Post on 02-Jun-2018
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Natalie O. Ford, DMD
Children are NOT Little Adults!
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Att itude of
dentists
Att itude of
dentists
Violence in society
Multicultural
Divorce (26% in 2
parent households)
Mental health
rather than
discipline
Unacceptable
behavior
management
techniques
Worse
Negative
parenting
Limit setting
Dentists less
assertive in
management style
The ChangingLandscape
Parental
Factors
Parental
Factors
SocietySociety
Not alwaysobjective
Mothers tend tounderrate all
negativebehaviors
Mothers seemsurpr ised at
childs poor oralhealth
{sometimes}
Mothers see morenegative
behaviors in otherchildren
A Mothers Observations
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4 Stages
Sensory Motor
0 to 2 years
Preoperational
2 to 7 years
Period of ConcreteOperations
7 to 11 years
Period of FormalOperations
11 to adult
Sensorimotor Period (0-2)
Child Infant
Objects in environment = permanent
Difficult communication (language
capabilities)
Little ability to interpret sensory data
Can think of time only in
the present
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Preoperational Period (2-7)
Use words to symbolize objects
Egocentric
Limited logical reasoning (dominated
by immediate sensory impression)
Animism inaminate objects
have life
Period of Concrete Operations
(7-11)
Improved reasoning
Can see other points of view
Ability to reason tied to concrete
objects
Limited abstract thinking
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Period of Formal Operations
(11-adult)
Intellectually treat like an adult
Have abstract reasoning & concepts
Do NOT talk down to a child
Lets Review
Each Age!
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Ages
2 Ages
CHRONOLOGICAL AGE
MENTAL AGE
ADDRESS the childs MENTAL
AGE
2 Year Olds terrible twos
Varied vocabulary
Solitary play, SHY
AFRAID of NOISE, sudden
movements
React better to showing rather
than telling Does not want to be separated
from parent
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2.5 Year Olds
Suggestible
Usually instinctive
May generalize (may see
white coat, and feel like at
the pediatrician)
Not interested ininterpersonal relationships
3-3.5 Year Olds
Better communication
Will develop interpersonal
relationships
Imaginative
Follows directions
Uncertain/insecure Will often sepearate from
parent
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5.5-6 yo
School age
Moves away from close family
dependency
Anxiety (new situations)
changed child
Prone to temper tantrums
May be afraid of animals, people,
darkness, bodily harm
6 yo
Anxieties diminish, behavior improves
Well adjusted, happy
Usually reacts favorably
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7 yo
Better control Somewhat withdrawn, moody, sulky
Anxious to please, CONSIDERATE
GIVE PRAISE
More verbal
Deep, worrisome fears (about acceptance)
Dont like to be touched
Fantasy, super-imaginative
8 yo
Dramatic, tall tales
Critical of themselves/others, sensitive
Verbal aggression
Fewer fears
More adaptable
Interested in relationships
Desires to be treated as an adult
NEVER DEMEAN
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9 yo
More responsible, independent,cooperative
Likes compliments, competitino
Self-critical, uncertain
Extreme emotional states
Fewer fears
Upset by own mistakes
Expected to be on own more
10 yo
Wonderful
Easy going, well-balanced
Infrequent anger (violent, but quickly
resolved)
Wants adult relationships
Matter of fact
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11 yo
BEHAVIOR PROBLEM- mostworried/fearful age
Health worries
FEARS: unknown, animals, INJECTIONS
Genuinely afraid of dental procedure
Sensitive
Proud, selfish, competitive,
belligerent, jealous, resentful Detailed conversation
12 yo
Well adjusted, happy
Want to be treated as an adult
Likes HUMOR
Preoccupied w/ food & eating
Usually not a problem in the dental office
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13 yo sad
14 yo outward, well adjusted
15 yo dislike authority, may blame
dentist
16 yo happy, well adjusted
BEHAVIOR MANAGEMENT
A continuum of interaction
Purposes:
Establish rapport
Promote + behavior
Facilitate effective, efficient, safe treatment
Base decisions off risk vs benefit
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ev ew o e av or
Management Terms
behavior: observable act that can be describedor measured reliably
Classical conditioning: conditioned reflexes
established by association of one stimulus w/
another stimulus thats known to cause
unconditioned reflex
Behavior modification: shaping
behavior
Behavior Modification
Stimulus-response
Motivation
+ reinforcement: right response produces a
goal/reward response reinforced
- reinforcement: response takes away an
unpleasant stituation
Generalization: may react to newsituation as if an old, similar situation
Discrimination: opposite of
generalization
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Behavior Mod . . . Cont.
Extinction: response not reinforced, thenresponse decreases until eliminated
Adverse conditioning: punishment
Desensitization: present milder component of
stimulus until no longer produces anxiety
Modeling: imitation
Successive approximations: reinforce behaviors
that more & moreclosely resemble the final desired
response
GOALS
Quality treatment
Trust, reduce fear
Positive attitude
Reinforce positive behavior
Extinguish inappropriate behavior
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Behavioral Evaluation
Parentalinterview(Parent-Dentist)
Developmentalmilestones
Social and healthhistory
At ti tudes and
Expectations
Indirectobservation ofChild-Parent
interaction byDentist
At tachmentand
temperament
Direct childinteraction
(Child-Dentist)
Behavior Eval
Child Temperament/Attachment
TEMPERAMENT
Childs interaction with the environment
Childs initial response to new situations
Easy, difficult, slow to warm up, mix
ATTACHMENT
Childs intensity of interaction withcaregiver
High intensity indicates emotional
immaturity and insecurity
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TEMPERAMENT
Easy:
Highly regular in biologic functions
Positive approach to new stimuli
Rapidly adaptable
Frequent positive moods
Low or mildly intense reactions
Difficult:
Irregularity of biologic functions
Withdrawal response with newstimuli
Very slow in adapting
High frequency of negative moods
Frequent intense negative reaction
Attachment: emotional bond felt byhumans to special people in their lives
Occurs in latterpart of first yearof life
Central part ofcognitive andsocialdevelopment
Once securebase formed ,
child isconfident in
exploring the
environment
Lack ofattachmentmay confersome risks ofbehaviordifficulties l ater
in life
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FEAR
Greatest management problem = primary emotion, feeling of impending danger,
cognitive development link
Types of Fear
Objective Fears responses to stimuli that are
felt, seen, heard, smelled, or tasted that are of a
disagreeable or unpleasant nature
Subjective Fears based on feelings or
attitudes that have been SUGGESTED
Imitative fears subtle transmission, parent
displays and child acquired withoutbeing aware of it
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Common Fears
Age 1-2
Largemovements
Loud sounds
StrangersSeparation
Age 3-4
AnimalsBeing alone
Imaginarycreatures
Physical harm
Dark
Age 5
Decrease infears
Age 6-8
School failure
Ridicule
Death of lovedone
DENTAL FEAR
History of non-invasive = less fear
Coping skills increase with history of non-
invasive appointments
Childs perception of appointment is decisive in
developing fear- over preparation
Dentist empathy childs perception of dentist
Parental fear Childs temperament
Age & gender
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Anxiety
= apprehension,tension, or uneasiness whichstems from the ANTICIPATION of danger, the
source of which is largely unknown or
unrecognized, intra-psychic
Often indistinguishable from fear
BEHAVIOR TYPES
Cooperative
Lacking cooperative ability
Potentially cooperative = pre-cooperative
Uncontrolled behavior
Defiant behavior
Tense-cooperative behavior
Whining behavior The fearful child
The timid/shy/bashful child
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Types of Crying
ObstinateCrying
ObstinateCrying
FrightenedCrying
FrightenedCrying
Hurt CryingHurt CryingCompensatory
CryingCompensatory
Crying
Reasons for Adverse Behavior
Fear
Lacks
comprehension
- Dental
procedures,
personnel, office
env
Immature or
impaired
development
Impairments
- Stability & m
control
- Impulse
control
Safety =
paramount
- For patient &
dental team
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Behavior Management
Begins at 1st Contact
InitialContact &
AppoinmentScheduling
InitialContact &
AppoinmentScheduling
Pre-VisitLetter ifDesired
Pre-VisitLetter ifDesired
DentalEnvironment
- Officedesign &decor
DentalEnvironment
- Officedesign &decor
TreatmentAround
OtherChildren
TreatmentAround
OtherChildren
Pre-Visit Letter
Includes:
Appointment confirmation/time
Express appreciation
Details of first visit
Specific information fees, policies
Advantages:
Education Parent understands how to prepare
child
Parent understands visit is
DIAGNOSTIC
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Dental Environment
Childrens corner in reception area toys, puppets, books, games
Childrens corner in reception area toys, puppets, books, games
Operatory adult chair OK to treatchildren, sound control?
Operatory adult chair OK to treatchildren, sound control?
Consultationrooms
Consultationrooms
Bright, attractivecolorful walls,
pictures
Bright, attractivecolorful walls,
pictures
Preventiveorientation sink
& mirror atchilds height
Preventiveorientation sink
& mirror atchilds height
INFORMED CONSENT
Legal standard requires that theconsenter be:
informed
competent
acting voluntarily
Doctorpatient relationship is: fiduciary
not dominate/subordinate
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Prognosis ofProcedure
- good- fair-poor
Prognosis ofProcedure
- good- fair-poor
Possible need forunforeseen treatment,
or change of treatmentas planned
Possible need forunforeseen treatment,
or change of treatmentas planned
Prognosis if procedurenot undertaken
Prognosis if procedurenot undertaken
Alternatives to
proposed procedure- sedation (may stillrequire immobilization)- treatment under GA
Alternatives to
proposed procedure- sedation (may stillrequire immobilization)- treatment under GA
INFORMEDCONSENTELEMENTS
INFORMEDCONSENTELEMENTS
Distraction
Voice
Control
Nitrous
Oxide
Positive
Reinforce
TSD
ParentalPresence
Absence
Non-verbal
Basic BehaviorGuidance
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Non-invasive ManagementTechniques
Communication-based techniques
Do not require separate informedconsent
Designed for helping child cope with anxiety
contingency management
behavior shaping
TELL-SHOW-DO
Tell: Explain what going to do (before, during,
while)
Truthful
Use words child understands, dont talk down to
Be cautious with fear-promoting words
Bother instead of hurt
pinch instead of stick
Show: show what to expect
Anesthesia: pinch hand as demo
Avoid fear promoting instruments
Do: do it, use same voice
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This is how I count my fingers.
Lets count your
fingers!
Lets count some teeth!.
DENTAL TERM WORD SUBSTITUTE
Air Mr. Wind
Water Water-gun
High speed handpiece Mr. Whistle sings to you
Low speed handpiece Mr. Bumpy
Anesthetic Sleepy juice
Burr Brush/pencil
Caries Sugar bugs, brown spot, sick tooth
Explorer Tooth counter
Evacuator Vacuum cleaner, straw
Impression material Pudding, mashed potatoes
Matrix Filling fence, ring
Prophy paste Special toothpaste
Fluoride Vitamins
Rubber dam Raincoat
Rubber dam clamp Tooth button/ring
Rubber dam frame Coat rack
Dental
term
substitute
SSC Tooth hat
SS band Tooth ring
X-ray head Camera
X-ray picture
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Distraction
Verbal distractions
Walkman-typeheadphones, handheldgames
Ceiling-mounted posters
TV
Distracters
Distracters must be
intense to competewith patients desire toescape
Alterat ion o f
body, tone, or voice
Appropr iate child
adult roles
Gain attention,
compliance
VOICE CONTROL
HEY . . . STOP THAT.
THATS NOT ALLOWED
HERE
Sudden, firm
commands.
Facial
expression
must mirror
tone.
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Voice Control
Rated as unacceptable by
parents (takes authorit yfrom parent)
Perceived as aggressive
Alternate method lowertone, cooperation as
choice, and disruptivebehavior wil l require a
start over
Praise desired behavior
Make sure negativebehavior is not r elated to
actual pain
Parental PresenceWide diversity in practitioner philosophy andparental attitudes regarding presence orabsence
Parenting styles coping skills and self-discipli ne required to deal with newexperiences
Communication can be hampered
Range great benefit / disaster
Always with Spec ial Needs Chi ld
Parent must be part of solution and not part ofproblem
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INFORMED
CONSENT aMUST before the
Following
Behavior
ManagementTechniques!
Stabilization Protective stabilization = immobilization = restraint
= support
Good for patient and personnel safety when
absolutely necessary
Use least restrictive necessary
ACTIVE STABILIZATION
Caregiver/assistant/dentist performs
Ex: holding arms, legs, head
PASSIVE STABILIZATION
Ex. Pediwrap, papoose board
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Passive Stabilization
Active Stabilization
Hand Over Mouth / Flooding Used to re-establish communication when a
child has become hysterical/defiant
** child must be of normal intelligence
HAND OVER MOUTH tell child must stop
screaming in order to remove hand
NEVER use with frightened children, NEVER
do if angry
DONT DO
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Nitrous Oxide Sedation
* Low
solubility in
blood
* Excreted
unchanged
in the lungs,
and readily
diffuses into
alveolar
membranes
Side effects:
diffusion hypoxia
nausea
Correct total
liter flow is
determined
by the
amount
necessary to
keep
reservoir bag
1/3 to 2/3 full.
Contraindications:URI
Psychotic hx
Conscious Sedation
Premedication oral, nasal,
parenteralroutes
Premedication oral, nasal,
parenteralroutes
Special permitsrequired,
certification,training. Need
experience
Special permitsrequired,
certification,training. Need
experience
Must have
specialequipment,monitor for
emergencies
*PULSE OX
Must have
specialequipment,monitor for
emergencies
*PULSE OX
Know:
- Age
- Weight (use weightthat is the least b/tdosing and ideal
weight)
- Mental attitude
- Drugproperties/dosing
Know:
- Age
- Weight (use weightthat is the least b/tdosing and ideal
weight)
- Mental attitude
- Drugproperties/dosing
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General Anesthesia
General Anesthesia- IndicationsWeigh Risks vs. Benefits
mental
disabilities to
degree that dentist
cannot
communicate.
adequate
cooperation
cant be achieved
by usual behavior
management
techniques,
predmedications,
or acceptable
physical
restraint
Multiple
quadrants that
will require multiple
appointments
in the young
child
Systemic
disturbances
and congenital
anomalies that
dictate general
anesthesia
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Deferred Treatment
ART
Risk/benefitPreventiveprogram
Review of Dos
and Donts
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Dos Be prepared (children have small attention span), start on
time Be relaxed
Introduce yourself & get to know child
Give child lots of attention
Explain everything
Compare to children in + ways
PRAISE (not flatter)
Allow to use restroom before and drink of water if ask
Make everything pleasant
Avoid getting mad
Keep communicating Set limits
Establish signals (to convey feelings/concerns)
Enjoy yourself
Donts Lie
Make fun of the child
Scold/ridicule
Compare to other children in a negative way
Be too loud/forceful/overbearing
Use baby talk or talk down
Dont ignore
Use words that incite fear (needle, cut, drill, sharp, stick,
blood, sting, shot, bur, bite, pull, break)
Carry without parents permission
Be over-sympathetic Ask questions where child can say no
Allow child to see scary instruments
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Some Key Law Terms to
Know and AVOIDAssault = An intentional display of force that would give
the victim reason to fear or expect bodily harm; which
may be committed without touching or bodily harm
Battery = Unlawful application
of force to the body of another;unprivileged touching of
another persons body
MEDICAL BATTERY
- no need to prove injury or negligence- Necessary to prove that the medical personnel engaged in
unauthorized touching, contact or handling of the victim
- Ex. Perform treatment without informed consent
MEDICAL MALPRACTICE
- negligent acts performed by medical personnel
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QUESTIONS??
Works Cited:
Rockman, Roy A. Child Taming: How to Manage Children in Dental Practice
Furnish, Guy. University of Louisville School of Dentistry Pediatric Manual