Dental Behavior Management Of Children presented by:

حسن عصام محمدطاهر يقظان محمد

محمد سالم عليالساده عبد حمزة

Introduction:

Behavior: Is an observable act, which can be described in similar ways by more than one person.Emotion is a state of mental excitement characterized by physiological, behavioral changes and alterations of feelings.

Types of children emotions:• Cry:

Obstinate cryFrightened cryHurt cry Compensatory cry

• Anger • Fear: It is defined as an unpleasant emotion or effect consisting ofpsycho-physiological changes in response to realistic threat or danger to one's own experience.Types of fear:• Subjective fear • Objective fear

• OBJECTIVE FEAR:- They are the responses to stimuli that are felt, seen, heard, smelt or tasted and are not liked or accepted.

• SUBJECTIVE FEAR:- These are based on the feelings and attitudes that have been suggested to child by others about dentistry without the child having had the experience personally.

• SIGNS AND SYMPTOMS OF FEAR:• Anxiety• Phobia

• Anxiety Is an emotion similar to fear arising without any objective source of danger. Is a reaction to unknown danger.

• It is often been defined as a state of unpleasant feelingcombine from within rather than from without. • It is a learned process being in response to one'senvironment. As anxiety depends on the ability toimagine, it develops later than fear. with an associatedfeeling of impending doom or danger

Types of anxiety

PHOBIA:• Defined as persistent, excessive, unreasonable fear of a specific object, activity or situation that

results in a compelling desire to avoid the dreaded object.

• Simple• Situational• Social

CLASSIFICATION OF CHILDREN’S BEHAVIORS:-

1- CO-OPERATIVE BEHAVIOR:- Reasonably relaxed, have minimal apprehension and can be treated by a straight forward behavior shaping approach.

2- LACKING CO-OPERATIVE BEHAVIOR:--This behavior is contrast to co-operative child.-Includes very young child (<2.5years) or with specific debilitating or handicapping conditions.

3- POTENTIALLY CO-OPERATIVE BEHAVIOR:- Differs from a child lacking cooperative ability in that this child is able to cooperate and is

physically and medically fit.- Potentially cooperative group are further categorized as follows:

A- Uncontrolled behavior:-• Seen in 3-6 years.• Tantrum may begin in the reception area or even before.• Tears, loud crying, physical lashing out and flailing of hands and legs all suggestive of a state of acute anxiety or fear.

B- Defiant behavior:-• Can be found in all ages, more typical in the elementary school group. • Distinguished by “I don’t want to” or “I don’t have to” or “I wont”.

• Once won over, these children frequently become highly cooperative.

C- Timid behavior:-• If they are managed incorrectly, their behavior can deteriorate to uncontrolled.• May be from an overprotective home environment or may live in an isolated area having little

contact with strangers. • Needs to gain self confidence of the child.

D- Tense cooperative behavior:-• Accept treatment, but are extremely tense.• Tremor may be heard, when they speak.

E- Whining behavior:-• They do not prevent treatment, but whine throughout the procedure.• Great patience is required while treating such children.

FACTORS INFLUENCING CHILD’S BEHAVIOR:-

1-FACTOR INVOLVING THE CHILD:-A. Growth and developmentB. Past dental experienceC. Social and adaptive skillD. Position of child in the family

2- FACTORS INVOLVING THE PARENTS:-A. Family influenceB. Parent-child relationshipC. Maternal anxietyD. Attitude of parents to dentistry

3- FACTORS INVOLVING THE DENTIST:-

A. Appearance of the dental officeB. Personality of the dentistC. Time and length of appointmentD. Dentist’s skill and speedE. Use of fear promoting wordF. Use of subtle, flattery, praise and reward.

BEHAVOUR MANAGEMENT:• Behavioral pedodontics :- It is a study of science which helps to understand

development of fear, anxiety and anger as it applies to child in the dental situations.

Objectives of Behavior Management :-• Establishes effective communication with the child.• Gains child’s confidence and acceptance of dental treatment• Provides a comfortable environment for the dental team to work in.

Behavior management can be achieved by basically two methods:-A- Non pharmacological methods B-pharmacological methods1- Communication. Conscious sedation:2-Tell-show do technique. * Nitrous/Oxide Inhalation3-Modelling. 4-Positive and negative reinforcement 5-Distraction 6-Voice control 7-Retraining8-HAND OVER MOUTH TECHNIQUE9-Physical immobilization

A-NON-PHARMACOLOGICAL METHODS:-

1-COMMUNICATION:-• The hallmark of successful dentist in managing children is his ability to

communicate with them and win their confidence.• Effective communication with children is critical for gaining the child’s

cooperation to receive dental care.

2-TELL-SHOW –DO TECHNIQUE

• TELL: The technique involves verbal explanations of procedures in phrases appropriate to the developmental level of the patient.

• SHOW: demonstrations for the patient of the visual, auditory, olfactory, and tactile aspects of the procedure in a carefully defined, non threatening setting.

• DO: and then, without deviating from the explanation and demonstration, completion of the procedure.

• The tell-show-do technique is used with communication skills (verbal and nonverbal) and positive reinforcement.

TELL-SHOW -DO TECHNIQUE

3-MODELLING• The basic modeling procedure involves allowing a patient to observe

one or more individuals (models) who demonstrate appropriate behavior in particular patient

• Stimulated models as live models (siblings or parents) , films, clips, posters, audiovisuals, or videos can be used to reinforce the desired behavior.

4-Reinforcement

Reinforcement can be :-• Positive reinforcement:- presentation of reinforces which increases the frequency of desired behavior.

• Negative reinforcement:- withdrawal of reinforces which increases the frequency of desired behavior.

Types of Reinforcement

Reinforcement

Social

MaterialActivity

Reinforcement

Social reinforces:- include positive voice modulation ,facial expression, verbal praise, and appropriate physical demonstrations of affection by all members of the dental team.

1. praise ( Good, Excellent, Thank you )2. Facial expression ( Smiling , laughing )3. Physical Contact ( patting on shoulder or shoulder ,

hugging , shaking / holding hands )

Nonsocial reinforces:- include tokens and toys.

5-Distraction• It is a technique used to divert the patient’s attention during the unpleasant

procedure such as:-• Music• Video• Talking• White noise….• Hypnosis• Breathing

6-Voice control

• Voice control is a controlled alteration of voice volume, tone, or pace to influence and direct the patient’s behavior to:-

1. Gain the patient’s attention and compliance2. avert negative or avoidance behavior3. establish appropriate adult-child roles.

7-Retraining• If a child have an unpleasant experience in the previous dental office, the

child still tends to generalized that an unpleasant event will occur in his new dental office also. This is non as stimulus generalization. To remove this the dentist has demonstrate a difference and create new stimulus which is pleasant and replaces the old.

8-HAND OVER MOUTH TECHNIQUE:-• This method is establish communication with children who are able to cooperate,

but exhibit a hysterical behavior to avoid treatment.• A hand placed over the child’s mouth and is told that the hand will be removed as

soon as appropriate behavior begins.• When the child responds, the hand is removed and the praised for his appropriate

behavior.• Contraindicated in immature frightened, or the child with a serious

physical, mental or emotional handicap

9-Physical immobilization:-

Are used to provide partial or complete immobilization of the patient to protect the patient and dental staff from injury while providing dental care, this is done by :-• dentist/staff/parents• Physical restraints

● Papoose board● Triangular sheet● Pedi wrap● Mouth prop or bite block

Papoose board Pedi wrap Mouth prop

B-Pharmacological methods:- Conscious Sedation:What is C.S ?• Minimally depressed level of consciousness that retains the patient’s ability

to independently and continuously maintain an airway and respond appropriately to physical stimulation and verbal command, produced by pharmacologic and non-pharmacologic methods alone or in combination, (NO LOSS OF CONSCIOUSNESS)

Nitrous Oxide• Nitrous Oxide is a very quick acting inhaled sedation medicine that decreases

discomfort and anxiety.Oxygen and nitrous oxide is given through a small breathing mask.Relaxing, but without putting them to sleep.Very safe and effectiveSometimes called “laughing gas”Often given at the dentists officeNitrous Oxide is a sweet-smelling, colorless gas.It is heavier than air or oxygenOnsetAnywhere from a few seconds up to 3-5 minutesCrosses the blood-brain barrier rapidly

The objectives of nitrous oxide/oxygen inhalation

1. Reduce or eliminate anxiety. 2. Reduce unwanted movement and reaction to dental treatment. 3. Enhance communication and patient cooperation. 4. Raise the pain reaction threshold.5. Increase tolerance for longer appointments. 6. Aid in treatment of the mentally/physically disabled or medically compromised patient. 7. Reduce gagging. 8. Potentiate the effect of sedatives.

Review of the patient’s medical history should be performed prior to the decision to use nitrous oxide/oxygen analgesia/ anxiolysis. This assessment should include:• 1. Allergies and previous allergic or adverse drug re- actions.• 2. Current medications including dose, time, route, and site of

administration.• 3. Diseases, disorders, or physical abnormalities • 4. Previous hospitalization to include the date and purpose. • 5. Recent illnesses (eg, cold or congestion) that may compromise the

airway.

Indications for use of nitrous oxide/oxygen analgesia/anxiolysis

• 1. A fearful, anxious patient• 2. Certain patients with special health care needs. • 3. A patient whose gag reflex interferes with dental care.• 4. A patient for whom profound local anesthesia cannot be obtained.• 5. A cooperative child undergoing a lengthy dental procedure.

Contraindications for use of nitrous oxide/oxygen inhalation1.Some chronic obstructive pulmonary diseases.2. Severe emotional disturbances or drug-related dependencies.3. Treatment with bleomycin sulfate.

Thank you