Factors underlying children’s cooperation,

non-pharmacological methods for behavior

management of the child in the dental office.

Prof. dr. Gateva_2022

 Dental anxieties
• Fears and anxieties form part of normal child
development, and generally developmental fears and
anxieties are transitory.
• For some children, dental fears and anxieties (DFA) do
not resolve and become persistent and problematic.
• The aetiology of childhood DFA is multifactorial.
– Exogenous sources of DFA are external contributory
factors which include direct learning experiences (e.g.
traumatic experience) and indirect learning
experiences (e.g. vicarious learning).
– Endogenous sources of DFA are internal contributory
factors which make individuals susceptible to the
development of dental anxiety.
 The dentists
• Who treat children must be able to:
– recognize the fear and anxiety of patients from an
early age
– to assess and manage their behavior.
• This will allow them to carry out the most appropriate
treatment for the child, without the risk of increasing and
escalating anxiety and fear in the next and future dental
treatment.
• requires understanding and sometimes modifying the
child's and family's response to oral health care
 IMPORTANT
• During the child’s first dental visit, the dentist needs to
assess behavior in the dental environment.
• Behavior is the key to treatment.
• Some children are robust and tolerant in stressful
situations and are unlikely to present uncooperative
behavior.
• Other children are vulnerable and may need more
attention and time in order to feel at ease and to
cooperate with dental treatment.
• Important is - who are these vulnerable children and
what might be the underlying factors which contribute to
their behavior in the dental office?
 Child behavior in relation to
development
• All children are different, and it is reasonable to expect their
behavior in the dental office to also vary.
• Children’s behavior is a function of learning and
development.
• The types of behavior that represent the ‘norm’ for a
particular chronological age group offer convenient means to
classify the expected level of cooperation.
– There will of course be much individual variation.
Child behaviour:
UNDER 2 YEARS
• The child has little ability to understand dental procedures
– effective communication is impossible.
• An oral examination and some treatment can be accomplished (without
sedation) - even without cooperation.
TWO YEARS OLD
• Communication ability - varies according to the level of vocabulary
development – it is expected to be limited.
– communication difficulty puts the child in a ‘pre-cooperative’ stage.
• prefer solitary play and rarely share with others.
– they are too young to be reached by words alone
– are shy of new people (including the dentist) and places.
• Child must be allowed to handle and touch objects to understand their
meaning.
– In the office - they should be accompanied by a parent.
– Sitting in the mother`s lap
 Child behaviour:
THREE-YEAR OLD CHILDREN:
• Are less egocentric and like to please adults.
• Have very active imaginations, like stories and can usually be
communicated and reasoned with.
• If they are stressed - they will turn to a parent and not accept a
stranger’s explanation – dentist or dental assistant.
• They feel more secure if parents are with them until they have
become familiar with the dentist and the assistant - in the room.
• Then a positive approach can be adopted.
 Child behaviour:
FOUR-YEAR OLD CHILDREN - THEY:
• Listen with interest and respond well to verbal directions.
• Have lively minds and may be great talkers
– who are prone to exaggeration.
• Will participate well in small social groups.
• Can be cooperative patients
– but some may be defiant and try to impose their views and opinions.
• Are familiar with and respond well to ‘thank you’ and ‘please’.
 Child behaviour:
FIVE-YEAR OLD CHILDREN:
• They play cooperatively with their peers.
• Usually have no fear of leaving their parents for a dental
appointment
- they don`t have fear of new experiences.
• They take pride in their possessions, and comments about
clothing can be effectively used to establish communication
and develop a rapport.
• By this age children should have no need of comfort objects
such as thumbs and ‘security blankets’.
• It is much more difficult for children, who
do not go to kindergarten to adapt in new
environment.

They not socialize easily and

is more difficult to adapt to the
dental office.
 Child behaviour:
SIX YEARS OLD
• Children are established at school.
• Are moving away from the security of the family so
they are increasingly independent of parents.
• For some children this transition may cause
considerable anxiety with outbursts of screaming,
temper tantrums and even striking parents.
• Furthermore, some will exhibit marked increase in
fear responses.
reasons for fear of dental treatment
FACTORS UNDERLYING
CHILDREN’S COOPERATION IN
DENTAL OFFICE
 Factors …
• Dental fear and/or anxiety is the feeling the
patient has regarding dentistry.
• Behavior management problems are the
experiences the dentist has treating the patient.
• Pediatric dental behavior management
problems and fear are different entities, but
because of their significant association, they
are discussed together as we explore variables
related to uncooperative behavior.
 Demographic factors...
• The negative behavior in the dental office is most intense
in younger children and decreases as children grow older.
• Dental anxiety also decreases as the child grows older,
as does needle phobia, most likely due to maturing
communication and coping skills.
• It is important to assess the patient's degree of
psychological development because that may be more
important than chronologic age when predicting disruptive
behavior.
• The role of gender in dental anxiety and misbehavior is
not as clear.
 Environment
• An area of recent interest - the influence of
environment on health or social determinants of
health.
• Toxic stress is the “result of strong, frequent, or
prolonged activation of the body's stress
response systems in the absence of the buffering
protection of a supportive adult relationship.”
– This type of stress may be a result of child
abuse and neglect, exposure to violence,
poverty, or maternal depression.
 Environment
• Exposure can begin prenatally and can result in
lasting changes to the neural architecture,
resulting in persistent developmental and
physiologic harm and increasing risks for lifelong
chronic diseases.
• Evidence suggests individual differences are
present in physiologic reactivity to stress,
– as measured by the amount of corticotropin
hormone released in stressful situations.
 Environment
• Some children, dubbed dandelion children
– are low reactors and exhibit little physiologic change
when presented with toxic stress
– are resilient to most adversity and manage to realize
their potential, regardless of the environment in which
they grow up.
• Other children, dubbed orchid children - exhibit extreme
physiologic changes (i.e., high reactors).
– Too susceptible to both favorable and unfavorable
conditions.
– If exposed to an unstable environment, they often suffer
from physical and mental illnesses, but thrive if raised
properly.
 Socioeconomic status and
household characteristics
• Are linked with dental anxiety and resultant
behavior management problems
– Explanations for this behavior may include
increased caries history and resultant invasive
treatment and/or lack of access to dentists with
experience treating children.
 Socioeconomic status and
household characteristics

• Behavior management problems have also

been linked to single parent homes, possibly
due to increased economic and social
pressures in these environments.
• Areas of study - the correlation between
dental behavior and residence in an area at
high risk for toxic stressors such as violence
and low socioeconomic status
 Cultural affiliation
• Culture – is defined as a system of shared beliefs,
values, customs, and behaviors that members of
society use to cope with their world; it is a shared
system of attitudes and feelings.
• Children are increasingly influenced by culture once
they reach the formal operations stage of cognitive
development. Although cooperation may be greater
in cultures that place great stress on obedience,
dental anxiety (typically based on behavior) may be
overlooked.
 Parenting styles
• may also affect child behavior. Baumrind defined 4
specific parenting styles — authoritative, authoritarian,
permissive and a neglecting.
• Positive behavior has been associated with children of
authoritative parents compared with children of
authoritarian and permissive parents.
– this parenting style is associated with improved behavior because
it reinforces adult authority so that a child will follow commands of
the dentist,
• positive correlation between authoritative parenting style
and positive child behavior and a correlation between
permissive parenting and negative behaviors.
Parenting style Description
Authoritative (high High parental responsiveness/affection and high parental demand
responsiveness + for obedience; warmth and involvement, reasoning/induction,
high behavior democratic participation
control)
Authoritarian (low Low parental responsiveness/affection but high parental demand
responsiveness + for obedience; clear parental authority, unquestioning obedience
high behavior and punitive strategies
control),
Permissive (high Permissive parents are less restrictive of their children and less
responsiveness + demanding of their behavior. They are allowed to make
low behavior independent decisions for most activities. Here the rules are not
control), clear, and the free expression of impulsive desires is stimulated. It
may be related to pampering - everything is allowed to the child.
This style lacks any control - there are no restrictions and no rules
or standards for "right and wrong"
Neglectful (low It is characterized by complete disinterest in the child's inner world,
responsiveness + mental state and experiences. The child is left alone. There is no
low behavior exactingness, but there are no incentives. Parents are emotionally
control). unstable and unpredictable, often changing their moods and
priorities. Here the contact between the child and the mother is
difficult. Coldness, disapproval and rejection are typical
 Parenting styles
• Authoritarian and Authoritative parents share their high
expectations for the child’s self-control.
• Parents with a Permissive parenting style indulge the
child’s wishes and agenda, placing the child in the power
position with an appeasing, nondirective, lenient
approach without clear rules or guidelines. They are
considered more responsive than demanding.
– The Permissive parenting style has more negative than positive
effects on the social outcome and is associated with aggressive,
impulsive children lacking independence and a sense of
responsibility.
 Parenting style
• Neglectful parents are less involved in their child’s lives
than parents within the other three categories. The passive,
emotionally removed, lax, or indifferent attitude exhibited by
them leaves the child to negotiate the world without
structure, assistance, rules, or guidelines.
• Indifferent parents tend to be cold and uninterested in the
needs of their children and adolescents, reflecting a desire
to keep them at a distance.
– They try to minimize time and interaction with their children.
– This type of parent is characterized as uninvolved, meaning that
they have a low degree of commitment to their role as a parent.
There is a risk of a child or adolescent being neglected by this type
of parent.
• Both Permissive and Neglectful parents have low
expectations for the child’s self-control.
 Clinically significant

• Dentists should be aware of the parent’s style of

interacting with their child.
• To an experienced clinician, the parenting style
may be obvious after a short observation of the
parent and child.
• Another possibility is for the parent to answer
sample questions that will enable the dentist to
determine parenting style.
Parenting Style Questions
1. Which best describes your family’s style of making decisions?
Parent in charge Democracy–shared control Child in charge
2. It is best to give children choices instead of telling them just what to do.
Disagree Neutral Agree
3. When acting with love, you can never do too much for a child.
Disagree Neutral Agree
4. My child interrupts my conversations often.
Disagree Neutral Agree
5. I generally need to ask more than once to get my child to do something.
Disagree Neutral Agree

A majority of answers in the left column indicates a parenting style with

high behavioral controls. A majority of answers in the right column
indicates a parenting style with low behavioral controls.
 Authoritative or Authoritarian
parents
• Children raised by Authoritative or Authoritarian parents
who expect, and demand appropriate, responsible
behavior will understand that the dentist and staff
members establish the rules and will guide them through
a dental visit.
• These children have been socialized to follow the lead of
adults.
• The dentist can expect that most Authoritative or
Authoritarian parents will endorse and support the rules,
structure, and behavior guidance that the dentist presents
to the child.
 Permissive parents
• Children raised by these types of parents have been
conditioned to view adults in a more egalitarian manner.
• They may expect the dentist to offer them the same degree
of choices and control that they are accustomed to in their
home environment.
• Since a dental appointment is not a situation where the
child should or can lead, then he may become unsettled,
disappointed, or frustrated with a role of diminished power,
and react negatively.
• ‘Permissive parents may take offence at the firm, clear
structure provided for their child by the dentist and
advocate for their child’s preferences to be
accommodated.
 Parenting style
• Dentists should consider the effects of different
parenting styles when providing care for the
anxious child.
• Where the parenting style appears to be
detrimental to behaviour management in the
dental environment consideration might be
given to an alternative accompanying adult
whose parenting style is more helpful.
Factors affecting child's behavior:
• Involving the child
– Growth and development
– I.Q. of child
– Past dental experience
– Social and adaptive skills
– Position of child in the family

• Under the control of parents

– Family influence
– Parent-child relationship
– Maternal anxiety and attitudes (of parents) to dentistry
• Overprotective, Overindulgent, Under-affectionate, Rejecting,
Authoritarian
Factors affecting child's behavior:
• Under the control of the dentist
• Others
– socioeconomic status, nutritional
 Medical history
• The quality of past medical visits are important.
– If they were unpleasant, this could have a bearing on
a child’s attitude toward future dental visits.
• Pain from previous procedures is often reported by a
parent and, although it may be inaccurate, this aspect of
the medical history ranks high on possible sources of
misbehavior.
• Other aspects of the medical history - frequency of
medical visits or even hospitalization, have not been
found to be consistently related.
 Under The Control of The Dentist
• Dental office should be:
– comfortable, bright
– not inspiring fear in the child
• Dentist’s attitude
• Dentist clothes
• Presence or absence of parents
• Presence of older sibling
Effect of Dentist’s Activity & Attitude
• The objective is to explain to the child
importance of dental treatment and its
purpose in a manner the child understands.
• Length of Appointment should be short.
• Appointment time should be early - avoid
nap time or at the end of work day.
 Dentist clothes:

• At the first meeting with the child not to

wear a mask and gloves.

• Avoidance of the white coat.

 Presence of pain!!!
• The child in pain will almost always exhibit
behavior guidance challenges.
• Pain is an inherently subjective experience and
should be assessed and treated as such.
• Pain has sensory, emotional, cognitive, and
behavioral components that are interrelated with
environmental, developmental, sociocultural, and
contextual factors.
• Tissue damage is not required to provoke pain,
and reports of pain should not be casually
dismissed.
 Presence of pain!!!

• It is counterproductive to argue with the child that

a sensation is “uncomfortable but does not hurt,”
• especially in young children who are unable to
describe levels of pain and experience noxious
stimuli dichotomously (i.e., either “yes, it hurts”
or “no, it does not hurt”).
 Dental fear
• The relationship between dental fear and negative
behavior is not straightforward, and it would be an
oversimplification to attribute all misbehavior to dental fear.
• The etiology of dental fear in children is multifactorial and a
product of previous experience, generalized fear, and
familial anxiety.
• Dental fear has been found in most but not all children with
behavior management problems.
– While the odds are increased that children who exhibit
negative behavior have dental fear, and children who have
dental fear may exhibit negative behavior, not all
uncooperative children report dental fear.
• Children who report being fearful by various measurement
tools are twice as likely to behave negatively than children
who are not fearful.
 Dental fears
• are classified as realistic and theorized fears.`(according to
Pinkham)
• Realistic fears are previous bad experiences, fears acquired
from siblings and peers, and the fear of the needle,
• an example of a theorized fear is the fear of being
electrocuted by the x-ray tube.
• Dental fear is a worldwide problem and a universal barrier
to oral health services; fears acquired in childhood through
direct experience with painful treatment or vicariously
through parents, friends, and siblings may persist into
adulthood.
 Dental fear
• Dental fear has been attributed to lack of trust in the dentist
and lack of control over a traumatic event.
• Dental techniques that help the patient regain trust and
control, such as use of signaling, may prevent or alleviate
these fears.
• Regarding specific procedures, the dental injection is the
most feared procedure, followed by “drilling” and “tooth
scaling.”
• Other common fears are “feeling the needle” and “seeing
the needle.”
• Needle phobia, however, does not imply a high level of
children's dental anxiety and diminishes with increasing
age.
 Dental fear and anxiety and
other behavior problems
• DFA have also been linked to increased general
fears.
• Dental fear itself may be a manifestation of
another disorder, such as fear of heights and
flying, claustrophobia, and other fears.
• DFA may also be linked to general behavioral
problems, and children at risk of developing
internalizing disorders (i.e., separation anxiety
disorder, generalized anxiety disorder, obsessive-
compulsive disorder) are more likely to exhibit
dental fear.
Presence or absence of parents

• If a parent is to be in the operatory, it is

important that she does not:
– Disrupt the relationship between the child and
dentist
– Distract the dentist
• They must attend as a silent observer.
 Under the control of parents:
• Maternal anxiety
– Anxious mother has a greater likelihood of having
a child that will be uncooperative in dental office.
• Child must visit the dental office regularly!
• The parents:
– Should not voice their own personal fears in front of the
child.
– Should not tell anything about what dentist is going to do.
– Never use dentistry as a threat or punishment.
 Behaviour Management:
• Is а mean by which the dental team
effectively and efficiently performs dental
treatment and thus establishes a positive
dental attitude.
• The fundamentals of behavior management
center on the attitude and integrity of the
entire dental team.
FUNDAMENTALS OF BEHAVIOR MANAGEMENT

• Positive approach - these includes positive

statements
• Team attitude - Friendly and caring
• Organization - Well organized dental team and
treatment
• Truthfulness - Black or White - the children
should not be deceived
• Tolerance - Ability to rationally cope with the
misbehaviors
• Flexibility - as situation demands
 Goals
of behavior guidance are to:
1) establish communication,
2) alleviate the child’s dental fear and anxiety,
3) promote patient’s and parents’ awareness of the need for
good oral health and the process by which it is achieved,
4) promote the child’s positive attitude toward oral health
care,
5) build a trusting relationship between dentist/staff and
child/parent
6) provide quality oral health care in a comfortable, minimally
restrictive, safe, and effective manner
Behavior guidance techniques
• range from establishing or maintaining
communication to stopping unwanted or unsafe
behaviors.
• Knowledge of the scientific basis of behavior
guidance and skills in communication, empathy,
tolerance, cultural sensitivity, and flexibility are
requisite to proper implementation.
• Behavior guidance should never be punishment
for misbehavior, power assertion, or use of any
strategy that hurts, shames, or belittles a patient.
 Behaviour shaping:

• This is the procedure which slowly

develops appropriate behaviour in
children.
❖The studies describing children's behavior in
the dental office have centered around three
main areas.
1.Classifying children's behavior.
2.Describing various forms of behavior, whereas
negative behavior patterns have been named.
3.Elaborating on factors which affect behavior in
dental environment.
 Description of Behavior:
• When a dentist examines a child patient,
one type of behavior – the cooperative
behavior is always identified.

• The key to fulfill a dental treatment is child

cooperation.
 Description of Behavior:
• Children’s behavior may be characterized in
three ways:
1. Co-operative
2. Lacking co-operative ability
3. Potentially co-operative - being referred to the
inaccurate term “uncooperative”
- include the very young children with whom communication cannot
yet be established (pre-cooperative)
- children with specific disabilities with whom cooperation in the usual
manner may never be achieved.
 Under the control of parents:
• There is conflicting evidence with respect to the
influence of different parenting styles on child
behavior in the dental setting.
• Dentists should take into account the effects of
different parenting styles when providing care for
the anxious child.
• Where the parenting style appears to be fatal to
behavior management in the dental office -
consideration might be given to an alternative -
another adult whose parenting style will be more
helpful.
 Previous Dental History:
• Fear sustained from previous unhappy
dental visits has been related to poor
behavior at subsequent visits.
• Poor cooperation has also been linked to:
– a history of toothache
– recent local anesthetic experience,
– previous poor behavior
– poor oral health status.
Behavior management techniques can be
broadly classified as:

• Non-Pharmacological Techniques

• Pharmacological Techniques
 NON-PHARMACOLOGICAL METHODS

1. Communication

2. Behavior shaping (modification)

3. Behavior management
1. Communication:
 Communication:
• Verbal
– establishment of communication
– establishment of communicator
– message clarity
– tone
• Nonverbal
– multi sensory communication
• Active Listening
• Appropriate Responses to the situation
 Communication
• At the beginning of a dental appointment, asking
questions and active/reflective listening can
help establish rapport and trust.
• The dentist may establish teacher/student roles
in order to develop an educated patient and
deliver quality dental treatment safely.
• Once a procedure begins, bi-directional
communication should be maintained, and the
dentist should consider the child as an active
participant in his well-being and care.
 Communication
• With this two-way interchange of information, the dentist
also can provide one-way guidance of behavior through
directives.
• Use of self-disclosing assertiveness techniques (e.g., “I
need you to open your mouth so I can check your teeth”,
“I need you to sit still so we can take an X-ray”) tells the
child exactly what is required to be cooperative.
• The dentist can ask the child ‘yes’ or ‘no’ questions
where the child can answer with a ‘thumbs up’ or
‘thumbs down’ response. Also, observation of the child’s
body language is necessary to confirm the message is
received and to assess comfort and pain level.
COMMUNICATION:
Verbal communication:
• The language used should always be age
appropriate.
• The first objective in the successful management of
young child is to establish communication.
• Effective communication is essential to the
development of a trusting relationship with child
patient.
• To be effective – the message has to be clear.
• The tone – often it is not what is said but rather how
it is said – that creates an impact.
Dental terminology Word substitute
• Rubber dam • Raincoat
• Rubber • Tooth button
• Rubber • Coat rack
• X-ray • Tooth picture
• Sealant • Tooth nail
• Explorer • Tooth counter
• Topical fluoride gel • Cavity fighter
• Air syringe • Wind gun
• Water syringe • Water gun
• Suction • Vacuum cleaner
• Bur • Brush
• Alginate • Pudding
• High speed • Whistle
• Low speed • Motorcycle
 COMMUNICATION:

Nonverbal communication:
• This form of communication
occurs continuously and may
reinforce or contradict verbal
signals.
• Such communication includes
having a child-friendly
environment and a happy,
smiling team.
 HOW TO COMMUNICATE:

• Should Be comfortable and relaxed.

• Language should contain words that express
pleasantness, friendship and concern.
• Voice that is used should be constant and gentle.
• Tone of voice can express empathy and firmness.
• Sitting and speaking at the eye level allows for a
friendlier atmosphere
 COMMUNICATION:

Nonverbal communication:
• Such as stroking the hand of child.
• Communicates the feeling of warmth.
• The dental team – movements should be
slow and smooth.
• Gentle application of instruments.
• This technique may be useful with all
patients.
 COMMUNICATION:

Active listening
• Listening is important in the treatment of all
children, especially older children.
• Ways in which children`s feelings are
recognized include:
– Listening quietly
– Acknowledging the feeling with “I see” or “Are
you really nervous about coming to see me”.
NON-PHARMACOLOGICAL
TECHNIQUES
Non-pharmacological techniques:
NON-INVASIVE INVASIVE
• Tell-show-do (TSD) • Hand-over-mouth (HOM)
• Behavior shaping • Restraint
• Reinforcement – Protective stabilization
– Physical restraint
• Operant conditioning
• Modeling
• Voice control
• Desensitization
• Visual imagery
• Humor
• Distraction
• Parental presence\absence
 Direct observation
• Description: Patients are shown a video or are
permitted to directly observe a young
cooperative patient undergoing dental treatment.
• familiarize the patient with the dental setting and
specific steps involved in a dental procedure;
• provide an opportunity for the patient and parent
to ask questions about the dental procedure in a
safe environment
• Indications: May be used with any patient.
• Contraindications: None.
 Tell-show-do (Addelston - 1959)
• 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 (Addelston - 1959)
• Lengthy complicated procedures are broken
down into steps.
• The dentist shows the child:
– what will be used and how it works
– how the procedure will be done demonstrating
on an inanimate object.
• Noisy instruments should be demonstrated
to the children at the distance to avoid
startling them.
Tell-show-do (Addelston - 1959)
• Instruments gradually come closer for
demonstration and inspection.
• Operating hand-pieces without touching
the child – or letting the patient feel the
vibration without cutting the tooth.
• This is a desensitizing technique.
 Tell-show-do
Objectives:
1. Teach the patient important aspects of the dental
visit and introduce the patient to the dental setting.

2. Shape the patient’s response to procedures

through desensitization and well-described
expectations.
 Ask-tell-ask
• Description: This technique involves inquiring about the patient’s
visit and feelings toward or about any planned procedures (ask);
• explaining the procedures through demonstrations and non-
threatening language appropriate to the cognitive level of the
patient (tell);
• and again inquiring if the patient understands and how she feels
about the impending treatment (ask).
• If the patient continues to have concerns, the dentist can address
them, assess the situation, and modify the procedures or behavior
guidance techniques if necessary.
• Objectives: The objectives of ask-tell-ask are to:
– assess anxiety that may lead to noncompliant behavior during treatment;
– teach the patient about the procedures and their implementation;
– confirm the patient is comfortable with the treatment before proceeding. •
• Indications: Use with patients who can communicate.
• Contraindications: None.
 Behaviour shaping

• This is procedure which very slowly

develops appropriate behaviour in children.
• This technique is a simple method of
teaching the child step by step what is
expected in the dental office.
• This method can be used with children who
demonstrate sufficient cooperation.
 Behaviour shaping
• Dental team should follow an established protocol
for introducing new procedures or instruments to
children.
• State the goal at the outset – Today we are going
to check your teeth.
• Divide the explanations: First we have to count
your teeth. We will start with the upstairs teeth.
Now we need to count your downstairs teeth….
• Use age-appropriate language – for young
children use euphemisms.
Systematic Desensitization ..exposure to hierarchy of
fear producing stimuli (Joseph Wolpe)
Systematic Desensitization ..exposure to
hierarchy of fear producing stimuli
 Voice control:
• Is a controlled alteration of voice volume, tone, or pace to
influence and direct the patient’s behavior. Parents
unfamiliar with this possibly aversive technique may
benefit from an explanation prior to its use to prevent
misunderstanding.
• The objectives of voice control are to:
— gain the patient’s attention and compliance;
— avert negative or avoidance behavior;
— establish appropriate adult-child roles.
• Indications: May be used with any patient.
• Contraindications: Patients who are hearing impaired
 Nonverbal communication
• This is the reinforcement and guidance of behavior
through appropriate contact, posture, facial expression,
and body language.
• The objectives are to:
— enhance the effectiveness of other communicative
management techniques;
— gain or maintain the patient’s attention and compliance.
• Indications: May be used with any patient.
• Contraindications: None.
 Positive reinforcement
• In the process of establishing desirable patient behavior, it is
essential to give appropriate feedback. Positive reinforcement
is an effective technique to reward desired behaviors and,
thus, strengthen the recurrence of those behaviors.
– Social reinforces include positive voice modulation, facial
expression -smile, verbal praise – ‘right’, ‘great’, ‘you are really
helping me by opening your mouth wide’, and appropriate
physical demonstrations of affection by all members of the dental
team.
– Nonsocial reinforces include tokens and toys.
• Objective: To reinforce desired behavior.
• Indications: May be used with any patient.
• Contraindications: None.
 Distraction
• This is the technique of diverting the patient’s attention
from what may be perceived as an unpleasant
procedure.
– Giving the patient a short break during a stressful
procedure can be an effective use of distraction
prior to considering more advanced behavior
guidance techniques.
• The objectives of distraction are to:
— decrease the perception of unpleasantness;
— avert negative or avoidance behavior.
• Indications: May be used with any patient.
• Contraindications: None.
 Parental presence/absence
• The presence or absence of the parent sometimes
can be used to gain cooperation for treatment.
• A wide diversity exists in practitioner philosophy
and parental attitude regarding parents’ presence
or absence during pediatric dental treatment.
• Practitioners must consider parents’ desires and
wishes and be open to change their own thinking.
• Indications: May be used with any patient.
• Contraindications: Parents who are unwilling or
unable to extend effective support (when asked).
 Еnhancing control
• is a technique used to allow the patient, especially an anxious/fearful
one, to assume an active role in the dental experience.
• The dentist provides the patient a signal (e.g., raising a hand) to use if
he becomes uncomfortable or needs to briefly interrupt care.
• The patient should practice this gesture before treatment is initiated to
emphasize it is a limited movement away from the operatory field.
When the patient employs the signal during dental procedures, the
dentist should quickly respond with a pause in treatment and
acknowledge the patient’s concern.
– Enhancing control has been shown to be effective in reducing
intraoperative pain.
• Objectives: The objective is to allow a patient to have some measure
of control during treatment in order to contain emotions and deter
disruptive behaviors.
• Indications: Use with patients who can communicate.
• Contraindications: None, but if used prematurely, fear may increase
due to an implied concern about the impending procedure.
 Parental presence/absence
OBJECTIVES: OBJECTIVES:
• For parents to: • For practitioners to:
— participate in infant — gain the patient’s attention and
examinations and/or improve compliance;
treatment (if asked); — avert negative or avoidance behaviors;
— offer very young children — establish appropriate dentist-child
roles;
physical and
psychological support; — enhance effective communication
among the dentist, child, and parent;
— observe the reality of their
— minimize anxiety and achieve a
child’s treatment. positive dental experience;
— facilitate rapid informed consent for
changes in treatment or behavior
guidance.
INVASIVE METHODS
 Protective stabilization
• This is the act of physical limiting аnd the restriction of patient’s
freedom of movement, with or without the patient’s permission, to
decrease risk of injury while allowing safe completion of treatment.
• The restriction may involve:
– another human(s),
– a patient stabilization device,
– or a combination of both.
• The use of protective stabilization has the potential to produce serious
consequences such as:
– physical or psychological harm,
– loss of dignity,
– violation of a patient’s rights.
• Stabilization devices placed around the chest may restrict respiration
– they must be used with caution.
 Protective stabilization
• The objectives of this method are to:
— reduce or eliminate untoward movement;
— protect patient, staff, dentist, or parent from injury;
— facilitate delivery of quality dental treatment.
• Dentist must receive informed consent for
stabilization.
 Protective stabilization
INDICATIONS:
• Patients require immediate diagnosis and/or limited treatment and
cannot cooperate due to lack of maturity or mental or physical
disability.
• To treat the emergencies on hysterical children and children who
can not be reached in language because of their age.
• Developmentally disabled children.
• Children who for whatever reason cannot cooperate with the dentist.
• The safety of the patient, staff, dentist, or parent would be at risk
without the use of protective stabilization.
• Sedated patients require limited stabilization to help reduce
untoward movement.
 Protective stabilization
CONTRAINDICATIONS:
• Cooperative non-sedated patients.
• Patients who cannot be immobilized safely due to associated
medical or physical conditions.
• Patients who have experienced previous physical or psychological
trauma from protective stabilization (unless no other alternatives
are available).
• Non-sedated patients with non-emergent treatment requiring
lengthy appointments.
 Hand Over Mouth - HOM
• Over last two decades this method has
gradually become less acceptable for parents
and profession.
• In 2006 it was no longer endorsed by the
AAPD.
• Still used in other countries where general
anaesthesia is not often applied.
 HOM
Indications:
• A healthy child (able to understand and cooperate), but
who exhibits hysterical avoidance behaviors.
• Most effective for gaining attention of children 3-6 years
of age.
Contraindications:
• Children who, due to age (under 3 years of age), disability,
medication, or emotional immaturity are unable to
verbally communicate, understand, and cooperate.
• Any child with an airway obstruction.
 HOM – technique:
• Place the hand over the child`s mouth to muffle the
noise.
• Bring your face close to the child and talk directly
into ear.
• Quietly, tell the child to stop screaming and listen,
and then you will remove the hand.
• Explain that you ‘only want to talk and look at your
teeth’.
• Repeat the instruction after few seconds, adding:
‘Are you ready for me to remove my hand?’
• Caution the child to be quite when the hand is
removed.
Reasons for fear of dental treatment
 Reasons:
➢ Increased anxiety about new events.

➢ Anxiety against medical interventions.

➢ Mother`s attitude to child development.

➢ Mother`s fear from dental treatment.

 Reasons:
➢ Presence of the child during dental
treatment of patient with negative behavior.

➢ Violent approach towards child during

dental treatment.

➢ Threat with dentist or physician.

 Clinically significant
Various tools are available - they should be used in conjunction with
good verbal and non-verbal communication, used liberally and used
in combination as appropriate for the child, carer and situation.
It is worthwhile to remember - the concept of patients being largely
grouped into two separate ‘camps’ in terms of how much information
they do, or do not, prefer regarding the care they are having:
‘monitors’ and ‘blunters’.
Monitors: seek information when under threat. The child who
constantly looks around at everything the clinician is doing/has ‘20
questions’ about each stage of the procedure.
Blunters: use distractive strategies when under threat – who prefers
to ‘plug themselves in’ to their electronic music device at the start of
the appointment and tells the clinician ‘just let me know when you’re
finished’.
 Clinically significant
• This is obviously an oversimplification of patient personality, i.e. to
categorise patients into only one of two ‘camps’, but generally, the
clinician will identify which of these personality camps the child
broadly
• monitoring patient is unlikely to respond well to ‘close your eyes and
imagine you are somewhere else,
• while a blunting patient is likely to feel more anxious if the clinician
provides a blow-by-blow account of the upcoming local anaesthetic
administration.
• Whichever combination of NPBMT the clinician utilises during the
course of care, it is important that the carer (and CYP where
appropriate/feasible) is aware, for the purposes of informed consent,
of which NPBMT the clinician is planning to utilise.
PHARMACOLOGICAL
TECHNIQUES
Pharmacological Techniques
• General • Sedation
anesthesia – Mild
– Moderate
– Deep
 General anesthesia
MEDICAL INDICATION:
• Children with
– Mental development disturbance
– Musculoskeletal joint disease
– Neurological disease
 General anesthesia
Dental indication
• Children with:
– Maxillofacial injuries.
– Strong negative behavior, for who the
methods for behavior modelling and pain
control aren’t successful.
– Indication for emergency dental treatment.
– Impossibility for multi-session treatment.
 General anesthesia
Contraindication
• Cooperative children
• Children under 3 years and less than 15 kg.
• Cardiac cyanosis
• Asthma relapse more than1 time per year
• Diabetes
• Coagulopathies
• Protracted vomiting after anesthesia
• Surgeries that require special post-operative care
PREANESTHETIC EVALUATION AND
PROCEDURES
• Instruction to patients
• Preoperative health assessment
• Clinical examination
• Doctors order

INSTRUCTION TO PARENTS
• The practitioner should provide verbal and written
instruction to the parents. It should include
explanation of potential/anticipated postoperative
behaviour and limitation of activities along with
dietary precautions.
PEROPERATIVE HEALTH ASSESMENT
It should be done within 2 days prior to procedure to be reviewed at the
time of treatment.

CLINICAL EXAMINATION
VITAL SIGNS - Pulse and BP to be recorded

LABORATORY INVESTIGATION
BLOOD-TC,DC,HB,PS,ESR,HIV,HBS,ELISA. URINE- urea and keratinine.

TEMPERATURE AND BODY WEIGHT

CHILD PHYSICIAN - Name and address of child’s physician.

DOCTOR’S ORDERS
1. To parents
2. TO ASSISTANT- To inform the Anesthesian, Pradiatrition.
Premedication with a systemic background
Patient with subacute bacterial endocarditis and abscess – antibiotic prophylaxis
is needed.
GUIDELINES BEFORE DENTAL TREATMENT
UNDER GA

1. Verbal and written instruction should be given to parents

about preoperative and postoperative care.
2. No milk or solid foods should be eaten after midnight before
procedure.
3. Only clear liquids should be ingested up to 4 to 8 hours
before appointment, depending on age.
4. Vital statistics should be recorded (weight and height).
5. Medical history should be completed.
6. Status of airway should be confirmed.
7. Vital signs, including pulse and blood pressure, should be
recorded.
 POST OPERATIVE PERIOD
• Procedure performed should be explained to
patient.
• The presence of any bleeding from the oral cavity,
extra oral swelling should be checked for.
• The patient can de start of with analgesic if pain is
present.
• The child should be evaluated for the various
system like cardiovascular function.
• Any instructions regarding the restorative
procedure performed should be given.
POST OPERATIVE PERIOD

• Do not drive an automobile, bike or use any

machinery.
• Do not drink any alcohol or take any medicine
that is not prescribed by the doctor.
• Do not take any complex or legal decision.
• Start with liquid and advance to other food.
• You feel groggy, dizzy and tired for 24 hours.
Sedation
• Pediatric dental treatment under
sedation is controversial.
• Indication
– healthy children - 6 years of age and older
– for short procedures with predictable end
 Treatment deferral
• Dental disease usually is not life-threatening,
and the type and timing of dental treatment can
be deferred in certain circumstances.
• When a child’s cognitive abilities or behavior
prevents routine delivery of oral health care
using communicative guidance techniques, the
dentist must consider the urgency of dental
need when determining a plan of treatment.
 Treatment deferral

• In some cases, treatment deferral may be

considered as an alternative to treating the
patient under sedation or general
anesthesia.
• However, rapidly advancing disease,
trauma, pain, or infection usually dictates
prompt treatment.
 Treatment deferral
• Deferring some or all treatment or employing therapeutic
interventions (e.g., interim therapeutic restoration - ITR,
fluoride varnish, antibiotics for infection control) until the child
is able to cooperate may be appropriate when based upon
an individualized assessment of the risks and benefits of that
option.
• The dentist must explain the risks and benefits of deferred or
alternative treatments clearly and informed consent must be
obtained from the parent.