PEDO. 5TH Y. 2016- 2017 Lec. -4- Dr. Sami Malik Abdulhameed

BEHAVIOUR MANAGEMENT IN PEDIATRIC DENTISTRY

(STRESS REDUCTION ) OR BEHAVIOR MANAGEMENT

Behavior Management techniques can be broadly classified as:*Non-Pharmacological Techniques.

*Pharmacological Techniques

No anesthesia/analgesia

Local anesthesia injection

Oral (enteral) medication

Inhalation agents (nitrous oxide/oxygen)

Intramuscular injection

Intravenous agents

General Anesthesia

Stress Reduction Protocol: Normal, Healthy Patient

Non-Pharmacological Techniques.

*Minimize waiting time

*Psychosedation during therapy, as needed

*Adequate pain control during therapy

*Length of appointment variable

*Postoperative pain /anxiety control

Stress Reduction Protocol: Medical Risk Patient

*Recognition of the medical risk

*Medical consultation as needed

*Morning appointment

*Preoperative and postoperative vital signs

*Psychosedation during therapy, as needed

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*Adequate pain control during therapy

*Length of appointment variable

*Postoperative pain /anxiety control

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

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1- Communication Verbal [establishment of communication,

establishment of communicator ,message clarity,tone]

Nonverbal [Multi sensory Communication]

NONVERBAL COMMUNICATION

Reinforcement of behavior

through provider contact,

posture and facial expression

• Enhances the effectiveness of other communicative management techniques

• Culturally sensitive

• Recognized behaviors that convey information

• Facial expression

• High Five

• Reciprocal Social Interaction

• Eye gaze

• Turn taking

• Respect personal space

• Respond to social signals

Communicating with children

Effective communication with children is critical for gaining the child’s cooperation to receive dental care.

1. Tell Show Do

2. Reflective listening

3. Self-disclosing assertiveness

4. Descriptive praise.

Effective communication is a primary objective.

Communicate in two basic ways:

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1. verbally: using therapeutic communication skills, as well as talking about school activities, pets, articles of clothing, children’s television programs, books, muppets

2. non-verbally: holding young child in lap; touching tenderly, smiling approvingly

Tell Show Do

• Tell-Show-Do is the classical model for communicating with children in the dental environment.

• It is essentially a “behavior shaping” strategy.

TELL :- before ,during ,after

• TELL… using euphemisms (substitute language)

• Be honest in your TELLing!

Childrenese’ Terms for Dental Equipment

Slow handpiece: ‘buzzy bee’

Air Rotor: ‘whizzy brush’

Triplespray/inhalation sedation: ‘magic wind’

Local anaesthetic: ‘jungle juice’ or ‘sleepy juice’

Giving a local: ‘put your teeth off to sleep’.

Rubber Dam: ‘raincoat’

Rubber Dam Clamp: ‘clip’ or ‘button’

Rubber Dam Frame: ‘coat hanger’

SHOW

• SHOW (demonstrate) the child what will happen, how it will happen, and with what equipment.

• But, it is not wise to SHOW fear- promoting instruments.

• Remember the multi-sensory perspective in SHOWing: children can HEAR, SEE, TOUCH, TASTE, and SMELL.

DO• DO what you said you were going to do.

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• DO it in the manner you said you were going to do it.

• As you DO it, continue to TELL the child what you are DOing.

• DO NOT DO until the child has a clear awareness and understanding of what you are going to DO.

• DO it expeditiously!

Tell-show-do

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.

Tell-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.

Acclimatisation…getting familiarized

Dentists are Professionals

In caring for children, “Dentists are professionals—engaging children therapeutically.

The care provided for improving the child’s oral health must be effective, that is, therapeutic.

In providing care, the dentist’s communication must also be therapeutic, that is, communication that will result in cooperation being gained and maintained, as well as the child is being treated humanely.

Enhancing control Here the patient is given a degree of control over their dentists' behaviour through the use of

a stop signal. Such signals have been shown to reduce pain during routine dental treatment and during injection. The stop signal, usually raising an arm, should be rehearsed and the dentist should respond quickly when it is used.

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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

2-Behavior 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

Systematic Desensitization ..exposure to hierarchy of fear producing stimuli Desensitization : (joseph Wolpe)

Systematic Desensitization ..exposure to hierarchy of fear producing stimuli

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Modelling

Bandura (1969) :- Live ,Filmed ,Posters ,Audiovisuals

Allowing the patient to observe one or more individuals [models]

Patient frequently imitates the models

Distraction

Diverting the patient’s attention from what may be perceived as an unpleasant procedure.

Music , Video ,Talking ,White noise ,Hypnosis ,Breathing

Objectives of Distraction

1. decrease the perception of unpleasantness;

2. avert negative or avoidance behavior.

Indications: May be used with any patient.

Contraindications: None.

Contingency management (Reinforcement )

Positive reinforcer

Negative reinforcers :- Social ,Material ,Activity

Reinforcement :- ‘is the strengthening of a pattern of desired behaviour & increasing the probability of that behaviour being displayed again in the future’

Types of Reinforcement

Positive Reinforcement

Negative reinforcement 7

Usual approach used in dentistry.

Appropriate behaviour exhibited by the child results in the child receiving some form of positive ‘reinforcer’.

Reinforcer:

Material: toy, badge.

Social stimuli: verbal praise, approval,tapping of the shoulder.

When should positive reinforcement occur ?

Directly after the appropriate behaviour has occurred.

Known to increase their value.

*Positive 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.

Praise

1. DO NOT use global terms of evaluation. Avoid great, good, wonderful, as in “you’re being good.”…and certainly negative and pejorative judgments such as “you’re being bad.”

2. RATHER, think about what is happening with the child that makes you want to say, “Your are being good!” and rather than saying that--describe the conditions present that make you want to say it. In this way, you are defining what good means, a much more meaningful way to “praise.”

3. ALLOW the child to form their own evaluations of their behavior.

4. ALWAYS look for opportunities to acknowledge correctness.

PRAISE

*Powerful positive reinforcer that helps children learn *Tell them what they can do!

*Verbal *Nonverbal (Visual, auditory, touch (high five) *Praise the behavior that you want repeated

*Be specific and simple

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REWARDS

*Closely tied to a performance criteria *Rewards are tangible *Set rule prior to desired behavior

*Age appropriate: stickers, tokens, computer /game boy time *Don’t give it ,Select and save for next visit

*Negative Reinforcement

‘involves removal of an unpleasant stimulus as soon as the required behaviour is achieved’. Often confused with punishment. Punishment: where a negative stimulus (usually unpleasant) is applied to a wrong response. E.g. Hand-Over-Mouth (HOM).Is controversial & needs written consent from parent

Negative Reinforcement: Negative Re-inforcer by Stokes & Kenndy 1980 is one whose contingent withdrawal increases the frequency of behavior.It is usually the termination of an aversive stimulus.e.g.:withdrawal of the mother S E P (selective elimination of parent)

3- Behavior Management

AVERSIVE CONDITIONING

Voice Control

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

Voice Intonation(Voice Control)

Occasionally it is necessary to send a strong “I Message” for a child who is being particularly uncooperative, and specifically when there is a dimension of defiance in the child’s behavior.

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Three elements of effective use of the “voice control” with difficult child: 1) voice must be raised to higher level than normal; 2) voice must reflect sternness; 3) and child must be looking directly into practitioner’s face.

Objectives:

1. gain the patient’s attention and compliance; 2. avert negative or avoidance behavior;

3. establish appropriate adult-child roles.

HOME

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.

HOME

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.

Several variations of home:10

*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

Informed 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.

VC/HOM GOALS – SAFETY

• Redirect the child’s attention, enabling communication with the dentist so appropriate behavioral expectations can be explained (rules and roles)

• Stop avoidance behavior and help the child gain self-control

• Ensure the child’s safety in delivery of quality dental treatment

• Eliminate the need for parental sedation or general anesthesia

Selective exclusion of parent (SEP)

Full parental consent.

Explanation of the need.

Children between 4-7 years.

Contraindicated in any child incapable of understanding what is being asked of them.

Parent should be at such a position where he/she out of sight of patient but can hear

what is going on in the setting.

Should be called in discreetly as the child’s behaviour improves to be present as a passive observer.

PARENT PRESENCE – ABSENCE

Objective: Set rules in the interview

• Remove competition for child’s attention and compliance

• Prevent negative or avoidance behavior

• Enhance trust

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• Tool - mommy in - mommy out (age appropriate

• Child takes on the role of the victim

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

Retraining

To review and retrain the response to a given set of stimuli

Acupuncture on DentistryAcupuncture is a medical treatment developed in China in which complaints are treated by inserting fine needles at various points on the body called acupuncture points. These needles can then be stimulated by hand or heat. Acupuncture has been used for over three thousand years but it is only over the last twenty years that it has begun to be accepted in mainstream Western medical practice. It is now increasingly popular in the West and may be used to treat a wide range of medical conditions. There are also alternatives to basic acupuncture available, e.g. electro-acupuncture and transcutaneous electrical nerve stimulation (TENS).

The main application for acupuncture is in the treatment of musculoskeletal problems but it has also been found useful in stress management and is also suitable for treating a number of dentally related problems. It has been suggested that acupuncture is a very refined way of affecting the central nervous system, of altering its responses in a selective manner. Like an old telephone exchange, insertion of the needles connects certain pathways, throws certain switches and blocks other lines of communication in a delicate and specific manner

Electrical Dental Anaesthesia (EDA) on DentistryEDA can be used in a number of ways. It can provide localised anaesthesia for restorative dentistry (e.g. fillings) and can be used on its own instead of a local anaesthetic (injection in the gum) in some patients, or in combination with some form of sedation, e.g. inhalational sedation, in other patients. It is therefore useful in needle-phobic patients and those who do not wish to have the prolonged feeling of numbness which follows conventional local anaesthesia. It is also useful in patients who cannot have a conventional local anaesthetic e.g. who are allergic to them or who have a medical condition which means they are best avoided. EDA tends to be more reliable when used on front teeth than on back teeth. It has also been used in combination with inhalational sedation for the extraction of deciduous teeth in children. Its use for extraction of teeth in adults is not proven and your dentist is very likely to advise a conventional method of pain control for this. EDA can be used to reduce the discomfort of an injection in the gum of local anaesthesia. It can also be used to help with painful extra-oral conditions such as temperomandibular joint disorders.

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