1. Several classifications of child behavior in dental settings are discussed, including Wilson's, Wright's, and Lampshire's classifications.
2. Factors like age, temperament, home environment, and past dental experiences can influence a child's behavior. Children's behaviors range from cooperative to disruptive.
3. Rating scales like Frankl's and the Houpt scale can be used to assess a child's level of anxiety or cooperation during dental treatment. Understanding a child's behavioral patterns is important for effective behavior guidance.
Non –pharmacological behavior management in childrenDr. Harsh Shah
Overview on nonpharmacological managent of behaviour in children
Presented by : Mayuri Karad
SDDCH Parbhani
Guided by : Dr. Rehan Khan
Dept, of Pediatric and preventive dentistry
Non –pharmacological behavior management in childrenDr. Harsh Shah
Overview on nonpharmacological managent of behaviour in children
Presented by : Mayuri Karad
SDDCH Parbhani
Guided by : Dr. Rehan Khan
Dept, of Pediatric and preventive dentistry
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
offering a wide range of dental certified courses in different formats.for more details please visit
www.indiandentalacademy.com
This seminar consists of an introduction to child psychology followed by psychodynamic theories and its applicatioms followed by description and types of fear and anxietry followed by various behaviour rating scales and classification of behaviour
Psychology /certified fixed orthodontic courses by Indian dental academy Indian dental academy
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.
Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
Dental implants courses.for details pls visit www.indiandentalacademy.com ,or call
0091-9248678078
This one is for the pedo lovers .this is all about child psychology for various theories given and the one most accepted.Students this a bit dry topic but of course interesting one.
Covered Psychosexual theories by Sigmund Freud, Psychosocial theories by Erik Erikson, Cognitive Development by Jean Piaget.
also have included dental application of each theory
Similar to Non Pharmacological Behavior Management (20)
Bleeding Disorders: Causes, Types, and Diagnosis Dr Medical
https://userupload.net/wxvqfbo7ywqu
A bleeding disorder is a condition that affects the way your blood normally clots. The clotting process, also known as coagulation, changes blood from a liquid to a solid. When you’re injured, your blood normally begins to clot to prevent a massive loss of blood. Sometimes, certain conditions prevent blood from clotting properly, which can result in heavy or prolonged bleeding.
Bleeding disorders can cause abnormal bleeding both outside and inside the body. Some disorders can drastically increase the amount of blood leaving your body. Others cause bleeding to occur under the skin or in vital organs, such as the brain.
https://userupload.net/szgab9mr3vdz
Epidemiology is the study of health and disease in populations and of how these states are influenced by biology, heredity, and physical and social environment, as well as personal behavior. Advances in research over recent years have led to a fundamental change in our understanding of the periodontal diseases. As recently as the mid-1960s, the prevailing model for the epidemiology of periodontal diseases included the following precepts: (1) all individuals were considered more or less equally susceptible to severe periodontitis; (2) gingivitis usually progressed to periodontitis with consequent loss of bone support and eventually loss of teeth; (3) susceptibility to periodontitis increased with age and was the main cause of tooth loss after age 35–55. Since the development of this paradigm, advances in the understanding of periodontal diseases have led this disease model to be reevaluated.
https://userupload.net/l2enk8kbflj8
Incidence, mortality, and survival are the primary measures for assessing the impact of cancer in population groups. Incidence is the frequency of new cancer cases during a defined period of time, generally expressed as the rate per 100,000 persons per year; the mortality rate is the frequency of cancer deaths per 100,000 persons per year. The observed survival rate is the proportion of persons with cancer who survive for a specified period of time after diagnosis, usually 5 years. This statistic is often presented as a relative survival rate, in which survival from cancer is corrected for the likelihood of dying from other causes.
Dentist patient relationship and quality careDr Medical
https://userupload.net/mo2f5z40rv8v
Although quality is a genuine concern for dentistry, nowadays more emphasis is placed on quality issues. As dentist-patient interaction is involved in many aspects of care and it is more crucial for dentistry when compared to many other professions, a good dentist-patient relationship is an integral element of quality care. This series of 'practice articles' examines various important dimensions of this interaction. The first and second papers examine the value of trust and communication, the third paper focuses on informed consent and the fourth paper evaluates the relatively broadened role of dentists in behavioural modification.
https://userupload.net/06gt5zcwvh90
Genetic counseling is the process of advising individuals and families affected by or at risk of genetic disorders to help them understand and adapt to the medical, psychological and familial implications of genetic contributions to disease.[1] The process integrates:
Interpretation of family and medical histories to assess the chance of disease occurrence or recurrence
Education about inheritance, testing, management, prevention, resources
Counseling to promote informed choices and adaptation to the risk or condition.
https://userupload.net/yk8shpcpwk19
Dentistry can do so much these days to improve a person’s health, appearance and self-confidence. From barely noticeable braces that straighten crooked smiles to dental implants that replace missing teeth, there is a state-of-the-art solution to virtually any dental problem. Of course, like anything that involves the time and resources of skilled professionals, highly technical and sophisticated dental treatment doesn’t come inexpensively; indeed, the phrase “you get what you pay for” probably applies doubly to dentistry. Also, the types of treatment mentioned above, as well as many others, are often considered elective and therefore may not be covered (or only partially covered) by dental insurance. This can be the case even when a given procedure offers proven health benefits.
https://userupload.net/8mky0eijld91
An understanding of the physiology of body fluids is essential when considering appropriate fluid resuscitation and fluid replacement therapy in critically-ill patients. In healthy humans, the body is composed of approximately 60% water, distributed between intracellular and an extracellular compartments. The extracellular compartment is divided into intravascular, interstitial and transcellular compartments. The movement of fluids between the intravascular and interstitial compartments, is classically described as being governed by Starling forces, leading to a small net efflux of fluid from the intravascular to the interstitial compartment. More recent evidence suggests that a model incorporating the effect of the endothelial glycoclayx layer, a web of glycoproteins and proteoglycans that are bound on the luminal side of the vascular endothelium, better explains the observed distribution of fluids. The movement of fluid to and from the intracellular compartment and the interstitial fluid compartment, is governed by the relative osmolarities of the two compartments. Body fluid status is governed by the difference between fluid inputs and outputs; fluid input is regulated by the thirst mechanism, with fluid outputs consisting of gastrointestinal, renal, and insensible losses. The regulation of intracellular fluid status is largely governed by the regulation of the interstitial fluid osmolarity, which is regulated by the secretion of antidiuretic hormone from the posterior pituitary gland. The regulation of extracellular volume status is regulated by a complex neuro-endocrine mechanism, designed to regulate sodium in the extracellular fluid.
https://userupload.net/s5uyonki1n7m
Pain is a somatic and emotional sensation which is unpleasant in nature and associated with actual or potential tissue damage. Physiologically, the function of pain is critical for survival and has a major evolutionary advantage. This is because behaviours which cause pain are often dangerous and harmful, therefore they are generally not reinforced and are unlikely to be repeated.
https://userupload.net/3ppacneii1wj
Toxicologic Pathology (Second Edition), 2010
INTRODUCTION
The oral mucosa is, in many ways, similar to the skin in its architecture, function, and reaction patterns. This section only emphasizes those characteristics of the oral mucosa that influence or result in a distinct group of pathologic entities.
Because of its location at the entrance of the digestive and respiratory tracts and its proximity to the teeth, the oral mucosa is subjected to numerous natural and man-made xenobiotics. The peculiar architecture and absorption characteristics of the oral mucosa, especially in areas of extreme thinness, coupled with the rich microorganism flora of the mouth, makes the oral mucosa a peculiar site deserving separate discussion.
https://userupload.net/6jbhjqr3gczd
Behavioural sciences explore the cognitive processes within organisms and the behavioural interactions between organisms in the natural world. It involves the systematic analysis and investigation of human and animal behavior through the study of the past, controlled and naturalistic observation of the present, and disciplined scientific experimentation and modeling. It attempts to accomplish legitimate, objective conclusions through rigorous formulations and observation.[1] Examples of behavioral sciences include psychology, psychobiology, anthropology, and cognitive science. Generally, behavior science deals primarily with human action and often seeks to generalize about human behavior as it relates to society
Antifluoridation lobby - Water fluoridation controversyDr Medical
https://userupload.net/u5vppli3jy1y
The water fluoridation controversy arises from political, moral, ethical, economic, and health considerations regarding the fluoridation of public water supplies.
Public health authorities throughout the world find a medical consensus that fluoride therapy at appropriate levels is a safe and effective means to prevent dental caries,[1] whether by fluoridation of the public water supply or topical application strategies.[2][3] Proponents of water fluoridation see it as a question of public health policy and equate the issue to vaccination and food fortification, claiming significant benefits to dental health and minimal risks
https://userupload.net/21or432od2kp
It is recommended that pacifiers and other types of artificial nipples be avoided for at least the first 3-4 weeks. I’d personally suggest that most breastfed babies – if they get a pacifier at all – would be better off without a pacifier until mom’s milk supply is well established (6-8 weeks, usually) and the 6 week growth spurt is over. That way you’ve established a good milk supply and don’t lose any much-needed breast stimulation to a pacifier.
Anemia Causes, Types, Symptoms, Diet, and Treatment Dr Medical
https://userupload.net/0gv9ijneu7hf
Anemia is a condition that develops when your blood lacks enough healthy red blood cells or hemoglobin. Hemoglobin is a main part of red blood cells and binds oxygen. If you have too few or abnormal red blood cells, or your hemoglobin is abnormal or low, the cells in your body will not get enough oxygen.
https://userupload.net/69zxggv1yww1
The mouth and teeth play an important role in social interactions around the world. The way people deal with their teeth and mouth, however, is determined culturally. When oral healthcare projects are being carried out in developing countries, differing cultural worldviews can cause misunderstandings between oral healthcare providers and their patients. The oral healthcare volunteer often has to try to understand the local assumptions about teeth and oral hygiene first, before he or she can bring about a change of behaviour, increase therapy compliance and make the oral healthcare project sustainable. Anthropology can be helpful in this respect. In 2014, in a pilot project commissioned by the Dutch Dental Care Foundation, in which oral healthcare was provided in combination with anthropological research, an oral healthcare project in Kwale (Kenia) was evaluated. The study identified 6 primary themes that indicate the most important factors influencing the oral health of school children in Kwale. Research into the local culture by oral healthcare providers would appear to be an important prerequisite to meaningful work in developing countries.
https://userupload.net/ucq2c1km5pb7
Preventive dentistry aims to stop the progression of dental caries by promoting daily habits and clinical therapies that either promote the remineralization of the tooth surface or prevent the formation of the oral biofilm responsible for lowering the oral pH levels in an attempt to prevent cavity formation.
Here is an overall glance on some recent concepts/advances in preventive dentistry with a detail note on pit and fissure sealants
Anomalies of the first and second branchial archesDr Medical
https://userupload.net/8n9v7tg9jkl1
Anomalies of the branchial arches are the second most common congenital lesions of the head and neck in children [1]. They may present as cysts, sinus tracts, fistulae or cartilaginous remnants and present with typical clinical and radiological patterns dependent on which arch is involved. The course of a particular branchial anomaly is caudal to the structures derived from the corresponding arch and dorsal to the structures that develop from the following arch. Branchial anomalies are further typed into cysts, sinuses, and fistulas.
Ankyloglossia a congenital oral anomaly Dr Medical
https://userupload.net/h9ig9byum706
Ankyloglossia, also known as tongue-tie, is a congenital oral anomaly that may decrease mobility of the tongue tip and is caused by an unusually short, thick lingual frenulum, a membrane connecting the underside of the tongue to the floor of the mouth. Ankyloglossia or tongue-tie is the result of a short, tight, lingual frenulum causing difficulty in speech articulation due to limitation in tongue movement. Ankyloglossia is a congenital condition in which a neonate is born with an abnormally short, thickened, or tight lingual frenulum that restricts mobility of the tongue. Ankyloglossia may be associated with other craniofacial abnormalities, but is also often an isolated anomaly.
Bleeding disorders Causes, Types, and DiagnosisDr Medical
https://userupload.net/v3l4i8jsk7wq
Factor II, V, VII, X, or XII deficiencies are bleeding disorders related to blood clotting problems or abnormal bleeding problems. Von Willebrand's disease isthe most common inherited bleeding disorder. It develops when the blood lacks von Willebrand factor, which helps the blood to clot.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
2. 22
“Although the operative dentistry may be perfect,
the appointment is a failure if the child departs in
tears”
Mc Elory (1895)
3. 33
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. 44
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. CLICK HERE TO DOWNLOAD
THIS PPT
https://userupload.net/5x4jgtw5sqs2
6. 66
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
7. 77
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
8. 88
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)
9. 99
psychologists - 3 distinct mechanisms
(1) classical conditioning ------ Ivan Pavlov
(2) operant conditioning ------ B.F skinner
(3) observational learning (modeling) ------
Learning & development of behavior
10. 1010
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
11. 1111
Even at the early age – child experiences with medical personals
12. 1212
•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
13. 1313
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
14. 1414
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
15. CLICK HERE TO DOWNLOAD
THIS PPT
https://userupload.net/5x4jgtw5sqs2
16. 1616
four basic types of operant conditioning- distinguished by the
nature of the consequence :
1. positive reinforcement.
2. negative reinforcement
3. Omission
4. punishment
18. 1818
Stone & church (1975): child development into 5 stages:
Infant
Toddler
Preschooler
Middle-yrs child
Adolescent
Normal behavior of children &adolescent
19. 1919
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.
20. 2020
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.
21. 2121
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:
22. 2222
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**
23. 2323
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
24. 2424
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.
25. CLICK HERE TO DOWNLOAD
THIS PPT
https://userupload.net/5x4jgtw5sqs2
26. 2626
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:
27. 2727
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.
28. 2828
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
29. 2929
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.
30. 3030
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
31. 3131
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.
32. 3232
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
33. 3333
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
34. 3434
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
35. 3535
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.
36. 3636
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
37. 3737
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.
38. 3838
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.
39. 3939
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
40. 4040
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
41. 4141
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
42. 4242
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.
43. 4343
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.
44. 4444
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.
45. 4545
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:
46. 4646
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
50. 5050
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
51. 5151
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
**
52. 5252
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.
53. 5353
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.
***
54. 5454
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
56. 5656
Global rating scale
5: excellent
4: very good
3: good
2: fair
1: poor/ aborted
IJPD 1995;5:87-95
57. 5757
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
58. 5858
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
59. 5959
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.
61. 6161
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
63. 6363
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 .
65. 6565
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
66. 6666
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
67. 6767
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
68. 6868
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
69. 6969
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
71. 7171
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
ll_________________________________l
72. 7272
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
73. 7373
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
74. 7474
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
75. 7575
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.
76. 7676
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/
77. 7777
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.
78. 7878
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.
79. 7979
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
80. 8080
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.
81. 8181
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.
82. 8282
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”
83. 8383
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
84. 8484
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.
86. 8686
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
87. 8787
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
88. 8888
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.
90. 9090
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
91. 9191
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
92. 9898
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
93. 100100
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.
94. 101101
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 accord-ing to the mother's presence or absence.
*Croxton --- final visit 93% of the children exhibited a
positive response.
95. 102102
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
96. 103103
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?
97. 104104
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?
98. 105105
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.
99. 106106
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.
100. 107107
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:
101. 108108
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.”
102. 109109
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.
103. 110110
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
104. 111111
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.
105. 112112
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;
106. 113113
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.
107. 114114
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
108. 115115
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
109. 116116
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
110. 117117
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
111. 118118
Other variables
Growth & development
Nutritional factors
Past dental experience
Genetics
School environment
socio economic status
112. 119119
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
113. 120120
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
114. 121121
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
115. 122122
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
116. 123123
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
117. 124124
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)
118. 125125
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
119. 126126
.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
120. 127127
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.
121. 128128
3. The parent often repeats
orders, creating an annoyance
for both the dentist and child.
4. The child divides attention
between parent and dentist.
122. 129129
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.
123. 130130
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.
124. 131131
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. )
125. 132132
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.”
126. 133133
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.
127. 134134
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.
128. 135135
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.
129. 136136
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.
130. 140140
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
131. 141141
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
132. 142142
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
133. 143143
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
134. 144144
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
135. 145145
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
136. 146146
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.
137. 147147
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
138. 148148
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.
139. 149149
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.
140. 150150
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
141. 151151
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.
142. 152152
•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
143. 153153
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
144. 154154
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
145. 155155
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.
146. 156156
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
147. 157157
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
148. 158158
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
150. 160160
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
151. 161161
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
152. 162162
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.
153. 163163
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
154. 164164
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
155. 165165
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
156. 166166
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
159. 169169
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.
161. 171171
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
162. 172172
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
163. 173173
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
164. 174174
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.”
165. 175175
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
166. 176176
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.
168. 178178
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.
169. 179179
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”.
170. 180180
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.
171. 181181
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.
172. 182182
•Dr. Herbcrt Goldstein, for-merly 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
173. 183183
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
174. 184184
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
176. 186186
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
177. 187187
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
178. 188188
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
179. 189189
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
181. 191191
Head:
Supports the head
Protects the pt from
getting injured himself &
pt.
Types:
Fore body support
Head protector
Plastic bowel
Extra assistant
183. 193193
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.
184. 194194
• 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.
185. 195195
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.
186. 196196
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.
187. 197197
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
188. 199199
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%.,
189. 200200
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
190. 201201
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.
191. 202202
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
192. 203203
• 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
193. 204204
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.
194. 205205
•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
195. 206206
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
196. 207207
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
197. 208208
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
198. 209209
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
199. 210210
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
200. 211211
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
201. 212212
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
202. 213213
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.
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Editor's Notes
First mention I dental literature of measuring the success or failure of child&apos;s appointment by anything other than technical proficiency.
Psychologists generally consider that there are 3 distinct mechanisms by which behavioral responses are learned
involved the presentation of food to a hungry animal, along with some other stimulus, for example, the ringing of a bell. The sight and sound of food normally elicit salivation by a reflex mechanism. If a bell is rung each time food is presented, the auditory stimulus of the ringing bell will become associated with the food presentation stimulus, and in a relatively short time, the ringing of a bell by itself will elicit salivation. Classical conditioning, then, operates by the simple process of association of one stimulus with another-------this mode of learning is sometimes referred to as learning by association.
occurs readily with young children and can have a considerable impact on a young child&apos;s behavior on the first visit to a dental office.
When a child experiences pain, the reflex reaction is crying and withdrawal.
the infliction of pain is an unconditioned stimulus – Pavlov
Eg;
it is unusual for a child to encounter people who are dressed entirely in white uniforms or long white coats.
If the conditioned association of pain with the doctor&apos;s office is strong, it can take many visits without unpleasant experiences and pain to extinguish the associated crying and avoidance.
The general rule is that if the consequence of a certain response is pleasant or desirable, that response is more likely to be used again in the future; but if a particular response produces an unpleasant consequence, the probability of that response being used in the future is diminished.
Acquired behavior depends :
characteristics of the role model. –
older sibling
peers
Fear and rage are primitive responses developed to the protect the individual from harm and self-destruction. emotional stimulation is discharged by way of the autonomic nervous system through the hypothalamus and needs very little cortical integration
A child who has been improperly subjected to intense pain in a hospital by persons in white uniforms may develop an intense fear of similar uniforms on dentists or dental hygienists.
**Even the characteristic smell of certain drugs or chemicals previously associated with unpleasantness may arouse unwarranted fear. so that any pain produced during dental treatment becomes magnified and leads to even greater apprehension.
***so that any pain produced during dental treatment becomes magnified and leads to even greater apprehension.
*The young inexperienced child, hearing of some unpleasant or pain producing situation undergone by a parent or others, so on develops a fear of that experience.
The mental picture producing the fear is retained in the child mind and, with the vivid imagination of childhood, becomes magnified and formidable.
A child hearing from parent or, playmates of the supposed terror of the dental office so on accepts it as real and to be avoided if at all possible
A child observing fear in others may soon acquire a fear for the same object or event as real and genuine as that observed by the child in others This is especially true if the fear is observed in parents. Children frequently identify themselves with their parents. If the parent is sad the child feels sad. If the parent displays fear the child is fearful. Child&apos;s anxiety and over negative behavior are correlated with parental anxiety.
A child&apos;s fear & handling characteristics, intensity varies with age
Life begins with crying. cries from hunger, pain, discomfort and also from denials which are not understood
Pinkham classified as:
These children just wont cope with the stimuli & behavioral demands of the dental experience
Because the dental experience for children is a fairly intense human encounter that- demands rapport and communication between the adult dentist and the child patient
Four categories:
Classified the behavior on 5 point scale.
5 point scale , assess the overall behavior after each visit, measure of both successful completion of the treatment at that visit & of the dentist perception of the child’s anxiety.
To asses dental anxiety in the children many measurements technique have been proposed. eg drawings, observation of behavior rating by dentists, verbal cognitive self reports
Several investigators have found that the attitudes children from .the preschool through the elementary level of quite positive in regard to dentistry.
Several investigators have attempted to evaluate the behavior of preschool or older children during their first dental visit and to identify factors which influence their behavior
Both psychological and physiologic monitoring of children’s responses to the dental injection support the clinicians&apos; empirical observations.
has long been recognized that the extraction of a child&apos;s tooth is one of the
Children reactions to dental extraction have also been evaluated with the
Many factors affect child’s behavior in the dental office.they may be categorized under following groups
While children&apos;s behavior can influence the behavior of mothers
The usual feeling mothers have for their children is one of love and affection. This is considered a prerequisite for the healthy emotionaldevelopment of the child. An exaggeration of this attitude-namely, overprotection-can be potentially harmful to a child&apos;s normal development
Since they have not learned or experienced love and affection at home, emotional contact and rapport with them is difficult.
Acceptance vs rejection is one of the most significant of family influence
Study the note for this slide.
It is quite probable that dentists generally prefer to have parents absent from the operating room while children are being treated because most,
found that, of 28 children referred to his private practice because they had exhibited behavior problems at other dentist&apos;s offices, most had had treatment attempted by the other dentists while a parent was present. 23 Croxton excluded the parent from the operatory during all appointments and used appropriate management technics to gain cooperation.
tested the reaction of young children, aged 42 to 66 months, to the presence of the mother in the operatory. 24 The 112 children in the study were divided ,into two groups. One group had the mother present during both an initial visit involving an examination, prophylaxis, and a radiographic series, and during a second, operative visit. The mothers were instructed to act as passive observers. The second group had the mother absent from the operatory during both visits. Frankl and associates found that
*Jenks cites several questions that a dentist should seek to answer about a child&apos;s behavior:
With proper structuring, children should know what to expect and how to react during the dental experience.
*The local injection procedure is an example of. when externalization is often required. During this procedure children tend to focus all of their attention, perception, and sensation on the site of injection. Their eyes may be closed, their mouths wide, and their bodies rigid as they withdraw from all other stimuli. There are two methods of externalizing the patient&apos;s attention: first, involve him in verbal activity; and second, involve him in the dental activity. The first method is appropriate during the injection procedure and could be accomplished in the following manner. Before the injection is given, the dentist can tell the child that he will slowly count to ten and that when he is finished counting the procedure will be over. The dentist then begins the injection and starts to count, taking about 60 seconds to do so. As he counts, he asks the child to count with him. This simple procedure accomplishes several things. First it distracts the child from the injection itself as he will have to concentrate on counting. It also involves the child because he has to count along with the dentist. Additionally, it will indicate to the child exactly when this phase of therapy is completed, and it is thus also a form of structuring.
Another approach involves finding out the child&apos;s interests beforehand. Then, as the injection is given, the dentist very expressively converses with the child about his&apos; chief interest and asks the child questions requiring &quot;yes&quot; or &quot;no&quot; responses. As the appointment progresses, the dentist can engage the child in conversation about the child&apos;s hobbies, his pets, or his favorite television programs. The conversation may often be one-sided, since the child with dental instruments in his mouth will be unable to reply verbally. He can, however, nod his head and show other signs of participating in the conversation.
The attire worn by dentists varies from a surgical gown or white clinic jacket to a shirt and tie or open-necked shirt. Some dentists who treat children even don cowboy or other garb.
*it has been stated that if a child has previously experienced a stressful situation which included the presence of someone in white attire such as a physician the mere appearance of a white-clothed individual would be sufficient to evoke negative behavior
Certain practices & concepts remain fundamental to good behavior management:
Use of the approximations of the anxiety evoking stimulus to a degree that the stimulus does not capture attention anymore & therefore does not produce any physiologic reaction.
Before the patient comes into the treatment room. the parent fills in an information sheet which concludes with the following statement:
Partial / completion of the pt sometimes is necessary to protect the pt & or the dental staff from injury while providing to the dental care.