This document discusses child behavior and behavior management techniques in dentistry. It defines concepts like fear, anxiety, and emotions commonly seen in children. It also describes various classification systems used to assess child behavior and factors that can influence it like parental attitudes. The document outlines non-pharmacological behavior management techniques including communication, modeling, desensitization and contingency management. It discusses practical considerations for behavior management in a dental clinic.
2. Are we managing our children’sAre we managing our children’s
behavior or just treating dental cariesbehavior or just treating dental caries
??
3. Behaviour: Is an observable act, which can be described
in similar ways by more than one person.
”It is defined as any change observed in the functioning
of the organism.”
Behavioural 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
4. Normal behaviour :-Normal behaviour :-
Psychomotor
Emot ional Development
Environmental Influences
PersonalityTraits
5. Emotion is a state of mental excitement
characterized by physiological, behavioral
changes and alterations of feelings.
9. FearFear
It may be defined as an unpleasant emotion or effect
consisting of psycho-physiological changes in
response to realistic threat or danger to one's own
experience.
Innate fear
Subjective fear
Objective fear:
10. Fear Evoking Dental Stimuli…
Factors Causing Dental Fear
1. Fear of pain or its anticipation.
2. A lack of trust or fear of betrayal.
3. Fear of.1oss of control.
4. Fear of the unknown.
5. Fear of intrusion.
SIGNS AND SYMPTOMS OF FEAR
11. AnxietyAnxiety
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 feeling
combined with an associated feeling of impending doom
or danger from within rather than from without.
It is a learned process being in response to one's
environment. As anxiety depends on the ability to
imagine, it develops later than fear.
12. Types of anxietyTypes of anxiety
Trait anxiety-temperament feature. These children are
generally jittery, hypersensitive to stimuli.
Free floating anxiety- persistently anxious mood
Situational anxiety- Seen only to specific situations or
objects.
State anxiety-
General anxiety -a chronic pervasive feeling of
anxiousness whatever the external circumstances.
14. Phobia: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
18. Behavior managementBehavior management
Behavior management is the means by
which the dental health team effectively and
efficiently performs treatment for a child
and, at the same time, instills a positive
dental attitude.
The fundamentals of behavior management
center on the attitude and integrity of the entire
dental team.
19. FUNDAMENTALS OF BEHAVIOR MANAGEMENTFUNDAMENTALS OF BEHAVIOR MANAGEMENT
Positive approach- Positive statements
Team attitude- Friendly and caring
Organization- Well organized dental team and
treatment
Truthfulness- Black or White ,nothing gray
Tolerance- Ability to rationally cope with the
misbehaviors
Flexibility-as situation demands
22. Frankel’s Behavioral Rating Scale.Frankel’s Behavioral Rating Scale. (1962)(1962)
Rating 1: Definitely Negative. Refusal of treatment,
forceful crying, fearfulness, or any other overt evidence of
extreme negativism.
Rating 2: Negative. Reluctance to accept treatment,
uncooperativeness, some evidence of negative attitude but
not pronounced.
Rating 3: Positive. Acceptance of treatment; cautious
behavior at times; willingness to comply with the dentist,
at times with reservation, but patient follows the dentist's
directions cooperatively.
Rating 4: Definitely Positive. Good rapport with the
dentist, interest in the dental procedures, laughter and
enjoyment.
23. Wilson's classification (1933)Wilson's classification (1933)
a) Normal or bold: The child is brave enough to face
new situations, is co-operative, and friendly with the
dentist.
b) Tasteful or timid: The child is shy, but does not .
interfere with the dental procedures.
c) Hysterical or rebellious: Child.is influenced by
home environment - throws temper-tantrums and
is rebellious.
d) Nervous or fearful: The child is tense and
anxious, fears dentistry.
24. Lampshire Classification (1970)Lampshire Classification (1970)
1. Co-operative: The child is physically and emotionally relaxed. Is
cooprative throughout the entire procedure
2. Tense cooperative: The child is tensed, and cooperative at the
same time.
3. Outwardly apprehensive: Avoids treatment initially, . usually
hides behind the mother, avoids looking or talking to the
dentist. Eventually accepts dental treatment.
4. Fearful: Requires considerable support so as to overcome the
fears of dental treatment.
5. Stubborn/Defiant: Passively resists treatment by using
techniques that have been successful in other situations.
6. Hypermotive: The child is acutely agitated and resorts to
screaming kicking etc.
7. Handicapped: Physically/mentally, emotionally handicapped.
8. Emotionally immature
25. Factors affecting ChildsFactors affecting Childs
behaviorbehavior
Under the control of dentist
Under the control of parents
– Maternal anxiety and attitudes [Overprotective,
Overindulgent, Under affectionate, Rejecting,
authoritarian]
Others [socioeconomic status, nutritional,past
dental experience]
26. Behavior Management techniques can beBehavior Management techniques can be
broadly classified as:broadly classified as:
Non-Pharmacological Techniques.
Pharmacological Techniques
27. Non-pharmacological methods
1. Communication
2. Behavior shaping (modification)
a. desensitization
b. modelling
c. contengency management
3. Behavior management
a. audioanalgesia
b. biofeedback
c. voice control
d. hypnosis
e. humor
f. coping
g. relaxation
h. implosion therapy
i. Aversive conditioning
29. CommunicationCommunication
Verbal [establishment of communication,
establishment of communicator ,message clarity,tone]
Nonverbal [Multi sensory Communication]
Problem Ownership –Use “I” messages,
Active Listening
Appropriate Responses to the situation
30. DENTAL TERMINOLOGY WORD SUBSTITUTES
rubber dam rubber raincoat
rubber dam clamp tooth button
rubber dam frame coat rack
sealant tooth paint
topical fluoride gel cavity fighter
air syringe wind gun
water syringe water gun
suction vacuum cleaner
Alginate pudding
study models statues
high speed whistle
low speed motorcycle
31. Behavior shapingBehavior shaping
By definition, it is that procedure which very slowly
develops behavior by reinforcing successive
approximations of the desired behavior until the
desired behavior comes to be.
: Stimulus – response (S-R) theory
32. Systematic DesensitizationSystematic Desensitization ..exposure to..exposure to
hierarchy of fear producing stimulihierarchy of fear producing stimuli
Desensitization : (joseph Wolpe)Desensitization : (joseph Wolpe)
34. Tell-show-do[ Addelston]Tell-show-do[ Addelston]
The technique involves verbal explanations of
procedures in phrases appropriate to the
developmental level of the patient (tell);
demonstrations for the patient of the visual, auditory,
olfactory, and tactile aspects of the procedure in a
carefully defined, non threatening setting (show);
and then, without deviating from the explanation and
demonstration, completion of the procedure (do).
The tell-show-do technique is used with
communication skills (verbal and nonverbal) and
positive reinforcement.
35. Tell-show-doTell-show-do
Objectives:
1. teach the patient important aspects of the
dental visit and familiarize the patient with the
dental setting;
2. shape the patient’s response to procedures
through desensitization and well-described
expectations.
41. Positive reinforcementPositive reinforcement
to give appropriate feedback.
to reward desired behaviors and thus strengthen
the recurrence of those behaviors.
Social reinforcers include positive voice
modulation,facial expression, verbal praise, and
appropriate physical demonstrations of affection by all
members of the dental team
Nonsocial reinforcers include tokens and toys.
Objective: Reinforce desired behavior.
.
42. 3. Behavior management3. Behavior management
a. audioanalgesia: white noise
b. biofeedback: detect physiological processes
c. voice control
d. hypnosis: altered state of consciousness
e. humor:
f. coping: signal system
g. relaxation:
h. implosion therapy
i. Aversive conditioning
44. Voice ControlVoice Control
Voice control is a controlled alteration of voice
volume, tone, or pace to influence and direct
the patient’s behavior.
Objectives:
1. gain the patient’s attention and compliance;
2. avert negative or avoidance behavior;
3. establish appropriate adult-child roles.
49. Informed consentInformed consent
All management decisions must be based on a
subjective evaluation weighing benefit and
risk to the child.
It is important that the dentist inform the
legal guardian about the nature of the
technique
Communicative management, requires no
specific consent.
50. HOMEHOME
Redirect inappropriate behavior.
Hand is gently placed over the child’s mouth and
behavioral expectations are calmly explained.
Maintenance of a patent airway is mandatory.
Upon the child’s demonstration of self-control and
more suitable behavior, the hand is removed and
the child is given positive reinforcement.
51.
52. HOMEHOME
.Indications:
A healthy child (Able to understand and
cooperate), but who exhibits hysterical
avoidance behaviors.
Contraindications:
1. children who, due to age, disability,
medication, or emotional immaturity are
unable to verbally communicate, understand,
and cooperate;
2. any child with an airway obstruction.
53. Several variations of home:Several variations of home:
HOMAR: HOM with airway restricted
HOM and nose with airway restricted
Towel held over mouth only
Dry Towel held over mouth and nose
Wet Towel held over mouth and nose
55. OralOral
At the time of injection
For stubborn child/ defiant child
Mentally handicapped child
Very young child who cannot keep its mouth open
for long time
59. Restrains - BodyRestrains - Body
Restrict the pt movements
Used frequently in pt < 2yrs of age
Papoose board:-
Advantages:
Store / use
Size(3)
Reusable
60. Body RestrainsBody Restrains
Triangular sheet with leg straps:-
Mink – bed sheet / triangular sheet
technique
Advantage:
– sit upright
Disadvantages:
Need of straps
Difficult for small children
Airway impingement
hyperthermia
61. Body RestrainsBody Restrains
Pedi wrap:-
Has nylon sheet
No head supports/
back board
Various sizes
Movement
Mesh fabric –
ventilation( no
hyperthermia)
Requires straps
62. Restrain : ExtremitiesRestrain : Extremities
Attach to the dental unit restraint a pt at the
chest waist, legs.
Mentally / physically handicapped
Prevent the pt from getting injured himself
Prevent from interfering in the dental
procedure.
– Posey straps
– Velcro straps
– Towel & tape
– Extra assistant
63. HeadHead
Supports the head
Protects the pt from getting injured himself & pt.
Types:
Fore body support
Head protector
Extra assistant
66. Convenience of the child
Convenience of the dentist
PEER grouping
SchedulingScheduling
67. ParentalParental
presence/absencepresence/absence
The parent often repeats orders, injects orders,
The dentist is unable to use voice intonation,
divides attention between the parent and child.
The
child divides attention between the parent and
dentist.
"performing with an audience."
68. Parental presenceParental presence
A parent can be a major
asset in supporting and
communicating with a
disabled child,
Very young children
(those who have not
reached the age of
understanding and full verbal
communication) have a
close symbiotic relationship
with parents; consequently,
they usually are
accompanied by them.
70. GoalsGoals
To facilitate the provision of quality care
Minimize extremes of disruptive behavior
To promote a positive psychologic response
to treatment
To promote patient welfare and safety
71. Patient Physical StatusPatient Physical Status
ClassificationClassification
ASA I - A normal healthy patient. (ASA = American Society
of Anesthesiologists)
ASA II - A patient with mild systemic disease.
ASA III - A patient with severe systemic disease.
ASA IV - A patient with severe systemic disease that is a
constant threat to life.
ASA V - A moribund patient who is not expected to survive
without the operation.
ASA VI - A declared brain-dead patient whose organs are
being removed for donor purposes.
E - Emergency operation of any variety (used to modify one
of the above classifications, i.e., ASA III-E).
72. STAGES OF ANESTHESIASTAGES OF ANESTHESIA
I stage of analgesia
II stage of delirium
III stage of surgical anesthesia
IV stage of respiratory paralysis
73. Conscious sedation ASDAConscious sedation ASDA
19851985
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
nonpharmacologic methods alone or in
combination
74. Deep sedationDeep sedation
A controlled state of depressed
consciousness accompanied by a partial loss
of protective reflexes including inability to
respond purposefully to a verbal command,
produced by pharmacologic and
nonpharmacologic methods alone or in
combination
75. General anesthesiaGeneral anesthesia
A controlled state of unconsciousness
accompanied by partial or complete loss of
protective reflexes including inability to
maintain airway independently and respond
purposefully to physical stimulation or
verbal command, produced by
pharmacologic and nonpharmacologic
methods alone or in combination
78. Indications of C.SIndications of C.S
Objectives Indications Contraindications
mood alteration
patient should be
conscious
respond to verbal
stimuli
Intact reflexes
Vital signs stable
and normal
Pain threshold
increased
amnesia
uncooperative
patients
Cannot
understand
definitive
treatment
lack of psycho-
logical or
emotional
maturity
fearful &
anxious
COPD
Epilepsy
bleeding
disorders
prolonged
surgery
79. Pre-requisitesPre-requisites
Knowledge about the agent
Documented rationale
Informed consent
Office facilities
Mobile emergency medical facilities
Patient selection and preparation
Medical history and patient evaluation
80. Patient Assessment Prior ToPatient Assessment Prior To
Conscious SedationConscious Sedation
The physician, dentist, or independent practitioner
responsible for overall conduct of the conscious
sedation is generally required to do the following
within 30 days prior to procedural sedation:
– perform a history and physical exam
– assign an American Society of Anesthesiologist (ASA)
health class
– document a sedation plan
– document NPO status and interval changes if H&P not
done immediately prior to procedure.
81. Focused History and ExamFocused History and Exam
History should focus on factors that may
increase
– patient sensitivity to sedatives/analgesics
– patient risk of respiratory/cardiopulmonary
complications
– difficulty in managing complications
84. ROUTES OF ADMINISTRATIONROUTES OF ADMINISTRATION
Inhalation
Enteral [ oral and rectal]
Parenteral [ IM, IV, IN, Submucosal, sub
cutaneous,]
85. InhalationInhalation
Indications Contraindications Advantages Disadvantages
Anxiety
Medicall
y
compromis
ed patients
Gagging
Severe
behavioral
problems
Acute
respiratory
conditions
COPD
Pregnancy
Rapid
onset
Peak
clinical
actions
Titration
permitted
Depth of
sedation can
be altered
Rapid
recovery
Cost
Space
Potency
Training
of staff
Occupatio
nal hazard
86. Nitrous oxide and oxygenNitrous oxide and oxygen
sp gr 1.53,low solubility in blood, rapid onset , no
bio transformation,excreted by lungs
Adverse effects [ N2O Entraped in gas filled
spaces]
87. Oral routeOral route
Advantages Disadvantages
Universally accepted
Easy
Low cost
Low incidence of
reactions
No pricks
No equipments
No special training
Reliance
Prolonged latent
period
Erratic & incomplete
absorption
Inability to titrate
Prolonged duration of
action
88. RectalRectal
Indications Advantages Disadvantages
Unwilling to
take orally
Nausea &
vomitting
Patient
objecting
injection
Post-op control
of pain
Low cost
Easy
No pricks
Absorb directly
into systemic
circulation
Bypassing
entero hepatic
circulation
Inconvenience
Variable
absorption
Inability to
reverse
Inability to
titrate
97. Sedative HypnoticsSedative Hypnotics
Barbiturates Chloral hydrate
Limited value for pediatric
patients
Must be individualized for
each
Recommended 25-50mg/kg
to a max of 1g supplied in
the form of oral capsules
500mg
Oral solution 250 and
500mg/ 5ml
Rectal suppositories 324
and 648mg
98. NarcoticsNarcotics
Meperidine Fentanyl
Oral/ SC/ IM – 1 to
2.2mg/kg not to exceed
100mg
Supplied : oral tablets 50
and 100mg
Oral syrup 50mg/ 5ml
Parenteral solution 25, 50,
75 and 100mg/ ml
0.002 to 0.004mg/ kg
Supplied 0.05mg/ ml in 2
and 5ml ampules
100. Ketamine [ Dissociative agent]Ketamine [ Dissociative agent]
Derivative of the street drug phencyclidine.
This drug carries an increased risk of deep sedation
and should be used only by those with hospital
privileges in deep sedation.
Induces a functional dissociation between the
cortical & limbic systems to create a sensory
isolation and “trance-like” state.
A potent pain reliever as the drug prevents cortical
interpretation of noxious stimuli.
101. KetamineKetamine
Produces CNS stimulation & inhibits catecholamine uptake,
so direct myocardial depressant effects are overcome.
While producing sedation, amnesia, & analgesia, ketamine
may also produce dreams & delirium. This is minimized by
co-administering small doses of midazolam.
1 TO 4.5mg/kg IV over 1min
102. PropofolPropofol
This drug carries an increased risk of progression to
deep sedation and should be used only by those with
hospital privileges in deep sedation.
no analgesic properties but does produce sedation
and amnesia.
widely distributed in the body and is eliminated via
hepatic & pulmonary systems.
DOSE 1mg/kg /iv followed by 3 to 4.5 mg /kg/hr
103. The Lytic CocktailThe Lytic Cocktail
A fixed combination of meperidine, promethazine,
and chlorpromazine.
Long history of use in pediatric sedation.
Commonly called DPT, an acronym for demerol,
phenergan, and thorazine.
Its use is strongly discouraged; equivalent or
superior sedation may be achieved with single
agents or individualized combinations of sedatives
& narcotics.