management
Contents
Part I Introduction
Age related behaviour patterns of child
Emotional development
Common emotions of a child
Learning objectives
At the end of the seminar the listener should be able to
Describe the Age related behaviour patterns of child
Describe the emotional development & Common emotions of
a child
Should know anxiety rating scales and should be able to
Introduction
Behavioural pediatric dentistry is described as the science that
understands the development of fear, anxiety and anger of a child in
a dental clinic.
The behaviour of a child cannot be dictated, the pedodontist can try
to understand, analyse and manipulate it with few strategic
techniques.
The technical skills of a pedodontist and his ability to acquire and
maintain the cooperation of child decide the success of dental
treatment delivered to the child.
Definitions
Behavior
Any activity that can be observed recorded or measured.
It is an observable act or any change in the functioning of an
organism.
Behavior shaping
Procedure which slowly develops behavior by reinforcing a
successive approximation of the desired behavior until the
desired behavior comes into being.
Behavior modification
The attempt to alter human behavior and emotion in a
beneficial way and in accordance with the laws of learning.
Behavior guidance
Continuum of interaction involving the dentist, the dental
team, the patient and the parent directed towards
communication and education which ultimately build trust
and alloys fear and anxiety.
Behavioral pedodontics
Study of science that helps to understand development of fear,
anxiety, anger and associated acts as it applies to child in the
dental situation.
Three years
Less egocentric; likes to please
Has very active imagination
Remains closely attached to parent
Four years
5 years
6 12 years
Emotional development
Emotion is a state of mental excitement characterised by
physiological, behavioral changes and alteration of
feelings.
Elements physiological, cognitive, cultural
Physiology of emotion
Development of emotions depends on maturation
Nervous
endocrine system.
between
At birth
Cortex development is completed
Frontal lobe is immature
Has little influence on functions of the lower parts of brain
resulting in unbalanced emotions
Theories of emotion
Cry or distress
Defined as a multimodal behaviour consisting of tears, nonverbal vocalization(wails, sobs) and facial expressions of
distress
At birth
Primary emotion present at
birth with vigorous body expressions.
At 6 months
Greatly replaced by a milder
expression of fussing or vocalization
During preschool
Only for the reasons of physical pain
In young adult
Limited quiet crying in private only for
reason of grief or other intense
emotions.
Frightened cry
Accompanied by a torrent of tears
Convulsive breath-catching sobs
Usually the child emitting this type of cry has been
overwhelmed by the situation
Hurt cry
Frequently accompanied by a small whimper
Compensatory cry
Not a cry
Sound that child makes to drown out the noise
Cry sound is slow, monotone
Sort of coping mechanism to unpleasant auditory stimuli,
finding himself uncomfortable in the situation
Anger
Outburst of the emotion is caused by the
childs lack of skill in handling situation
Infants and young children respond in anger in a direct and
primitive manner
As they develop the responses become violent and more
symbolic
Fear
Reaction to the known danger
Defined as an unpleasant emotion or effect
consisting of pshychophysiological changes
in response to realistic threat or danger to
ones own experience.
Development of fear
Birth to 2yrs
Primary response at birth
With age becomes aware of fear producing stimuli
Pre-schooler(2-5years)
Fear of animals or being left alone
More apprehensive about failures
Early schooler
Fear of the dark, staying alone
Fear of supernatural powers like ghosts and witches,
imaginary objects and situations such as fear of war, spies,
beggars.
Late schooler
Fear of bodily injury
Fear of failure, not being liked, competition, fear of
punishment
Adolescent
Fear of social rejection and fear of performance
Objective fear
Acquired objectively or
Produced by direct physical stimulation of the sense organs,
but not of parental origin
Fears from previous unpleasant contact with dentistry
Unrelated experiences
Subjective fears
Based on the feelings and attitudes suggested to child by
others without the child personally experiencing them.
May be due to family experiences, peer, information media.
These are
imaginative
Suggestive
Imitative
Significance of fear
Protective mechanism
Keeps the child away from dangerous situation
Fear of being punished or parental disappointment is an
important factor that reinforces discipline in a child
Fear should never be eradicated
Rather should be channalized towards situations, where
danger really lies.
Fear assessments
The childrens dental fear picture test (Klingberg, 1994)
A sentence completion task
A sentence completion task Contains 15 incomplete sentences, which are read to the child
consecutively
The child is instructed to complete the sentences by saving the
first word or words that come to the mind.
Anxiety
Defined as a state of unpleasant
feeling combined with an associated
feeling of impending danger from
within.
Learned process being in response to
ones environment.
Develops later than fear
Types of anxiety
Trait anxiety
Life-long pattern of anxiety as a temperament feature
Children are generally jittery, skittish and hypersensitive to
stimuli
State anxiety
Acute situational-bound episodes of anxiety
Do not persist beyond the provoking situation
Phobia
Defined as a persistent,
excessive, unreasonable fear of
specific feared object, activity or
situation that results in a
compelling desire to avoid the
dreaded object.
Characteristics
Being out of proportion to the stimulus or situation
Cannot be reasoned with
Being out of voluntary control
Persistent and inadequate
Types(Shehan 1982)
Exogenous
Other causes
Simple phobia
Isolated fear of a single object or
situation leading to avoidance of the
object or the situation
Situational phobia
Popularly interpreted as fear of open
space
Usually refers to cluster of complaints
Social phobia
Phobia due to fear of being looked
at and the concern about appearing
shameful or stupid in presence of
others.
Types public speaking, fear of
eating, fear of blushing
Phobia in childhood
Fear of animals
Phobia of darkness
School phobia
In 12 years children of both sexes,
previous
aversive
dental
experiences are more closely
related to dental phobia than
general fear.
Adolescents fear of being
looked at.
Classification of behaviour
Wilsons classification of child behaviour
Behaviour
Description
Normal or bold
Tasteful or timid
Shy
Hysterical or rebellious
Rebellious
Unacceptable behaviour
temper tantrums
Nervous or fearful
Interrupts
treatment
dental
Behaviour
1. Definitely negative(--)
2. Negative(-)
3. Positive(+)
4. Definitely positive(++)
and
extremely
displays
Lampshire
Behaviour
Description
Cooperative
Tense cooperative
Outwardly apprehensive
Fearful
Stubborn/defiant
Behaviour
Description
Hypermotive
Handicapped
Emotionally immature
Wright
Cooperative (positive behaviour)
1. Cooperative behaviour
child is cooperative, relaxed with minimal apprehension
2. Lacking cooperative ability
usually seen in young child(0-3yrs), disabled child, physical
and mental handicap.
3. Potentially cooperative
has the potential to cooperate, but because of inherent fears
the child does not cooperate
2. Defiant/obstinate
Can be seen in any age group
Usually in spoilt and stubborn children
Can be made cooperative
3. Tense cooperative
Borderline between positive and negative behaviour
Does not resist treatment but the child is tensed at mind
4. Timid/shy
Seen in overprotective child at first dental visit
Shy but cooperative
5. Whining type
Complaining type of behaviour
6. Stotic behviour
Seen in physically abused children
.
Garcia-Godoy
1. Fearful resist entering treatment room, cries, screams.
2. Timid enters treatment cautiously, thoughtful with eyes on
floor.
Home environment
Nutritional factors
Dentists attire
Maternal behaviour
Presence/absence of
parents in the operatory
genetics
Presence of an older
sibling
School environment
Socioeconomic status
Features
Outcome
Structuring
Externalization
Gains confidence
Flexible authority
Education &
training
Nutritional factors
Skipping breakfast can lead to an impaired performance
School environment
In the school, teachers and peers help to influence the
behaviour of the younger children
Seniors become role models to the juniors
Socioeconomic status
High socioeconomic status child develops normally
This child may also become spoilt
Low socioeconomic status child develops resentment and is
tensed.
Directly affects the childs attitude towards the value of dental
health
Maternal behaviour
Maternal influence begins even before birth
Somatic development nutritional status of mother
Neurohormonal system of mother transfers emotion to the
fetus
Postnatal behaviour of the child is linked to prenatal
emotional status of the mother
Overprotective mother
Close relationship between the
mother and child
Exaggeration of this love and affection
leads to overprotection
Harmful to the normal psychological
development of the child
Features
Child is not permitted to use his own initiative
or make decisions for himself
Mother takes active part in his social activities
Child is submissive, anxious, shy and fears new situations
Cooperative but difficult to create a good rapport.
Polite, obedient, disciplined
Overprotective-overindulgent mother
Features of the child
Aggressive, demanding, displays temper tantrums
Expect constant attention and services
Obstinate, stubborn, spoilt
Dominate over the dentist and are demanding
Well behaved and well adjusted but difficult to establish a
good rapport.
Underaffectionate mother
Features
Well behaved and well adjusted
Shy and difficult to establish good rapport
May be uncooperative to dental treatment
Through affection & love the child may be made to respond
Rejecting mother
Features
Over reactive, revolting, aggressive, disobedient
Tries to gain attention of other by showing overt behaviour
Constantly criticized, nagged, torture
with displays of displeasure.
Lack of self-esteem
Most difficult to deal in the clinic
Authoritarian mother
Features Submission with resentment and
later evasion
Evasive, dawdling child, obeys
command slowly and with delay
Parents are not supportive to child
and often criticize them
Heightened avoidance gradient and seek to evade or delay the
response.
Mothers
behavior
Childs behavior
Over protective
dominant
Submissive, shy
anxious
Overindulgent
Aggressive, demanding;
displays temper tantrums
Under
affectionate
Rejecting
Authoritarian
Aggressive, overactive,
disobedient
Evasive & dawdling
Conclusion
Emotional expressiveness through bodily movements, facial
expressions and vocalizations are within a human being.
Home environment is an important factor in development of a
childs personality
Pattern of mother- child relationship during early childhood
exerts a profound influence on the development of personality
of a child
References
Dentistry for the child & adolescent , Mc Donalds
Management of Children in Dental Office- Louis Ripa
Child Behaviour in dental Office Wright
Textbook of pedodontics Shobha Tandon
Questions
Discuss step by step management of a 7 year old child with a
previous painful dental experience.(RGUHS, Oct 2008)
Contents
Pre-appointment behaviour modification
First dental visit
Techniques for non pharmacological behaviour management
Learning objectives
At the end of the seminar the listener should be able to
describe
Methods for pre-appointment behaviour modification in child
First dental visit
Various techniques for behaviour management in children.
Emotional development
Early infancy (birth to 6 months)
Between six and ten weeks, a social smile emerges.
As infants become more aware of their environment, smiling
occurs in response to a wider variety of contexts.
Laughter, which begins at around three or four months,
requires a level of cognitive development.
Preschoolers(3-6years)
Children's capacity to regulate their emotional behavior
continues to advance during this stage of development.
Parents help preschoolers acquire skills to cope with negative
emotional states by teaching and modeling, use of verbal
reasoning and explanation.
Beginning at about age four, children acquire the ability to
alter their emotional expressions
Introduction
Behaviour management techniques in pediatric dentistry are
directed towards the goals of communication and education.
The relationship between the dentist and the child is built
through a dynamic process of dialogue, facial expression and
voice tone.
The goals of behaviour management are to achieve good
dental health in the child and to help develop the childs
positive attitude towards dental health
Definition
Behavior management (Wright 1975)
Means by which the dental health team effectively and
efficiently performs dental treatment and thereby instills a
positive dental attitude.
Behavior shaping
Procedure which slowly develops behavior by reinforcing a
successive approximation of the desired behavior until the
desired behavior comes into being.
Behavior modification
The attempt to alter human behavior and emotion in a
beneficial way and in accordance with the laws of learning.
Goals
To establish a proper communication with the child and the
parent
Deliver quality dental care
To alleviate anxiety and fear
To impart a positive attitude in the child and the parents
towards maintaining good oral health
Team attitude
Organization
Truthfulness
Tolerance
Flexibility
METHODS
Films, video tapes developed to provide model for a young
patient
Live patient models- siblings, other children, parents
Preappointment parental education via mailings, prerecorded
messages or customized web pages
Letters & pamphlets
120
clinical examination
Radiographical examination
Endodontic procedures
Oral prophylaxis
Extractions
Sealant application
Fluoride application
Restoration of enamel carious lesion
Rubberdam application
125
Non-pharmacological methods of
behaviour management
1. Communication
2. Behavior shaping(modification)
Desensitization
Modelling
Contingency management
3. Behavior management
Audio analgesia
Biofeedback
Voice control
Hypnosis
Humor
Coping
Relaxation
Implosion therapy
Aversive conditioning
Communication
Imparting or exchanging thoughts, opinions or information
Primary strategy of behaviour management
Multisensory process
A thorough understanding of the childs cognitive
development and vocabulary is necessary to effectively
communicate with the child.
Verbal communication
Ideal approach for children more than
3 years of age.
Gentle and constant voice
Tone firm and express empathy and support
The words and expressions should be comfortably understood
by the child.
Word substitute
Rubber dam
Rain coat
Tooth button
Sealant
Tooth paint
Tooth fighter
Air syringe
Wind gum
Suction
Vaccum cleaner
Study models
Statues
Alginate
Pudding
Non-verbal communication
Eye-to-eye
Physical
Facial
Voice
quality
expression
contact
contact
Behavior Shaping
Desensitization
Introduced by joseph wolpe in 1975
Works on the principle of classical conditioning
Employed in dental clinic to remove fears and tensions in
children who have had previous unpleasant experience.
Procedure -
Tell show do
Closely related to desensitization
Introduced by Addlestone in 1959
Behaviour shaping technique and should be employed in all
patients in the first visit and the subsequent visits for
explaining a new procedure.
Objectives
To allow the child to learn about and understand dental
procedures in a way that minimises anxiety.
Modelling
Introduced by Bandura in 1969
Encompasses the principle of his observational learning
Works on the principle that when a child is allowed to observe
one or more individuals who demonstrates a positive
behaviour in a particular situation, the child imitates the
model when placed in a similar situation.
Stages of modelling
1. Acquisition
The child observes the behaviour of the model and tries to
imitate him under similar circumstances
Basic requirements attention, retention, reinforcement,
motivation.
2. Performance
Reproduction of the behaviour of the model
Advantages
Reduces the anxiety and improves the behaviour of an
apprehensive child.
Extinction of fear
No additional equipment or alterations in the dental routine
are required
Contingency management
A method of modifying the behavior of children by
presentation or withdrawal of reinforcers
Uses principle of operant conditioning
Positive reinforcement
The contingent presentation increases the frequency of
behaviour
The reinforcer or a pleasant stimuli is presented after a dental
procedure if the behaviour of the patient is acceptable.
Negative reinforcement
Withdrawing an aversive stimuli reinforces a positive
behaviour.
Social
Objectives
- To strengthen desired behaviours.
Indications.
- Can be used with all patients
Behaviour management
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.(Wright,1975)
Audio analgesia
Audioanalgesia or white noise is a method
of reducing pain and associated stress by a
sound stimulus.
The intensity of the sound is so high that the patient finds it
difficult to listen to anything else.
It works on the principle of distraction or displacement of
attention from the source of stress
Distraction
A technique of shifting the attention of the anxious patient
away from the anxiety-provoking stimulus.
Distraction is probably most effective when anxiety is mild.
Several types of distraction have been reported in the
literature, including the use of video-taped cartoons,
audiotaped stories and video games
Biofeedback
System that obtains signals from physiological functions such
as electromyographic activity, heart rate and blood pressure.
The system intimates any increase in anxiety, stress,
discomfort and pain.
The responses are intimated to the dentist as a visual or
auditory signal.
The dentist in turn reassures the patient and helps in reducing
the anxiety of the patient
Disadvantages
It is labour intensive
Voice control
Controlled alteration of voice volume, tone or pace to
influence and direct the patients behaviour.
Used in children of 3-6 years who cries loudly
Done when the child is uncontrollable and other forms of
communicative management cannot be employed.
The intensity and pitch of the voice is modified as an attempt
to dominate the interaction between the dentist and the child
Objectives
To avert the negative behaviour
Gain the attention of the child
Hypnosis
An altered state of consciousness characterized by a
heightened suggestibility to produce desirable behavioural and
physiological changes.
When used in dentistry, it can be termed as hypnodontics
(Richardson 1980) or psychosomatic or suggestion therapy.
One of the most effective non-pharmacological therapies that
can be used with children for a number of different procedures
(Ramanson 1981)
Humor
Helps to elevate the mood of the child which in turn helps the
child to relax
Functions: Social : Forming and maintaining relationship
Emotional: Anxiety relief in the child
Information : Transmission of essential information in a
non threatening way
Motivation: Increases the interest and involvement of
the child
Cognitive: Distraction from fearful stimuli
Coping
It is defined as the cognitive and behavioral efforts made by an
individual to master, tolerate or reduce stressful situations
(Lazaue 1980)
Types :
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
Signal system
Generally used as a part of coping
The child is asked to raise his hand when it hurts
(Musslemann, 1991)
Normal coping mechanisms utilized by dentists to reduce pain
and tension are friendliness, support & reassurance
Relaxation
Effective in reducing anxiety & fear
Involves series of basic exercises which may take several
months to learn & practice
Which patient requires to practice at home for atleast 15
mins
per day
Implosion therapy
Sudden flooding with a barrage of stimuli which have affected
him adversely & the child has no other choice but to face the
stimuli until negative response disappears
Mainly
comprisesVoice control
Aversive conditioning
Child who displays a negative behavior and does not respond
to moderate behavior modification technique falls into the
category of Frankels definitive negative behaviour.
Technique
After determining the childs behaviour, the dentist firmly
places his and over the childs mouth
Behavioural expectations are calmly explained to the child
close to his ear
When the childs verbal outburst is completely stopped and
the child indicates his willingness to cooperate, the dentist
removes his hand.
Indications
A healthy child who can understand but who exhibits defiance
and hysterical behaviour during treatment.
3-6 years old
A child who can understand simple verbal commands
Contraindications
Children under 3 years of age
Handicapped/immature child, frightened child.
HOMAR(airway restricted)
Advantage is that the child will be quiet so as to breathe and
the screaming will decrease so that the doctor can proceed.
Together with hand and over mouth, nostrils are punched for
15 sec.
Airway restriction is a critical element and it should be
avoided (Belanger, 1993)
Physical restraints
Usually needed for the children who are hypermotive,
stubborn and defiant (Kelly 1976).
Involves restriction of the movement of the child s hand, feets
or body.
Passive
Active
Indications
A patient requires immediate diagnosis and/or urgent limited
treatment and cannot cooperate due to emotional and
cognitive developmental levels or lack of maturity or medical
and physical conditions.
Emergent care is needed and uncontrolled movements risk the
safety of the patient, staff, dentist, or parent without the use of
protective stabilization.
Benefits
Reduction or elimination of untoward movements.
Protection of the patient, staff dentist, or parent from injury.
Facilitation of quality dental treatment.
Contraindications:
Cooperative non-sedated patients.
Patients who cannot be immobilized safely due to associated
medical, psychological, or physical conditions.
Patients with a history of physical or psychological trauma due
to restraint (unless no other alternatives are available).
Patients with non-emergent treatment needs in order to
accomplish full mouth or multiple quadrant dental
rehabilitation.
FOR MOUTH
Tongue blade / Open wide mouth prop
Can be used directly to open mouth
Has a durable foam core on outside of tongue depressor
Easy to use
Available in two sizes
Disadvantages
Possibility of lip and palatal laceration
Luxation of teeth if not used correctly
Precaution
To prevent injury to patient
Prop should not be allowed to rest on teeth
Patients mouth not be forced beyond its natural limit
FOR BODY
Papoose board
Originally a wood & leather device used by many American
tribes to swaddle their infants & children
It is a device with flat board & wide fabric straps that can be
fastened with velcro
Available in areas to hold both large and small children
The child is made to lie on board & the straps are wrapped
around the upper body , middle body & sometimes legs
Various sizes available
Has head & arm immobilizers
Advantages
Can be applied quickly
Reusable
Prevents drills & needles from slipping & causing injury
Triangular sheet
Described by Mink
Triangular sheet to control an extremely resistant child
Allows the patient to upright during radiographic examinations
Disadvantages
Frequent need for straps to maintain the patients position in
the chair
Difficulty in using on small patients
Possibility of airway impingement
Hyperthermia
Constant supervision
Pedi wrap
Various sizes available
Allows some movement while confining the patient
Mesh fabric prevents Hyperthermia
Requires straps to maintain body position in the dental chair
For extremities
Allow limited movement of extremities
Prevents overreaction by combative patients
Conclusion
A wide variety of behavioural management techniques are
available to paediatric dentists
Must be used as appropriate taking into account cultural,
philosophical and legal requirements in the country of dental
practice of every dentists concerned with dental care of
children, solely for the benefit of the child
References
Dentistry for the child & adolescent , Mc Donalds
Management of Children in Dental Office- Louis Ripa
Child Behaviour in dental Office Wright
Textbook of pedodontics Shobha Tandon
QUESTIONS
Discuss step by step management of a 7 year old child with a
previous painful dental experience.(RGUHS, Oct 2008)
Importance of first dental visit ( RGUHS, 2003)
Audio analgesia in the management of fear ( RGUHS 2003)