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Pediatric Dentistry-

Little Teeth,Big Smile..

Presented By-ANJALI Guided By-Dr.Anil Kohli
Dr.Ashish Katiyar
YADAV Dr.Garima Singh
IV year Dr.Karuna Sharma
Roll No.-13
Behaviour Management-Non
Frankl’s Classification of child behaviour in dental office
Pinkham’s Classification
Lampshire Classification
Wright Classification
Classification of behaviour management
Normal behavioral characteristics
Objectives of behaviour management
Factors influencing child’s behaviour in dental office
Fundamentals of behaviour management
Role of dentist in child’s behaviour
Maternal influence on child’s behaviour
Fear and phobia
• Behaviour-It is any activity that can be
observed,recorded & measured.It is an
observable act or any change in the
functioning of an organism.
• Behaviour Management-It is the means by
which the dental health team effectively
performs treatment for a child & at the same
time,instills a positive dental attitude.
Frankl’s Classification Of Child
Behaviour in Dental Office
• Frankl in 1962 introduced a behavior-
rating scale,which is one of the most
reliable tools developed for behavior
Behavior Rating Symbol Features
Definitely Negative No. 1 (-) • Refuses treatment
• Cries forcefully
• Extreme negative behavior associated
with fear
Negative No. 2 (-) • Reluctant to accept treatment
• Displays evidence of slight negativism

Positive No. 3 (+) • Accepts Treatment

Definitely Positive No. 4 (++) • Unique behavior

Category 1 Emotionally compromised child

Category 2 Shy,introvert child

Category 3 Frightened Child

Category 4 Child who is adverse to authority

• Cooperative
• Tense Cooperative
• Outwardly apprehensive
• Fearful
• Stubborn/Defiant
• Hypermotive
• Handicapped
• Emotionally Immature

• Cooperative Behaviour
• Lacking Cooperative Behaviour
• Potentially Cooperative Behaviour(5
 Uncontrolled Behaviour
 Defiant/Obsinate Behaviour
 Timid Behaviour
 Tense-cooperative Borderline Behaviour
 Whining behaviour
Classification of Behavior


Psychological Physical
Approach Approach
behavior modification


Use of second

Tell Show Do

Tender Love Care

Approach Desensitization


Parental presence or


Voice control
Hand Over Mouth
Physical Restraints


cal Conscious Sedation

General Anaesthesia
• Pre-appointment Behaviour Modification-
-Audiovisual Modeling-The goal is for the
patient to reproduce the behaviour exhibited by
Child sees the video cassette before
proceeding to dental clinic,on day of appointment.
Type of model used can be siblings,other
children or parents.
Advantages-Extinction of fear
Disadvantages-Expensive and time consuming
-Preappointment Mailing-Contact with the child’s
parents before the first dental visit can alienate
some concerns.
• Communication-
-First objective in successful management of the
young child is to establish communication.
-By involving the child in conversation,the dentist not
only learns about the patient but also may relax the
-There are 2 ways of establishing communication-
Verbal (spoken language)& Non Verbal(expression
without words like handshake,welcome).
-Effective vocabulary is important aspect as the
dentist must only use the words that are
understandable by the child.
-The 3 most important facets of communication are
source,medium and receiver.In reference to
dentistry ,dentist is the source,dental clinic is the
medium and child is d receiver.
• Use of second language(Euphemisms)-
-Address the child at his or her level of
comprehension.This does not suggest
the use of baby talk,but rather employing
words that have meaning for that child.
-The dental staff as well as the dentist
should be oriented to the use of “second
language”.The tone of the voice can also
be very effective in altering the child’s
behaviour.A kind,firm,or a soft or a loud
voice says a lot to the child.It is not what
you say but it is how you say it.

Anesthetic Sleepy medicine or Sleepy

Bur Brush or pencil
Caries Brown Spot-Sugar Bugs
Evacuator Vacuum cleaner
Matrix Fence for filling
Rubber dam Raincoat
Stainless steel band Ring for the tooth
Stainless steel crown Hat for the tooth
X-Ray Camera
Radiograph Picture
Handpiece Whistling Train
• Tell-Show-Do-
-TSD is the cornerstone of behaviour
management.The classic model for
communicating with children and favourably
conditioning them to the dental experience is
-Specifically,the dentist tells the child what is
going to be done in words the child can
understand.Second,the dentist demonstrates to
the child exactly how the procedure will be
conducted.Finally,the practitioner performs the
procedure exactly as it was described and
-Objective is to teach the patient aspects of dental
visit and to familiarize him with the dental setting.
• Desensitization-
-It is a therapeutic technique that pairs an
anxiety-evoking stimulus with a response
inhibitory to anxiety.In such situations
the perceived link between the stimulus
and the anxiety response is weakened.
-This is used in children having pre-
established fears and uncooperative
• Modeling-
-It is based on the psychologic principle that
much of one’s learning or behaviour acquisition
occurs through observation of a suitable model
performing a specific behaviour.
-Types of Models-i)Mastery ii)Coping
-Objective is to eliminate the avoidance
behaviour and extinction of fear.
-Advantages-i)Patient’s attention is obtained.
ii)Designed behaviour is modeled.
iii)Physical guidance of desired
• Contingency Management-
-The presentation of positive reinforcers or
withdrawal of negative reinforcers is termed
contingency management.
It includes-
i)Positive reinforcement
ii)Negative reinforcement
iii)Omission or time out
Types of Reinforcers-
a)+ve reinforcers-It is the one whose presentation
increases the frequency of desired behaviour.
b)-ve reinforcers-It is the one whose contingent
withdrawal increases the frequency of behaviour.
toys.Rewards are given after the dental
procedure and bribes are given before.Bribes
should not be given in pediatric dental
d)Social-Praise,+ve facial expression,hand
shake,smile,pat on the shoulder.This is the
best kind of +ve reinforcer.
e)Activity-Opportunity to participate in
preferred activity like cartoon show,visit to
the park.Before patient can accomplish this
activity ,he has to behave accordingly in
dental office.
• Externalization-
-It is the process by which child’s attention is
focused away from the sensation associated
with the dental treatment by involving in verbal
or dental activity.
-Objective is to decrease the perception of
• Distraction-
-In this method the patient is distracted from
the sounds and/or sight of dental treatment
thereby reducing the anxiety.
-Objective is to relax the patient and to reduce
anxiety during treatment.
-Use stories and fairy tales or use slow
instrumental music.
-Relaxation effect of music and the
sound of music will eliminate unpleasant
dental sounds like the sound of
Types-a)Audio distraction
b)Audio-visual distraction
• Assimilation & Coping-
-Stress can act to increase pain perception while
coping decrease it by a process called as
-Coping refers to cognitive and behavioral efforts
made by individuals to master,tolerate or reduce
stressful situations.
-Behavioral coping-Efforts include physical or
verbal activities in which the child engages to deal
with stress.
-Cognitive coping-Efforts which include
manipulation of emotions.
-Children taught coping skills like
imagery,relaxation,self talk demonstrated less
stress during treatment.
• Parental Presence or Absence-
-Objective-To gain patient’s attention and
-To avert the avoidance behaviour.
-Advantages of parental presence-
Supporting and communicating with the
-Very young patients.
-Advantages of parental absence-Avoiding
parental interference.
-Overcoming the parental conditioning.
• Retraining-
-A technique similar to behavior
shaping,designed to fabricate positive
values and to replace the negative
• Visual Imagery-
-Subject is asked to imagine being in his
favorite place/performing his favorite
activity and this can act as a fantasy
during his dental treatment.
• Voice Control-
-Given by Pinkham in 1985
-Sudden and firm commands that are used to get the
child’s attention and stop the child from his current
-Soft,monotonus soothing conversation can also be
used as it is supposed to function like music to set the
-The tone of voice and the facial expression of the
dentist are also important as they function like a mirror.
-Objective-to gain the patient attention and compliance.
-to avoid negative or avoidance behaviour.
-to establish authority.
-Indications-Uncooperative and inattentive patients
• Use of poetry and drawings-
-Use of poetry-This technique is
employed in children above 7 years of
-Use of drawings-This technique was
developed when it was discovered that
with a little manipulation the forms of a
familiar teeth could be altered to look like
common animals,insects,birds.
-useful for children of 3-5 years of
-Advantages-It allows repetition without
• Hypnosis-
-First suggested by Franz A Mesmer,in 1773.
-It is defined as a state of mental relaxation and
restricted awareness in which subjects are
usually engrossed in their inner experiences
such as imagery,are less analytical and logical
in their thinking and have enhanced capacity to
respond to suggestions in an automatic and
dissociated manner.
-Uses-To reduce nervousness.
-To induce anesthesia.
-To prevent thumb sucking and bruxism.
• Hand Over Mouth Technique-
-This technique was first described in 1920 by Dr.E
-Also known as “Aversive conditioning”terminology
given by Lenchner and Wright.
-Objective-i)To gain child’s attention enabling
communication with dentist so that appropriate
behavioral expectation can be explained.
ii)To eliminate the inappropriate avoidance behavior
to dental treatment.
iii)To increase child’s confidence in coping with
-Indication-A healthy child who is able to
understand and cooperate but who exhibits defiant
and hysterical behavior to dental treatment.
-Contraindications-i)Immature child
ii)When it prevents child from breathing.
-Technique-When indicated,a hand is placed
over child’s mouth and behavioral
expectations are calmly explained.Child is
told that the hand will be removed as soon as
the appropriate behavior begins.When child
responds,the hand is removed and child’s
appropriate behavior is reinforced.If the child
shows negative behavior again the procedure
is repeated.
-Legality of use-Use of HOM airway restricted
is more nearly objectionable legally and may
result in liability of dentist.
Normal Behavioral
Word picture of
a 2-year-old-

Emotional Development Mental Development Motor Development

Self-centered Cannot recognize Whole body action

Gives up readily Irresponsible Climbs onto stairs

Clings to familiar people One/two word sentences Unsteady

Easily distracted Attention span 1-5 minutes Depends on adults for


Dependence on adults Matches words with object Push/pull,pokes

Word picture of

Emotional Development Mental Development Motor Development

Highly imitative of adults Makes simple choices Well-balanced body

Jealous Alert,excited,curious Rides a tricycle

Exuberant-very talkative Very talkative regardless Enjoys rhythm

of listener

Wants to please adults Tries new words Finger control in handling

small objects

Often gets frustrated Attention span 4-8 Walks erect

Word picture of a 4-year-old

Emotional Development Mental Development Motor Development

Dominates-Bossy,Boastful Likes variety of material A longer,leaner body built

Hit,grabs for what he Confuses fact & fancy Vigrous,dynamic

Explosive,destructive Calls people names Can’t set limit-active until
Loves to tease,to outwit Attention span-8-12 Can jump about own
minutes height
Terrific humour,nonsense Birthday conscious Lands upright
Word picture of a 5-

Emotional Development Mental Developmet Motor Development

Becoming poised,self Curious about everything Able to skip on both feet

Plays in group of 2-5 Attention span-12-28 Skill & accuracy with

children minutes simple tools

Enjoys pointless riddles & Uses big words Can sit still for brief
jokes periods

Accepts & respects Knows name & address Enjoys stunting & jumping
authority,will take
Silly,Giggling Uses complete sentences Likes dancing gracefully
Objectives Of Behaviour
• To establish effective
communication with child &
• Gain child & parent confidence
for dental treatment.
• Teach child positive aspect of
preventive dental care.
• Provide a comfortable,relaxing
environment to the child.
Factors Influencing Child’s
Behaviour In Dental Office
Wright summarized the following factors-
• Medical history
• Maternal anxiety
• Family & peer influence
• Dental office environment
• Growth & development
• Personal factors
• Environmental factors
• Other variables
• Medical History-Children who view medical
experience positively are more likely to be

• Maternal Anxiety-Highly anxious mother

has a negative influence on the child.The
effect is greater with those younger than 4 yr
of age.
• Family & Peer Influence-Socioeconomic
status of the family directly affects child’s
attitude towards the values of dental health

• Growth & Development-A child’s

chronological age plays a significant role in
growth & developmental patterns.Younger
the child,more atypical will be the response.
• Dental office enviornment-Efforts should be put in
to make environment comfortable for them.
• FINN summarized few factors related to dental
office which influence child’s behaviour-
 -Waiting room should be made in respect to
home enviornment.
 -A sketch of some cartoon on card helps.
 -Simple toys should be kept to amuse very small
 -Have library with books for children of all ages.
• Personal Factors-Temperament,general
fearfulness are some of the personal factors
which influence the child’s behaviour the

• Environmental Factors-Various factors

like socioeconomic status,age of the
child,family situation,past experience of
operative dental care etc. influence the
behaviour of chld.
• Other variables-Stephen Wei explained that
many other variables affect the behaviour of
child in dental office like socioeconomic
status,culture,sex,sibling relation,number of
children,presence of parent & attitude of
Fundamentals Of Behaviour
• Team attitude
• Organization
• Positive approach
• Truthfulness
• Tolerance
• Flexibility
Role of dentist in child’s
• Appearance of dental office should be appealing to child.
• Personality of dentist should be impressive.
• Duration of appointment should be short.Its better to have
morning appointments.
• Dentist’s skill & speed should be good.
• Dentist should keep talking to child to gain his
• Give attention to patient as he is the only one seen during
that day.
• Use of fear promoting words like injection,needle should
be avoided.
• Dentist should never lose his temper.
Maternal Influence on Children’s
Behaviour In Dental Situation
• Most of the characters of the child like
behaviour,personality,anxiety & reaction to
stress are directly influenced by the
parents’s character.
• Both mother & father play an important role
in child’s psychologic development but more
emphasis is placed on mother.
• This is because mother generally has
intimate contact with the child since prenatal
• The mother-child relationship falls into 2 broad categories:
1-Autonomy VS. Control
2-Hostility VS. Love
Mother either have control over the child’s behaviour or
they give the child freedom.The other category includes
loving or hostile mothers.

BAYLEY & SCHAEFER summarized the

maternal attitude as-:
Maternal Attitude Child’s Behaviour
Overprotective Submissive,shy,anxious
Overindulgence Aggressive,spoilt,demanding,displays temper tantrums
Under Affectionate Usually well behaved,maybe unable to cooperate,may cry
Rejecting Aggressive,overactive,disobedient
Authoritarian Evasive
Fear and Phobia
-Fear can be defined as an unpleasant emotional
state consisting of psychological and
psychophysiological responses to a real external
threat or danger including
agitation,alertness,tension of alarmed reaction.
-Phobia can be defined as a
persistant,unrealistic and intense fear of a
specific stimulus,leads to avoidance.
Example-Tension when a larger dog approaches you on a walk is FEAR
but avoiding the park because u might see a dog is PHOBIA.
• It is a common feeling • It is a from of anxiety disorder
experienced by everyone. characterized by excessive and
persistant fear of objects and
situations which may not carry
real threats.
• Characterized by • Can cause tachycardia,shortness
nervousness,anxiety,discomfort of
and distress. breath,dizziness,nausea,vomiting
or even panic attacks.
• Does not need medical • Needs medical help
• In dentistry,fear of loud • In dentistry,odontophobia is an
noise,fear of pain can be seen. irrational fear of dentistry.
 Define behaviour management.Describe
various non-pharmacological methods of
behaviour management.
 Write short note on aversive conditioning.
 Discuss subjective fear and objective fear &
measures taken by pedodontist to alleviate
the fear.
 Write short note on Tell-Show-Do.
• Behaviour management is a key element to
establish a successful treatment in
pediatrics.An effective behaviour management
creates a positive environment.It is affected by
the characteristics of the dentist,child and

“Although the operative dentistry maybe perfect,but

appointment is a failure if the child departs in tear”

• Textbook of pedodontics-
Shobha Tandon
• Textbook of pediatric
dentistry-Nikhil Marwah
• Net sources