Behavioral Management Flashcards
What is behavioral management
the continuum of interaction with a child/parent directed toward communication and education
What is the goal of behavioral management
○ Ease fear and anxiety
Promoting an understanding of the need for good dental health
What is the normal childhood development for a 2 year old
Fear of unexpected movements, loud noises and strangers
These children are not yet in nursery so the dental environment is unknown and strange which can cause fear
This reaction is a normal part in evolvement of a child as at age 2 they begin to understand fear and it stops them running away
What is the normal childhood development for a 3 year old
○ Many children of this age will be at nursery and so are receptive to positive comments
○ Reacts favourably to positive comments about clothes and behaviour
○ Less fearful of separation from parents due to nursery
○ Experience will however dictate reaction to separation
What is the normal childhood development for a 4 year old
○ May have been at nursery for a while or started school
○ More assertive but can be bossy & aggressive
○ Fear of the unknown and bodily harm is now at peak
○ Fear of strangers has now decreased
○ With firm and kind direction will be excellent patients
What is the normal childhood development for a 5 year old
○ At school and more likely to come in by themselves
○ Readily separated from parents
○ Fears have usually diminished
○ Proud of possessions so engage with them
○ Comments on clothes will quickly establish a rapport
What is the normal childhood development for a 6 year old
○ Seeks acceptance
○ Success in this can affect self-esteem
If while a dentist child develops a sense of inferiority or inadequacy behaviour may regress to that of a younger age so do not belittle them
What is the normal childhood development for a 7-12 year old
○ Learn to question inconsistencies and conform to rules of society
○ Still have fears but are better at managing them
○ Boys may feel the need to conform to social norms and hide their fears - this may present by them saying they are too tired, need to go to the toilet etc. the MCDAS is extremely good at getting boys to communicate their dental anxieties
How do anxiety and behavior link
- Anxiety, behaviour and compliance are all related
* From age 3-8 these are going to be linked
How do we communicate with anxious children
• We use MCDAS and message to dentist to communicate with anxious children and both of these are validated from the age of about 8 or 9
What is dental anxiety
occurs without a specific stimulus and may be a reaction to an unknown danger or anticipatory due to previous negative experiences
What is dental fear
normal emotional response or situations perceived as genuinely threatening, common specific threats include the sound of the drill or the needle
What is dental phobia
is a clinical mental disorder where subjects display persistent and extreme fear of objects or situations with avoidance behaviour and interference of daily life
What are the components of DFA
physiological and somatic sensations (fight or flight)
cognitive features (Changes in the thinking process)
behavioral reactions
How do physiological and somatic sensations present
○ Breathlessness
○ Perspiration
○ Palpitations
○ Feeling of unease
How do cognitive features present
interference in concentration
hypervigilance
inability to remember certain events while anxious
imagining the worst could happen
How does hyper vigilance present
§ swivelling their heads trying to work out what’s happening. Explain to them you wont put anything in their mouth unless you have explained it first
What are the behavioral reactions for DFA
avoidance
escape from the station which precipitates anxiety
anxiety may manifest with aggressive behaviors especially in adolescence who are brought by their parents but don’t want to be there
How does avoidance present
§ The postponing of a dental appointment, or with children disruptive behaviour in an effort to stop treatment being undertaken
What should be done if a px turns aggressive
§ They may turn aggressive if they feel they are not being listened to
§ Ensure that you as the dentist are safe
§ The best thing to say if the patient is aggressive is that the dentistry is second and the most important thing is to discuss how the patient is feeling as nothing can be done until they are comfortable
What are signs of DFA
○ Younger children may time delay by asking questions
○ School age children may complain of stomach aches/or ask to go to the toilet frequently
○ Older children may complain of headaches or dizziness, may fidget or stutter, can’t be ‘bothered’
What are factors that influence fear and anxiety
- Fear of choking
- Fear of injections/drilling
- Fear of the unknown
- Past medical and dental experience
- Dental experience of friends and siblings
- The attitudes of parents towards dental experience
- Preparation at home before the dental visit
- The child’s perception that something is wrong with their teeth
What can be be asked to asses children dental fear
assess patient’s desire t influence course of tx w rest breaks, signal stops and info (control related)
ask about previous dental experience
ask about past experience
items relating to trust include attention to dentist/px relationship and perceptions to vulnerability
What is faces MCDAS
• Used for assessing children’s dental fear and anxiety
What is MCDAS’s benefits
○ Quick and easy to use
○ Different aspects of dental experience rated
○ Base line levels of anxiety are established
What age is MCDAS for
Validated for children aged 8 plus
What questions does MCDAS ask
○ How do you feel about § Going to the dentist § Having a check up § Having teeth polished § Having an injection § Having a filling § Having a tooth taken out § Being put to sleep (GA) § Mixture of gas and air (inhalation sedation) § Having a needle in the back of your hand (IV)
Why is good dentist patient communication important
○ It improves the information obtained from the patient as the more you build a rapport with the patient and parent the more they tell you
○ It enables the dentist to communication information to the patient
○ Increases the likelihood of patient compliance as they feel listened to
○ Decreases patient anxiety
What are the components of communication
○ Verbal (5%)
○ Paralinguistic (30%)
○ Non verbal communication (65%)
What are the ways to reduce px anxiety
○ Preventing pain ○ Being friendly and establishing trust ○ Working quickly ○ Having a calm manner ○ Giving moral support ○ Being reassuring about pain § Acknowledge if they feel something ○ Empathy
What are things that increase fear related behavior
○ Ignoring or denying feelings ○ Inappropriate reassurance ○ Coercing/coaxing ○ Humiliating ○ Losing your patience with the patient
What is the expression of pain
○ Screwing up the eyes and lowering the eyebrows with the mouth open in a squarish appearance
○ Can be seen drilling with LA failure
○ Important to look at them as the child may not know how to communicate the pain
What is the expression of fear
○ Opening eyes widely and raising eyebrows with mouth open and tense
What does letter to dentist ask
○ How worried are they? ○ How painful do they think treatment will be? ○ What do they want to happen? ○ How will they cope? ○ What is their stop signal?
With an infant or toddler, why is parental presence beneficial
○ Patient is incapable or unwilling to sit for examination (positioning the child on the lap of the dentist and parent permits the child to be in direct visual and physical contact with the parent) aka knee to knee examination
○ Opportunity exists for the parent to witness the behaviour the clinician must contend with as the child may need referred for behavioural issues so the parent must see why that is the case
What are behavioral management techniques
positive reinforcement tell show do acclimatization desensitization voice control distraction role modelling relaxation hypnoses
What is positive reinforcement
○ Presentation of a stimulus that will increase the likelihood of a positive behaviour being repeated
Use of social and non social reinforcers
What are social re-inforcers
§ Facial expression
§ Verbal praise
§ Appropriate physical contact
What are non-social reinforcers
§ Stickers
§ Colouring posters
§ Clever certificates
What is tell show do used for
to familiarise a patient with a new procedure
How is tell show do done
§ Tell involves an age appropriate explanation
§ Show is demonstrating for the patient aspects of the procedure in a non-threatening setting e.g using the slow speed to draw a happy face on their finger nail
§ Do phase is initiated with minimal delay
What is acclimitisation used for
○ The planned sequential introduction of environment, people, instruments and procedures all done in a timely manner
○ An integral part of the treatment plan
What are examples of acclimatization
§ Introducing the 3:1, suction and cotton rolls on the visit before you plan a fissure sealant
§ Introduce topical one visit before using LA for the first time
§ Use the slow speed first with a prophy cup, later with a bur and later introduce the high speed
§ Give rubber dam home on the visit before you plan to use it
What is desensitization
○ This is based on the assumption that repeated non-distressing exposure to an anxiety-provoking stimulus will eventually reduce anxiety
○ The child must be reassured that they are in control
○ This is done in an ordered manner from what they perceive as the least anxiety provoking to the most anxiety provoking, in imagination or in real life until no anxiety is produced
We teach them how to relax and how to cope
What is voice control
control
○ A controlled alteration of voice volume, tone or pace to influence and direct the patient’s behaviour
§ To gain the patients attention and compliance
§ To avert negative or avoidance behaviour
What is distraction
○ Technique of diverting the patient from what may be perceived as an unpleasant procedure
What are examples of distraction
§ Pulling the upper lip so they focus on that rather than injection
§ Telling a story while giving LA
§ Letting an older child bring in music to listen to
What is role modeling
○ Imitation of others
What does role modeling require
§ Both children to be of similar age
§ Both children getting similar treatment
§ The presence of an older sibling is best for children aged 3-5
What is relaxation
○ Progressive muscle relaxation
○ The space exercise can be used which focuses on breathing
What is hypnoses
○ An interaction between one person, the hypnotist and another person or people, the ‘subject’
○ The hypnotist attempts to influence the subjects, perception, feelings, thinking and behaviour by asking them to concentrate on ideas and images
○ The verbal communications that the hypnotist uses to achieve these effects are termed suggestions
How does hypnoses work
○ The person is so relaxed that the subconscious brain is more open to these suggestions that the conscious brain would be
What is homer
• An old technique that used to be used if children didn’t behave
The hand would be put over the mouth causing airway constriction
Wha were the problems with homar
○ Adverse psychological effects
○ Parental consent
○ Professional acceptance
○ Litigation
What should a treatment plan fo ra child dental
- The gradual introduction of dental equipment and procedures
- This is done in a predetermined manner
- Some aspects can be completed while other instruments and procedures are being introduced
- Tell show do is an effective way to introduce instruments, in this way the child is acclimatised as treatment progresses
How do we ensure painless tx for children
○ Care should be taken not to hurt any child
○ Restorative care is usually carried out under LA
○ A painless technique of administering LA is of vital importance with topical an integral part of treatment
○ Upper carious teeth are normally restored with LA before lower as upper LA is easier
Give an example of an ideal order of treatment
- Simple exam, fluoride varnish application, give diet sheet, ask child to bring toothbrush next visit. Take radiographs or explain for next visit
- Brush teeth using child’s brush, invite to sit on chair. Check diet. Take radiographs. Polish teeth and dry teeth and so introduce slow speed and air syringe. Explain F/S process
- Fissure sealants or dressing. Introduce the saliva injector.
- Remove carious tissue with hand excavator if immediate temporisation is required. Use slow speed drill for small buccal and cervical cavities. Introduce topical and give rubber dam home to play with
- Restore upper teeth with LA using topical prior to injection
- Restore lower teeth with LA again using topical prior
- Pulp treatments then extractions last if px is pain free
To successfully treat children what should be done
○ Px, dentist and parent must work as a team to ensure children is treated at their level in an empathetic and caring manner
○ Always be honest and explain what is happening, using a combination of behavioural management techniques
○ Be positive
○ Ensure treatment plan allows for acclimatisation at the child’s pace
○ Ensure LA is given with the use of topical gel when required
