Behaviour management Flashcards
Up to what % of the child population have dental fear & anxiety and dental behaviour management problems?
10%
What is dental fear?
a normal emotional reaction to one or more specific threatening stimuli in the dental setting
What happens to fears with age?
They change
How do fears change between a child 2-3 y/o vs. a child 7-8 y/o?
2-3 y/o: fear anything that differs from the norm
7-8 y/o: fewer fears in general but able to verbalise them
What may you be scared at at the dentists?
Failure in front of strangers Smell Needles Lack of control Self protection = May be neurotic/disproportionate
What is dental anxiety?
a state of apprehension that something dreadful is going to happen in relation to treatment
= multidimensional consisting of somatic, cognitive and emotional elements
What is predictive of child onset dental anxiety?
A family history of dental anxiety
What is adoloscent onset dental anxiety usually characterised by?
Trait anxiety
What is adult onset anxiety?
= severe fears
Can indicate psychiatric problems
What is exogenous dental anxiety?
Through conditioning, learning and experiences e.g. from parents or due to bad previous dental experience
What is endogenous dental anxiety?
Due to constitutional vulnerability = due to internal stressors = typical of an anxiety disorder
What can determine the consequences of traumatic dental experiences?
The context in which they occurred e.g. pain occurred during treatment
n.b. there are often problems with accurate recall = false memory syndrome
What is dental phobia?
A severe type of dental anxiety = marked and persistent anxiety that is excessive and unreasonable
What causes most patients to have a dental phobia?
Fear of injections
What can dental phobias be in response to?
Either to specific situation or the dental situation in general
Because the person can recognise that the anxiety is excessive and unreasonable why is it still an issue?
The person cannot physically help themselves get over it
What are the behaviour management techniques?
Pharmacology (Sedation or GA)
Psychology
What is the IOSN used for?
Estimating the need for sedation
What is the IOSN based on?
- anxiety score
- medical history
- treatment complexity
n.b. these are all sliding scales and can change on any day of the week
What are the different sources of guidelines for behaviour management?
- Non pharmacological behaviour management BSPD -2011
- Use of GA in pages BSPD 2008
- Sedation in children and young people NICE 2010)
Name the different measurement techniques?
- Behavioural rating scale (Frankyl scale)
- Anxiety rating (dental anxiety scale)
- Pain rating (FACES)
What is the behavioural rating scale (Frankyl scale)?
Observation of childs behaviour during treatment
Bx1 = definitely negative (not looking at you, crying, unable to walk in)
Bx2 & Bx3 = more hesitant
Bx4 = definitely positive (lovely pt.)
What is the anxiety rating (dental anxiety scale)?
Reports of anxiety by child/parent using psychometric scales in a questionnaire
= 5 x questions with a total summed score of 5- 25, score >19 indicates highly anxious pt.
With an anxious patient, what determines what treatment you carry out and how?
Level of anxiety
Presence of urgent treatment needed
If a patient is highly anxious and needs urgent treatment what do we do?
Relative analgesia, conscious sedation or general anaesthesia
If a patient is highly anxious but does not need urgent treatment what do we do?
Cognitive behavioural therapy
If a patient is moderately anxious whether or not they need urgent treatment what do we do?
The same as for low levels of anxiety + provision of preparatory information
If a patient is a low level of anxiety whether or not they need urgent treatment what do we do?
Rapport building Voice control Distraction Modelling Memory reconstruction Environmental change
Which interventions do we use for low levels of anxiety?
Distraction Voice control Positive reinforcement Modelling Show tell do Behaviour shaping Enhancing the sense of control Environmental change Rapport building
What is voice control?
A controlled alteration of voice volume, tone or pace to influence behaviour
= gains patient attention and compliance, alters negative or avoidance behaviour, establishes adult - child roles
What is positive reinforcement?
Rewarding positive behaviour
What is modelling?
One child observing a predictably reliable and well behaved patient having treatment (older siblings are often good = demonstrates the desired behaviour)
What is tell-show-do?
= age appropriate verbal explanation of a procedure, demonstrating the procedure (auditory) and completion of procedure)
n.b. too much information can tip the balance
= helps familiarise the patient with the surroundings and shape the patient response
Which interventions do we use for moderate anxiety?
Provide information about what will happen (procedural information), what the patient can do to cope, what sensations the individual will experience
Restraint
Parental acceptance
How can restraint be used?
Parental, Papoose board (often sedated too to keep comfortable)
= to mobilise and protect them from harming themselves
What is parental acceptance?
What a parent will allow you to do!
Tell show do, positive reinforcement, sedation, voice control, GA an physical restraint (increasingly unacceptable down this list)
What is behaviour shaping?
A series of small steps towards ideal behaviour achieved with selective reinforcement
What interventions do we use for high anxiety individuals?
Pharmacological
Cognitive behavioural therapy
Systemic desensitisation
What are the different pharmacological interventions?
Nitrous oxide (inhale)
Midazolam
GA
What is cognitive behavioural therapy?
Changes how you think about anxiety inducing things, and challenges your beliefs (more realistic and effects the thoughts)
n.b. change is not necessarily permanent
What are the 3 steps of systemic desensitisation?
- Identification of an anxiety inducing stimuli
- learning coping techniques
- react towards and overcome situations in the heir achy
n. b. goes through the heirachy of fear stimuli e.g. think about spider, look at picture of spider, look at it in a closed box, go into the closed box, touch it, let it crawl on your hand etc.
What is the paediatric triangle?
The interactions between the child, dentist and parent (can be complex)
What is important with the paediatric triangle?
Good communication is important to build trust and communication, parental presence can significantly affect the atmosphere and influence child behaviour (not necessarily in good way e.g. if parent anxious) also depends how confident you feel in sending the parent out
What is an important indicator of behaviour?
Child parent interaction
N.b. behaviour management problems are not a quality of the child… but…
the quality of the relationship between the dentist and child
