressions?
4. Does he/she shake hands with the dentist?
5. Is he/she enthusiastic to see the place (operatory, the dental chair) or shies away?
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6. Is the child dependent on the instruction of parents to comply with the demands of
the dentist?
7. Does the child receive the gift happily?
8. Does the child wave bye-bye or say it aloud while leaving?
9. Does the child communicate to his parent anything that he/she liked in the place
(such as the fish tank in the waiting area, the gift, the poster on the wall, etc.)?
10. Is the child’s initial dental experience overall satisfactory?
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The child must spend 20-45 minutes in a dental clinic during first visit as:
 10-15 minutes in waiting room/ play area, greeted and introduced to toys by the
receptionist
 5-10 minutes in consulting area with parents to meet the dentist
 1-3 minutes on dental chair (either alone or on parent’s lap) and a very brief
introduction to dental operatory
 5-10 minutes; parents in consulting area while the child is playing outside
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I. Behavior management techniques can be classified –(by Nathan 1995):
1. Primary / preventive orientation
Objective: primarily directed to prevent development of anxiety and are aimed at
enhancing the trust, lack of which exacerbates anxiety.
Includes:
• Appointment to familiarize child with dental environment.
• Use of modeling
• Pre appointment letters.
• Communication.
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BEHAVIOR MANAGEMENT CLASSIFICATION

2. Secondary prevention: (management of anxiety, fear): Such techniques allow the
child to face the fearful dental situation in a supportive environment.
Includes:
• Communication
• Structured dental appointment
• Distraction
• Guided imagery/reframing
• Behavior modification(reinforcements)
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3. Tertiary behavior management techniques:
children with extreme negativity, phobias.
Includes:
• Desensitization, modeling.
• Biofeedback
• Hypnosis
• Assertive techniques- implosion/ flooding
• Aversive techniques- voice control, HOME, physical restraint
• Retraining
• Pharmacologic treatment- nitrous/ sedations/ general anesthesia.
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II. Domains for behavior management: (Pinkham 1995):
There are 5 domains:
• Physical domain: papoose board, Pedi-wrap. Also includes moth props, active
restraints –dental assistants/ parents.
• Pharmacologic domain: - conscious sedation, general anesthesia.
• Aversive domain: voice control, time out, HOME.
• Reward oriented domain- promise of gift, special treat by parents.
• Linguistic domain: communication; persuasion & reframing.
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III. Behavior management techniques (AAPD guidelines-2000):
• Basic behavior management: Communication, voice control, nonverbal
communication, tells- show- do, positive reinforcement, distraction, parental
presence or absence, Nitrous.
• Advanced behavior management: HOME, immobilization, sedation, general
anesthesia.
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BEHAVIOR MANAGEMENT TECHNIQUES

NON- PHARMACOLOGICAL
BEHAVIOR MANAGEMENT
TECHNIQUES
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1. Communicative
• Use of euphemisms
• Reframing
2. Behavior shaping
• Desensitization
• Modelling
• Contingency management
• Retraining
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3. Behavior management
• Audio analgesia
• Biofeedback
• Voice control
• Hypnosis
• Humor
• Coping
• Relaxation
• Impolsion therapy
• Aversive conditioning

A) Communicative management
Weiner 1972 – a definition of communication includes getting your point
across, making yourself understood, or simply using expressions that mean
the same thing to you as they do to the person with whom you are talking.
Establishment of communication – general verbal communication is best
initiated for younger children with complimentary comments, followed by
questions that elicit answer yes or no.
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A) Communicative management
• Establishment of communicator: it is important that communication is
through a single source to avoid confusion.
• Communicative management is used universally with both cooperative and
uncooperative children. – chambers, 1976
• Communicative management is the basis for establishing a relationship with
a child which may allow the successful completion of dental procedures and,
at the same time, may help the child to develop a positive attitude towards
dental care.
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• During the course of communicative management, the child is provided with
a playful environment.
• Verbal communication is best for children above 3 years of age. Voice should
be constant and gentle.
• Dentist should make the child feel that we are his well wishers. It should
include asking the child’s name, age, class and background. Patient always
prefers to be addressed by his name.
• Compliment him about his appearance. Sitting and speaking at eyelevel
creates a friendly atmosphere.
72

Use of Euphemisms
(substituting mild word) can be used, in presence of children. Choice of words
influences the emotional status of the child.
73
Dental tool/procedure Euphemism
Mouth mirror Spoon mirror to count/ check teeth
X-ray machine, Film Camera/ photo film
Water syringe, air syringe Water spray, air spray (wind-blower
Suction tube Tube pipe to remove dirty water
Air rotor handpiece Tooth shower
Burs Shower button
Light cure machine Light torch to shine teeth white

Reframing:
It is defined as taking a situation outside the frame that up to that
moment contained the individual in different conditions, and visualize
(reframe) it in a way acceptable to the person involved and with this
reframing, such that both the original threat and the threatened
situation can be safely abandoned
(Watzlawick et al 1974)
Successful reframing convert the unpleasantness into acceptance by the
patient.
74

b). Behavior shaping
• It involves the use of selected reinforcers that being learned will
hopefully change a child’s behavior from an inappropriate to an
appropriate form.
• This is based on the “stimulus-response” theory. For example,
when a child enters the reception room and associates this with a
previous dental experience which was unpleasant, the child’s
internal responses would be fear and anxiety while the external
response would be crying.

• This is a step-by-step procedure to make the child involved in
dental therapy. When shaping the behavior, the dentist is
teaching a child to behave. It is necessary to divide the
explanation for the procedure and consequently have to be led
through the procedure slowly.
• Behaviour shaping or modification involves 3 techniques:
a. Desensitization
b. Modelling
c. Contingency management

1. Desensitization –
 Joseph Wolpe (1975)
 Desensitization is accomplished by teaching the child a competing response
such as relaxation and then introducing progressively more threatening
stimuli.
 It is an effective method for reducing a maladaptive behavior
 Systemic desensitization is effective because the patient learns to substitute
an appropriate or adaptive emotional response (relaxation) for an
inappropriate or maladaptive response – anxiety.
 Method popularly used for modifying behavior desensitization in children is
tell show do technique.

Tell Show Do technique (TSD)- Addleslon (1959).
 Tell and show every step and instrument and explain
what is going to be done.
 Continuously and in grades from the least fear
promoting object or procedure move to higher grades to
more fearful objects.
 By having verbal (tell) and non-verbal (show and do)
interactions, available, one can overcome the many
small dental related anxieties of any child.
 Tell: Verbal explanation of procedures and phrases
appropriate to the developmental level of the patient the
names of dental instruments and materials with the
names which the child can understand and is familiar
with. Thus, the stimulus which was causing the anxiety
is now weakened.

 Show: Demonstration for the patient
of the visual, auditory, olfactory, and
tactile aspects of the procedure in a
carefully defined, non-threatening
setting.
 Do: Without deviating from the
explanation and demonstration,
completion of procedure.
 Indications
1. First visit
2. Subsequent visits when introducing
new dental procedure
3. Fearful , Apprehensive child
79

81
TSD technique is applied as follows:
• The dentist using the language that the child can
understand, tells the patient what is to be done. It is
presented slowly and repeatedly.
• The dentist demonstrates the procedure to the child
using a model or himself and is done slowly.
• The dentist proceeds to do the dental procedure
exactly as described.
• This is effective in children more than 3 years of age.

82
2. Modeling:
Introduced by Bandura (1969),
developed from social-learning
principles, procedure involves allowing
a patient to observe one or more
individuals (models) who demonstrate
a positive behavior in a particular
situation. Therefore the patient will
frequently imitate the models behavior
when placed in a similar situation.

Modeling can be done by:
• Live models – siblings, parents of child etc.
• Filmed models
• Posters
• Audiovisual aids
Learning through modeling is effective when:
• Observer is in a state of arousal.
• When the model has relatively more status and prestige.
• When there are positive consequences associated with model’s behavior
• Modeling technique seems to improve the behavior of apprehensive children
who have had no previous dental experience (Klarman R, 1980)

Pretreatment modeling. A technique for reducing children's fear in the
dental operatory.(Greenbaum PE, Melamed BG)
• Research on modeling indicates that this technique offers dentists a
means of reducing fear in child patients of all ages.
• As a preventive measure used with children who have had no prior
exposure to dental treatment, it can be particularly efficacious.
• Practicing dentists consider the fearful, disruptive child to be among the
most troublesome of problems in their clinical work, pre-treatment
modelling was found to be effective in such patients.

• Although modeling is not restricted to videotape media, the
emergence of current videotape technology provides the practitioner
with the means for incorporating patient viewing of prerecorded
modeling tapes as part of the usual waiting period.
• Such a procedure would mean that in the long run, the dentist will
spend more time doing dentistry and less in behavioral
management tasks.
85

86
3. Contingency Management:
It is a method of modifying the behavior of children by presentation or
withdrawal of reinforcers.
Positive reinforce: is one whose contingent presentation increases the
frequency of behavior
(Henry W Fields, 1984)
Negative reinforce: is one whose contingent withdrawal increases the
frequency of behavior
(Stokes and Kenndy, 1980).

Types of reinforcements can be:
• Social: e.g., praise, positive facial expression, physical contact by
shaking hand, holding hand, and patting shoulder or back.
• Material: May be given in the form of toys, games
• Activity reinforcers: Involving the child in some activity like
watching a TV show/special programs with him.
• For the benefit of contingency management social reinforcers are
the most effective.

88
Negative reinforce:
• Strengthening of a pattern of behaviour by the removal of a stimulus which
the individual perceives as unpleasant (a negative reinforcer) as soon as the
required behaviour is exhibited.
• The stimulus is applied to all actions except the required one, thus
reinforcing it by removal of a negative stimulus.
• It should not be confused with punishment, which is the application of an
unpleasant stimulus to inappropriate behaviour.
• Well known examples in dental practice are selective exclusion of the parent
(SEP).
• When inappropriate behaviour is exhibited the parent is asked to leave.
Ideally, the parent should be able to hear, but be out of sight of the child.
When appropriate behaviour is exhibited the parent is asked to return, thus
reinforcing that behaviour.

4. Retraining:
• The dentist, on occasion, will encounter the child who has had a
previously poor dental experience or who displays a negative behavior
for other reasons. The individual will require retraining, a technique
similar to behavior shaping, but it is designed to fabricate positive
values to replace the negative behavior that has developed.
• Before retraining devices are used, the cause or causes of the child’s
negative behavior should be established. With this type of knowledge
in hand, the task of retraining can be augmented with a more
effectively structured set of devices.

90
• The approaches to retraining fall into three main categories:
(1)avoidance,
(2)deemphasis and substitution,
(3)distraction.
• Lenchner and Wright (1975) draw on a real example of avoidance as a
retraining technique.

91
3. Behavior management/guidance:
a. distraction:
Distraction is the technique of diverting the patient’s attention from what may be
perceived as an unpleasant procedure
Objective: decrease the perception of unpleasantness.
Types of distractions used:
a. Audioanalgesia
b. Visual imagery
c. Relaxation
d. Visual / Verbal self talk

92
1. Audio analgesia:
• Also known as “white noise” is a method of reducing pain. This technique
consists of providing a sound stimulus of such intensity that the patient finds it
difficult to attend to anything else.
(Gardner, Licklider, 1959).
• Auditory stimulus such as pleasant music has been used to reduce stress and
also reduce the reaction to pain.
2. Relaxation:
• This technique is used to reduce stress and is based on the principle of
elimination of anxiety. Relaxation involves a series of basic exercises, which may
take several months to learn, and which require the patient to practice at home
for at least 15 min per day.

3. Visual imagery
• This consists of asking a child to picture a preferred scene. e.g. the child can
be instructed to close his eyes and think of a favorite game or place .The
child is asked to describe what he sees and made to feel at ease. The dental
procedures are now attempted and this is repeated as necessary throughout
the treatment.
• 2-4 yrs: story telling can be employed.
• 4-6yrs: visualizing a favorite TV program or favorite activity. E.g., imaginary
birthday party.
• 7-11 yrs: “cloud gazing”, some colors the child likes, imagine beautiful colors
&see them change.
4. Verbal/visual self talk
• child is asked to picture himself in the dental chair receiving dental
treatment in a happy state of mind.
93

b. Biofeedback:
• It involves the use of certain instruments to detect certain physiological
processes associated with fear (Buonomono, 1979).
• For example, if blood pressure is high the instrument gives stimulation and the
subject is taught to control the signals; therefore, it is useful in anxiety and
stress related disorders. Electroencephalogram, electromyography can also be
used in biofeedback.

c. Humor: helps to elevate the mood of the child, which helps the child to relax.
 Social: Forming and maintaining a relationship
 Emotional: Anxiety relief in the child, parent and doctor.
 Informative: Transmits essential information in a non-threatening way
 Motivation: It increases the interest and involvement of the child.
 Cognitive: Distraction from fearful stimuli.
d. Coping: It is the mechanism by which the child copes up with the dental
treatment. It is defined as the cognitive and behavioral efforts made by an
individual to master, tolerate or reduce stressful situations (Lazaue ).

 Behavioral: are physical and verbal activities in which the child engages to
overcome a stressful situation.
 Cognitive: The child may be silent and thinking in his mind to keep calm.
 Cognitive coping strategies can enable the children to:
1. Maintain realistic perspective on the events at hand
2. Perceive the situation as less threatening
3. Calms and reassures themselves that everything will be all right (emotion
regulating cognitions) (Sandra L Curry, 1988).
• Signal system: This method is followed in clinic wherein as a part of coping, when
it hurts, ask the child to raise his hand as suggested by Musslemann (1991).

e. Voice control
• It is the modification of intensity and pitch of one’s own voice in an attempt to
dominate the interaction between the dentist and the child.
• Fundamental element in obtaining childs compliance. Requires an attitude of
confidence by the practitioner.
• Used in conjunction with some form of physical restraints and hand-over-
mouth exercise.
• Change in tone from gentle to firm is effective in gaining the child’s attention
and reminding him that the dentist is an authority figure to be obeyed.

f. Hypnosis:
Hypnosis is an altered state of consciousness characterized by a heightened suggestibility
to produce desirable behavioral and physiological changes, one of the most effective
nonpharmacologic therapies used with children (Romanson, 1981). When used in
dentistry, it can be termed as hypnodontics (Richardson, 1980) or psychosomatic or
suggestion therapy. Greatest benefit of hypnosis is to reduce anxiety and pain.
Main features
• Discontinuity from normal waking experience but different from sleep
• A compulsion to follow the cues given by the hypnotist both during and after hypnotic
experience
• Ability to tolerate logic inconsistency that would normally be disturbing
• Potential for experiencing as real any distortions of perception,memory or feeling based
on suggestions given by hypnodontist rather than on objective reality.

g. Aversive conditioning
• Child who displays a negative behavior and does not respond to moderate behavior
modification technique falls into the category of Frankel’s definitive negative
behavior. Aversive conditioning can be a safe and effective method of managing
extremely negative behavior. Those dentists who contemplate using it should
obtain parental consent prior to its use (Patricia P Hagan, 1984).
• Two common methods used in the clinical practice are HOME and physical
restraint:
1. HOME (Hand-Over-Mouth Exercise)
• Introduced by Evangeline Jordan, 1920
• The purpose of HOME is to gain the attention of a child so that communication
can be achieved. The clinicians move to a frontofacial position to have an eye
contact with the child.

HOME (Hand-Over-Mouth Exercise)
Indications
• A healthy child who can understand but who exhibits defiance and hysterical
behavior during treatment.
• 3-6 years old.
• A child who can understand simple verbal commands.
• Children displaying uncontrollable behavior.
Contraindications
• Child under 3 years of age
• Handicapped child/immature child, frightened child
• Physical, mental and emotional handicap

Technique
• After determining the child’s behavior, the
dentist firmly places his hand over the child’s
mouth and behavioral expectations are calmly
explained close to the child’s ear.
• When the child’s verbal outburst is completely
stopped and the child indicates his willingness
to cooperate, the dentist removes his hand.

• Once the child cooperates, he should be complimented for being quite and
praised for good behavior. It should be noted that the child’s airway is not
restricted while performing the technique and the whole procedure should not
last for more than 20-30 sec.
Several Variations of HOME
• Hand over mouth with the airway unrestricted.
• Hand over mouth and nose and airway restricted
• Towel held over the mouth only

HOMAR (Airway Restricted)
• The advantage behind airway restriction is that the child will be quiet so as to
breathe and the screaming will decrease so that the doctor can proceed.
• Together with hand over mouth, nostrils are pinched for 15 sec.
• Belanger, (1993) believed that airway restrictions was the critical element and it
should be avoided.
• Recently, there have been a lot of controversies and criticism regarding HOM as a
behavior management modality. It is believed to cause mental scarring and
psychological trauma to the child. This technique has been banned in many
countries and the dentist is liable to face legal action for practicing HOM.
• This emphasizes the need for obtaining a written informed consent from the
parents before practicing HOM.

2. Physical Restraints/Protective stablization
• Restraints are usually needed for children who are hypermotive, stubborn or defiant
(Kelly 1976).
• The child is seated in the mother’s lap and one of the mother’s hands is placed on
child’s forehead while the other hand is placed on both the child’s wrists.
• Physical restraints involve restriction of movement of the child’s head, hands, feets
or body. It can be:
Active – restrains performed by the dentist, staff or parent without the aid of a
restraining device.
Passive – with the aid of restraining device.

105
Indications:
a. Patient with lack of maturity
b. Mental or physical disability
c. When other behavior management techniques have failed
Contraindications:
a. In cooperative patients
b. A patient who can’t be mobilized safely because of any systemic or medical
conditions
c. As a punishment
d. Not for the convenience of practitioner only

106
part Aid Feature
Mouth Tongue blades Easy to use, durable, can be used directly, available in two
sizes
Molt mouth prop • In difficult to manage patients
• Can be used for prolonged period
• Made in both adult and children size
• Disadvantage: possibility of lip and palatal laceration
and luxation of teeth if not used properly
Rubber bite blocks
Finger guards
Available in various sizes
Attach floss for easy retrieval

2. For body
a. Pedi – wrap:
• A reinforced nylon mesh sheet with Velcro closures. It is
available in small, medium and large sizes.
• Allows some movements while still confining the patient.
• The pedi-wrap should be placed in the prepositioned
chair. The child should be placed on the wrap so that the
dentist and assistant can secure the child’s arms at his
sides and close the Velcro fastener over his chest.
• The third fastener should be secured from the head first
to control excessive and movement and then secure the
remaining closures.

b. Papoose board:
• The Papoose Board secures the child against a rigid base
with three pairs of canvas straps.
• The papoose Board, like the Pedi-wrap uses the easy to
close and adjust Velcro system of press together – peel
apart fasteners.
• This device is able to restrain even the most uncooperative
patients.
c. Triangular sheet:
d. Bean bag dental chair insert
e. Saftey belt and extra assistant

3. For extremities:
a. Posey straps
b. Velcro straps
c. Towel and tape
4. For head stabilization:
a. Head positioner

Recent behaviour management techniques
110
1. Mobile dental app:
• In 2017, Patil VH et al utilized mobile dental app for
reducing fear and anxiety in children in the dental set
up.
• An interactive session of using the dental application
during the treatment was allowed and the children
were virtually made dentists and allowed to provide
different treatments through the application.
• By this technique, the fear towards different dental
instruments and its use in children could be reduced
and more cooperative behaviour could be achieved.
• Mobile dental application could be used as an adjunct
behaviour management technique however further
research is needed.

2. Videogame distraction:
• The use of videogame as a distraction tool is based on
the principles of cognitive- behavioural therapy and
neuro feed back mechanism for children with anxiety
disorders.
• Videogames are interesting and commonly available
media, which can help in implementing distraction in
children by active participation of the child during the
dental procedure.
a. For health promotion: Aljafari A et al 2017 used
Oral health education related videogames for
promoting healthy diet and good oral hygiene for
high caries risk children.
111

b. For Management of dental anxiety:
Ko JS et al 2016 used Ipads for reducing anxiety in children during their
orthopaedic visits.
Sil et al 2013 and Wohlheiter KA et al 2013 used videogames to reduce pain
perception during cold-pressor trials.
Videogames could be an effective distractor and improve oral health related
outcomes, however extensive studies in its applicability in the field of
pediatric dentistry is required.
112

3. Virtual reality based distraction:
• In 1968, Ivan Sutherland and Bob
Sproull invented virtual reality with a
head mounted device that was
connected to a computer.
• Later in Heim(1998) described virtual
reality as an interactive computer
based software that can be used to
immerse children in the virtual
environment which completely
obstructs the present situation.
113

• The VR equipment contains head mounted display and a tracking device.
The head mounted device contains the display screen which provides the
view of virtual reality environment in a 3600 view.
• The tracking device monitors the head movements. The equipment
provide an attachment for mouse, joystick or dataglove for playing
games.
Uses of Virtual reality:
a. For distraction:
• In 2014, Tanja-Dijkstra K et al used virtual reality distraction for
reducing anxiety towards previous dental experiences.
• Factors that influence the distraction using virtual reality device are the
level of interest shown by the child and the level of immersion of the
child into the virtual world.
114

b. Minor procedures:
• In 2011, Hoffman et al showed that virtual reality reduced pain perception
in children by reducing pain related brain activity
Contraindications of Virtual Reality:
• 1. Medically compromised children especially children with epilepsy,
migraine and vestibular disturbances.
• 2. Children with previous history of nausea or dizziness following the use of
VR device.
115

4. Audiovisual distraction:
• Involves the concept of imagery and distraction delivered via
audiovisual aids, thereby removing the focus on the dental
procedures, avoiding anxiety provoking stimuli and providing a
relaxing experience throughout the procedure.
• GOALS:
a. imagination (helps in distracting children from present situation),
b. engagement (enables children’s attention to focus on a single thing)
c. motivation (helps children to encourage getting treated for dental
problems in future)
116

Audiovisual distraction could be an effective method for managing dental anxiety
and pain related to dental procedures.
• Management of dental anxiety: A systematic review by Barreiros D 2018
concluded that audiovisual distraction is effective in controlling dental anxiety in
children
• Management of pain: Oliveira NCAC et al 2016 found audiovisual distraction
could reduce the intensity of pain during painful puncture procedures.
117

5. Tell- Play- Do
• The commonly used behavior guidance
technique namely Tell- Show-Do was
modified by Vishwakarma AP as Tell-
Play-Do in 2017 for children aged 5-7
years
• an additional component of allowing
the child to play with dental
equipment's was carried in Tell-Play-
Do.
• As per the learning theory of Bandura,
the child’s anxiety towards the dental
equipments reduces, thereby feels
more comfortable and develops
cooperative behavior
118

• There is insufficient research on behavior management in context to
pediatric dentistry.
• The literature on efficacy of behavior management strategies in the past
have been largely based on expert opinion.
• The study of human behavior does not lend itself easily to randomized
controlled clinical trials.
119
CONCLUSION

• We are not able to say which technique is more effective than the other.
Rather, we have to choose behavior management techniques by
experience.
• What works well for one dentist may not be successful for another. In this
instance the saying that “the map is not the territory” has never been
truer.
• Behavior management, when used judiciously can result in the most
satisfying of all results i.e. a child eager to return to the dental operatory
for his next appointment.
120
CONCLUSION

• Text book of Pedodontics – Shobha Tandan
• S.G damle
• Dentistry for the child and Adolescent – Mc. Donald, Avery, Dean
• Krista Baier, Peter Milgrom, Stephen Russell. Children’s Fear and Behaviour in Private Pediatric Dentistry
Practices. pediatr Dent. 2004; 26:316-321.
• Guidelines for behaviour management reference manual 2000-2001 AAPD.
• DCNA – 1988 Oct 32 (4) 693-704 Pre treatment Modelling: A technique for reducing children fear in dental
operatory
• Aruna Prashanth VishwakarmaEffectiveness of two different behavioral modification techniques among 5–7-year-
old children: A randomized controlled trial
.
121
REFERENCES:

non pharmacological behavior management techniques

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