Pedo Sheet #2 By Nada Kadri

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Behavioral Management
What is behavioral management?
It is the means by which the dental health team can effectively and efficiently perform treatment for a child. The aim is to instill a positive dental attitude, and not just performing dental treatment.

• It is about communication (between the child patient and the family) and education (we educate the child what we expect of him/her in the clinic.)
• A healthy relationship between the child, child’s family and dental team. It is a dynamic process and starts before the patient arrives to the surgery. It involves dialogue, facial expression, voice tone, body language and touch.
• We face dental anxiety a lot in the clinic
• The appropriate management technique should be based on the individual child’s requirements, that is, the management of a 5 yr old is different than a 12 yr old’s. Also, every practitioner integrates his own personality in basic psychological principles in managing children in the dental environment. What works for one practitioner may not work for another, so each practitioner integrates the principle that he/she is more comfortable with.

Anxiety
It is a vague, unpleasant feeling, accompanied with a premonition that something undesirable is about to happen
Fear
It is bred from something specific in the external environment whereas anxiety is a more general, nonspecific feeling of apprehension

In literature, anxiety and fear and sometimes are used interchangeably. However, they do differ. Fear is, as we said, more specific. The patient knows what he is apprehensive of.

A study was made in the USA in the 60s. It was found that generally, people do not enjoy coming to the dental clinic. Such a study was repeated in Holland recently and similar results were obtained. The fear of the parent is sometimes transmitted to the child!
It was found that patients are most fearful of the local anesthetic, followed by the dental drill.

How does anxiety manifest?
1. Physiological
Perspiration, palpitations, breathlessness
2. Cognitive features
The patient is focusing, he/ she starts to think of the worst case scenario. Cognitive features affect the behavioral ones.
3. Behavioral
The patient cancels dental appointmens and postpones treatments. General anxiety (patient staring at the tv).

How is anxiety measured?
1. Physiological
Polygraphic recording of heart rate, hand and face (??? 7:55)
Leads (of the ECG) are placed on the patient, and pictures depicting dental treatment are shown to the patient. The heart rate of the patient is then monitored. However, this method carries disadvantages as it is in itself anxiety producing, and thus inaccurate. The pictures themselves cause the patient to worry.


2. Cognitive

We use self rapport methods such as interviews (younger children) and questionnaires (older children).
One example of this is Venham Picture Test for small children. The child points to the picture that depicts their feeling and is given a score



Older children take the Corah’s Dental Anxiety Scale. It consists of 4 basic questions, and depending on his/her answers the child is given a score.
These tests are psychometrically correct, they sound simple but they were all created according to many researches.
3. Behavior
You observe the child’s behavior in the dental clinic. (all psychometrically corrected.)
Frankl Behavior Scale

Cards (eight cards) are given to the patient and the practitioner asks the patient to the pick the cards that portray his/her feelings. The greater the number of negative images the child picks, the more anxious the child is. Used for children that are up to 9 yrs old. (this sounds like the venham picture test but the doc said this after reading the frankl behavior scale title.. if I find any info later to clear things up I’ll post it inshallah)


The patient enters and you observe their behavior; based on that you give a rating.
Definitely Negative Refusal of treatment, crying forcefully, fearful
Negative Reluctance to treatment, uncooperative, some negativity but not pronounced
Positive Generally cooperative, there is acceptance of treatment but cautious
Definitely Positive There is good rapport , the patient is interested, laughing and enjoying treatment
Negative and positive are similar and borderline. Most patients lie in these categories.
Unfortunately, the definitely positive category is rarely encountered.
Children lying in the definitely negative category generally require general anesthesia.
Another way to classify behavior is to the Wright’s Clinical Classification
Cooperative They get along fine in the dental environment without significant distraction.
Lacking Cooperative Ability They don’t have the ability to cooperate (less than 2 years of age {occasionally less than 3} or mentally too young.) These patients are unable to cooperate and unable to communicate at the proper level.
Potentially Cooperative Most of the patients that we see. They have cooperative abilities but for some reason they choose not to cooperate. The most challenging patients!

Further classification of potentially cooperative patients…

Uncontrolled 3-6 years of age. They have tantrums in the dental chair. It can result in a dangerous situation. If the patient is having a bad tantrum, try to temporize and defer treatment (put a TF and dismiss your patient).
Defiant Can present at all ages. In younger children, you tell the patient open your mouth and he/she keeps repeating “I don’t want to.” Slightly older patients are slightly more cooperative but there is passive resistance, the patient may constantly hit you with his/her elbow. So passive resistance in older children
Timid Usually in younger children and mostly females. Shielding behavior or hesitating. The child hides behind his/her mother or hands. It is fine most of the time but the situation may deteriorate and result in tantrums
Tense Cooperative “white knucklers” Older children >7 years of age. They try to be helpful but are anxious most of the time. They tense their hands and thus the term white knucklers
Whining Usually continuous with absence of tears. They cooperate but keep on whining despite the absence of pain! This is annoying for the practitioner but clinical work is done.
What are some of the factors that influence child behavior?
Anxiety is a recognized personality trait but there are some factors which have been found to increase the likelihood of behavior problems at dental appointments. That is, some children are naturally more anxious than others and this simply lies in their personality. But what about other factors?

1. Medical history
• Children who have had negative experiences associated with medical treatment may be more anxious about dental treatment.
• Children who have previous bad dental treatment can be related to poor behavior in subsequent visits.
2. Parental influence
• If the mother or father is dentally anxious, they can transmit that anxiety to their children.
• This is more common to result from the mother as she generally has more contact with her children.
• Children learn the basic aspects of life from their parents. This is known as primary socialization. It is an ongoing and gradual process. After the child goes to school, secondary socialization develops in which the child learns from his/her fellow classmates.
• Primary socialization can have a profound and lasting effect. So if they catch dental anxiety as children this can grow with them through life.
• Fear of dental treatment can often be traced back to family influence
• Parents can shape a child’s expectation and attitude about oral health
• The importance of maternal anxiety has been recognized for over a century.
• The relationship between maternal anxiety and child behavior is well documented. Questionnaires were given to mothers and it was found that the more anxious the mother, the more prone the child is to have bad behavior on the dental chair. So it affects the child’s anxiety and behavior! This is particularly important for children under 4 years of age (primary socialization).
• When a parent is unable to contain their own dental anxiety, it may be helpful to find another adult to accompany the child.
• Parents are able to accurately predict whether or not their child is going to cooperate. So you can communicate with the parents before the appointment.

3. Awareness of a dental problem
When a child don’t know what’s going on or why they are visiting the dental office seem relaxed and happy and look around excitedly. The visit is positive. Whereas when the child is going to the dental clinic in pain, the child is aware that there is a dental problem and knows that a procedure is going to be done. It is more likely that the visit will be negative. In such cases, it is best to leave the first visit as a checkup only

Communication
• Communication in pediatric dentistry is between the practitioner and the parents anddd the child.
• Good communication is essential; it’s not just about manual skills.
• With children, the communication pathway is more complex than the simple 1 to 1 communication that exists with most adult patients
• The child, dentist, dental nurse and parents are all potentially involved. However, the child can only concentrate with one individual and that should be the dentist.
• Each member of the dental team should understand their roles and so much the accompanying parent
• Children are very good at reading body language. Communication may be impaired when the body language is inconsistent with the intended message. For example, saying comforting things when your body language conveys uncertainty, anxiety and uncertainty. The dentist will be unable to convey confidence in his/her clinical skills.
• It is possible to communicate with your patient before the dental appointment to establish rapport and trust. Spending up to a few minutes on social history is important. However, once a procedure begins the dentist’s ability control and shape behavior becomes paramount and information sharing becomes secondary. You have already established rapport earlier and now it is time to work!
• Buildup of a 2 way interchange of information gives way to one way manipulation of behavior through commands.
Do we allow parents to stay with us in the clinic?
• Most research suggests that children’s behavior in the clinic is unaffected by their parents’ presence or absence. An exception exists with children less than 4yrs of age who have shown to behave better with their mothers’ presence.
• Many parents prefer to be present during treatment especially if the child is young or it’s their first visit. T
• he major concern for dentists is the potential of parents to destruct treatment by showing anxiety.
• The parent often repeats the orders of the dentist which creates annoyance for the dentist and the child.
• The parent intercepts orders, becoming a barrier to the development of rapport.
• The dentist may be unable to use voice control with the parents’ presence. We will talk about this next week.
• The child divides attention between parents and the dentist.
• The dentist divides his/her attention between parents and child.
• Dentists are more relaxed and comfortable when the parents remain in the reception area
• As we said, for young children parental presence is important whereas for older children parental presence appears not to have such a clear effect on child behavior but may be important to the parents. If you dismiss the parents from the clinic, make sure that you inform them that the treatment will be better this way. You must explain your policies to the parents and reassure them.
General considerations of child patient management
• Always call your patient by their nickname or first name
• Direct the conversation towards the child whenever possible
• Approach the child in an easy going manner
• Talk at the child’s level… physically and socially!
• Avoid quick and sudden movements when performing dental procedure
• Avoid provoking words such as pain, drill, stick etc..
• Once treatment use short concise commands rather than questions or suggestions
• Admire and praise good behavior when you can, this enhances repetition
• The operator most keep his/her self control at all times.

Scheduling
• Many children become restless and tired when faces with long delays in the reception area
• Many children are more alert and concentrated in the morning. The dental team is also
• Age groups are kept together, preschoolers in the morning and older children in the afternoon. The children can thus serve as models for each other. Teenagers aren’t fond of entering the clinic after a preschooler!

Appointment length
• Children have a short attention span
• A long visit is traditionally recognized as any visit in excess of 30 to 45 minutes. The current trend towards quadrant or half mouth dentistry has altered this view. Leschner found no significant difference in children’s (4-5 years old) behavior in short or long appointments. Other studies in the same age groups showed that the longer the restorative, the greater the likelihood of stress-fear (I don’t know if she said stress-fear or stress-free) reaction. Current evidence on appointment duration is divided.

Dental Attire
• Children who have had previous medical experiences may be afraid of strangers in white uniforms. Some pediatric dentists have become accustomed to wearing scrubs that are decorated with cartoon characters. However, this is a personal preference and some dentists prefer to look more professional as they fear that street clothing hurts their professional image. Less formal attire will have a beneficial effect on some children. It may also help if the staff is wearing casual clothes to give a more natural attitude. In conclusion, the dental attire remains a personal decision.
• Some children who have been exposed to surgical treatment may be frightened by facemasks. Always talk to your patients without one especially when it is the first time or are in the reception area.




Non-pharmcological Behavioral ManagementTechniques

1. Lab info
2. Non verbal communication
3. Voice control
4. Tell-Show-Do
5. Systemic Desensitization
6. Enhancing Control
7. Behavioral Shaping and Positive Reinforcement
8. Modeling
9. Distraction
10. Negative reinforcement
we will be looking into these next week inshallah


Done by: Nada Kadri
Date of lecture: 16.2.2011
Pedo lecture #2