Behavioural management Flashcards
Background of anxiety
Fear of pain or its anticipation
Lack of trust, fear of betrayal
Fear of loss of control
Fear of the unknown
Fear of intrusion.
What is the background of dental fear?
A reaction to a specific external threatening
stimulus: this is a normal reaction to threatening
stimuli in the dental situation.
Dental Behaviour Management Problems
Uncooperative and disruptive behaviours
resulting in delay of treatment or rendering
treatment impossible.
Fears timing- loud noise and separation?
9-12 months
Imaginary objects
2-4 years
Dark/unknown
4 years
Social and school fears
5-6 years
Injury, death, natural events, social anxiety
6-16 years
What is the background of dental phobia?
special kind of fear out of proportion to
the demands of the situation which will not
respond to reason, is apparently beyond
voluntary control and leads to the
avoidance of dental treatment where this is
necessary.
What are the complications of dental anxiety?
Anxiety
Stress
Patient
Parent
Clinical Staff
Compromises provision of dental care
Persistence of unfavourable attitude into adulthood leading to avoidance.
Aetiology of dental anxiety, exogenous?
dental Previous dental
treatment treatment
Dental health statusDental health status
SES
Parental dental Parental dental
anxietyanxiety
Siblings/peers
PMH
Aetiology of dental anxiety, endogenous?
Gender
General fears
Personality type
Recognising dental anxiety
Clinical affect
Ask accompanying adult
Ask child
Questionnaires
MCDASf
Venham’s Picture test
- CFSS Dental sub scale
Modified child dental anxiety Scale Faces Version (MCDASf
Questions and then smiley faces to quantify the extend of agreement
Venham’s picture test
Little boy doing stuff to quantify fear
Children’s Fear Survey Schedule-
Dental Subscale (CFSS-DS)
Dentists
Doctors
Injections (shots)
Having someone examine your mouth
Having to open your mouth
Having a stranger touch you
Having somebody look at you
The Dentist drilling
The sight of the Dentist drilling
The sound of the Dentist drilling
Having somebody put instruments in your mouth
Choking
Having to go to hospital
People in white uniforms
Having the nurse clean your teeth
Types of child dental patients
Co-operative
Potentially co-operative
Lacking in co-operative ability
Specific disability affecting ability to
cooperate
Pre co-operative
The very young
Setting up a child friendly
practice
Pre-appointment information
Child friendly waiting area
See patient on time
Consider introductory visit
Good communication skills
Positive communication
Verbal and non-verbal
Respect
Show interest in the child as an individual
Give well-stated instructions
Communicate at child’s level
Focus on +ve
Show ethnic, cultural and gender sensitivity
Principles of communication
Verbal
Be understandable
Questioning
Listening
Reassure
Praise
Humour
Principles of communication
Non-verbal
Body language
Proximity-personal
space
Eye contact
Reinforcers
Level and posture
Empathy
Methods of communication
Tell-Show-Do
Reinforcement
Parents
Behaviour Shaping
Voice control
Distraction
Modelling
Other methods
Desensitisation
Tell show do
Universal use
3 in 1
Curing light
Drilling
Encapsulated GIC
Fissure sealants
LA
Positive reinforcement
The strengthening of a pattern of behaviour
which increases the probability of that behaviour in the future
Positive Reinforcement
Praise appropriate behaviour
mouth opening
sitting still
Timing of praise
Don’t praise disruptive behaviour- withdraw
praise
- Don’t use bribes
Voice Control
Variation in tone, pace or volumetone, pace or volume to influence
and direct child’s behaviour
Bright and airy when behaviour good
Even and low to calm anxiety
Low and quiet if poor behaviour
Behaviour Shaping
Influencing behaviour towards desired
ideal by,
Planned introduction to procedures
- Move through stages at the child’s pace
Distraction
Use of a distracting stimulus to divert attention away from
disruptive behaviours and potentially unpleasant sensory stimuli
Distractors
Cartoons
Audio tapes
TV
Virtual reality
Video games
Stories
Lip holding
Leg raising
Talking whilst carrying out a procedure
Modelling - live
a non fearful child
successfully receiving
treatment
e.g. sibling
passive or participant
Modelling- symbolic
Symbolic
video/cartoon
same sex, similar age if possible
additional equipment required
passive or participant
Other methods
Externalising
short break in a different environment before resuming
treatment
ContractsContracts
Count downCount down
counting aloud along with procedures
Stop signals
Desensitisation
Hierarchy of fear provoking stimuli presented to a relaxed patient
Time consuming
psychologist
Hypnosis
Systematic desensitisation - LA
Preamble & hierarchy
Relaxation techniques
LA components
Patient handles syringe
- sheathed & unsheathed
Operator
- sheathed & unsheathed
Administer
Specific Management problems
Pre-cooperative child
Tantrums
Gagging
Specific phobias
Pre co-operative patients
Examine with help from
parent
Tell them to ask you to
stop at any time
Limited intervention
possible
GA usually required for
advanced treatment
Exam with parental help
Knee to knee exam
Management of Gagging
Relaxation
Breathing
Chin position
Care with instruments
Patient watching in mirror
Home practice kit
Inhalation sedation
How can you avoid using a “needle”? (Needle phobia)
EDA - electronic dental anaesthesia
The ‘Wand’
Computer Controlled pressure & flow injection system
‘Injex’ system – high pressure jet
Desensitisation programmes
Hypnosis
Injex System= needle free LA
Drill phobia
Consider alternative methods for caries removal
include,
Hand excavation – ART restoration
Chemo-mechanical removal
Eg Caridex or Carisolv
Air abrasion
Lasers
Hall technique
What do you do if nothing seems to work?
Consider pharmacological adjuncts
Consider the need to refer the patient.
Reasons for referral:-
* Specialised dentistry
* Special child
Pharmacological adjuncts
Conscious sedation
General anaesthesia
Who to refer to?
Colleague
- More experienced
- Sometimes a change of clinician is enough
Specialist
- Community Dental Service
—Remit varies between trusts
Hospital Dental Service
- Consultant led service
Details to include in referral
letter
Patient Details
-Personal details including social history.
Presenting complaint
- Patient, parent and your perception
- Your concerns
- Details of examination, differential diagnosis
and reason for referral and urgency of the referral
Details to include in referral
letter
Previous dental history
Previous medical history (include family history)
Specify what you are requesting
- Advice or treatment?
- Indicate what aspects of treatment are within the scope of your skills.
Your details
- Remember to sign letter yourself
Enclosures
- Avoids repeating and repeating and previous records aid diagnosis and treatment planning
What to include in referral
letter
When referring for treatment under GA, the
referring dentist has a responsibility to and
must include in the letter of referral:-
That the risks associated with GA and the
alternative methods of pain control have been
discussed
Clear justification for the use of general
anaesthesia
Remember to keep a copy of your referral letter!
