Behavioural Management Flashcards
What is the goal of behaviour management?
- ease fear and anxiety
- promoting an understanding of the need for good dental health
What does behaviour management involve?
- continuum of interaction with a child/parent directed towards communication and education
- communication between dentist and patient build on a dynamic process of dialogue, facial expression and voice tone
- dentist can alleviate fears and anxiety, teach appropriate coping mechanisms and guide child to be cooperative, relaxed and self confident in the dental setting
At the age of 2 what are the behaviours relevant to the dental environment?
- fear of unexpected movements, loud noises and strangers
- dental situation can produce fear in the child
At the age of 3 what are the behaviours relevant to the dental environment?
- reacts favourably to positive comments about clothes and behaviour
- less fearful of separation from parents
- experience will dictate reaction to separation
At the age of 4 what are the behaviours relevant to the dental environment?
- more assertive but can be bossy and aggressive
- fear of the unknown and bodily harms is at a peak
- fear of strangers may start to decrease
- with firm and kind direction can be excellent patient
At the age of 5 what are the behaviours relevant to the dental environment?
- readily separated from parents
- fears have usually diminished
- proud of possessions
- comments on clothes will quickly establish a rapport
At the age of 6 what are the behaviours relevant to the dental environment?
- seek acceptance
- success in this can affect self-esteem
- if while at the dentist child develops sense of inferiority or inadequacy behaviour may regress to that of a younger age
At the ages of 7-12 what are the behaviours relevant to the dental environment?
- learn to question inconsistencies and conform to rules of society
- still have fears but are better at managing them
How does dental anxiety occur in children?
occurs without a present triggering stimulus and may be a reaction to an unknown danger or anticipatory due to previous negative experiences, can include parental influence
very common when proposed treatment has never been experienced before
How does dental fear occur in children?
normal emotional response to objects or situations perceived as genuinely threatening
reaction to a known danger, involves fight-flight-freeze response when confronted with threatening situation
How does dental phobia occur in children?
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 dental fear and anxiety?
- psychological and somatic sensations
- breathlessness
- perspiration
- palpitations
- feelings of unease
- cognitive features
- interference in concentration
- hypervigilance
- inability to remember certain events while anxious
- imagining the worst that could happen (catastrophising)
- behavioural reactions
- avoidance
- postponing appointments
-disruptive behaviour - escape from the situation
-precipitates anxiety - agressive behaviour
- avoidance
What are signs of dental fear and anxiety in children?
- some anxious children are easy to spot
- some children are more subtle
- younger children
- time delay by asking questions - school age children
- complain of sore stomach
-ask to go to toilet frequently - older children
- complain of headaches/dizziness
- fidgeting
- stuttering
- say they can’t be bothered
- younger children
What are common dental fears in children?
- fear of choking
- fear of injections/drilling
- fear of unknown
What can contribute to dental fear and anxiety?
- past medical and dental experience
- negative experience can increase fear and anxiety
- dental experience of friends and siblings
- attitudes of parents towards dental experience
- parental anxiety
- parenting style
- preparation at home before dental visit
- child’s perception that something is wring with their teeth
- awareness increases fear and anxiety
- behaviour of dental staff
- should always endeavour to create positive experience
- child temperament
How can dental fear and anxiety be managed in children?
- allowing children some control during treatment
- rest breaks
- signals to stop
- acknowledge patient’s need for information
How can a child’s dental fear and anxiety be assessed?
- ask about previous dental treatment
- past experience
- modified child dental anxiety scale - faces (MCDASf)
- quick and easy to use
- different aspects of dental experience rated
- baseline levels of anxiety are established
What questions are asked in the MCDASf?
- how do you feel about…
- going to the dentist
- having your teeth looked at
- having teeth scraped and polished
- having an injection in the gum
- having a filling
- having a tooth taken out
- being put to sleep to have treatment
- having a needle put in the back of your hand
What are the two categories of behaviour management?
- pharmacological behaviour management
- non-pharmacological behavioural management
What does pharmacological behaviour management involve
- local anaesthetic
- premedication
- inhalation sedation
- nitrous oxide
- sufficient anxiolysis increases suggestibility and relaxation
- combined with non-pharmacological techniques
- intravenous sedation
- midazolam, propofol
- good for complex treatment in anxious anaesthetics
- over 12 years old
- combined with non-pharmacological techniques
- general anaesthetic
- requires justification
How can children’s ability to tolerate treatment be described?
- pre-cooperative
- children who lack co-operative ability
- potentially cooperative
- co-operative
What is the purpose of preparatory information and what does it include?
- decrease anxiety for both the child and parents
- welcome letters
- social stories
- dental widgets
- patient information leaflets
- acclimatisation
What does non-verbal communication and role-modelling involve?
- happy smiling team
- gentle pats or squeezing shoulder
- environment
- eye contact
- modelling most effective when child of similar age and same family
- live or by video
- can work with dentist, dental nurse, parent or cuddly toy
What does voice control involve?
- alteration of voice to influence and direct behaviour
- volume
- tone
- pace
- improves attention and compliance
- establishes authority
What is tell-show-do?
- tell
- age appropriate explanation of procedure
- show
- demonstration of procedure
- do
- perform procedure with minimal delay
- widely used to familiarise patients with new procedures
- emotive and negative words avoided
- make it fun
What is enhanced control?
- allows patients a degree of control over treatment
- shown to reduce pain during routine dental treatment and injection
- stop, go, rest signals
- very effective anecdotally
- provide caveat (cannot always stop immediately)
- structured time and timed treatment (work for set time)
- ask which tooth they would like to start with
- ask this or that questions
What is behavioural shaping and positive reinforcement?
- defined series of steps towards ideal behaviour
- reinforcement is strengthening of behaviour pattern
- increases probability of behaviour in future
- positive reinforces
- social stimuli (smiles, positive voice modulation, praise)
- stickers
- badges
- tick charts
- dental passports
- child centred phrases
- use name
What is distraction?
- video glasses
- music
- ceiling projectors
What other behavioural management techniques exist?
- ‘magic’
- motivational interviewing
- particularly adolescents
- gamification
- make procedures fun
- cognitive behavioural therapy
- ‘your teeth, you’re in control’
- particularly adolescents
- hypnosis
- only trained practitioners with explicit consent
- semi-hypnotic (relaxation and breathing techniques)
- snoezelen environment
- multi sensory environment
- systemic desensitisation
- for systemic fears
- repeated, graded exposure
Provide examples of inappropriate behaviour management techniques
- negative reinforcement
- chastisement or punishment
- hand over mouth technique
- gloved hand placed over mouth
- absolutely not appropriate, not taught in UK
- selective parental exclusion
- parent asked to leave
- bribery
How can topical anaesthetic be used in local anaesthetic administration?
- do not hide the taste
- describe it as like toothpaste
- dry mucosa
- warn of temporary tongue numbness
- apply for adequate time
- 5% lidocaine or 18-20% benzocaine
- not recommend for under 2 year olds
What non-pharmacological pain control is used with local anaesthetic administration?
- hypnosis
- semi-hypnosis
- relaxation techniques
- distraction
- shaking cheek
- counting on fingers
- audio and visual (music/tv programme)
- controlled language
- guided imagery
- systematic desensitisation
- computer controlled LA devices
- wand
- control parental behaviour
- parent squeezing leg
- high tone of voice
- concern
How is local anaesthetic delivered in paediatric dentistry?
- lidocaine 2%
- first line
- max dose is 1x2.2ml cartridge per 10kg body mass - articaine 4%
- first line
- profound anaesthetise
- younger patients for mandibular pulpal anaesthesia
- alternative to lidocaine IDB
- max dose is 0.8x2.2ml cartridge per 10kg body mass
- IDB
- never use articaine
- always aspirate
- short needle often required for children
- palatal and lingual injections
- chasing techniques
- topical anaesthatic administered buccally
- buccal infiltration administered
- infiltration into papilla once tissue is blanched
- infiltration on palatal or lingual once tissue is blanched
- ultra-short anaesthetic needle
