Behavioural Management Flashcards
behaviour management
continuum of interaction with a child/parent directed toward communication and education
goal of behaviour management
ease fear and anxiety
promoting an understanding of the need for good dental health
communication between dentist and pt
built on a dynamic process of dialogue, facial expression and voice tone
dentist communication role to pt
allay fears and anxiety, teach appropriate coping mechanisms and guide the child to be cooperative, relaxed and self confident in the dental setting
5 different aspects of behaviour management
Age and its relationship to behaviours in the dental surgery
Dental fear and anxiety in children and predisposing factors
The role of the dentist and the parent
Behavioural management techniques
Building a treatment plan
age 2 normal childhood development
Fear of unexpected movements, loud noises and strangers
The dental situation can produce fear in the child
age 3 normal childhood development
Reacts favourably to positive comments about clothes & behaviour
Less fearful of separation from parents (due to nursery placement)
Experience will however dictate reaction to separation
age 4 normal childhood development
More assertive but can be bossy & aggressive
Fear of the unknown and bodily harm is now at a peak
Fear of strangers has now decreased.
With firm and kind direction will be excellent patients
age 5 normal childhood development
Readily separated from parents.
Fears have usually diminished.
Proud of possessions – can be used to engage with them and build rapport
Comments on clothes will quickly establish a rapport
age 6 normal childhood development
Seeks acceptance
Success in this can affect self –esteem
If while at dentist child develops a sense of inferiority or inadequacy behaviour may regress to that of a younger age
age 7-12 normal childhood behaviour
Learn to question inconsistencies and conform to rules of society - engage
Still have fears but are better at managing them
- Ask obvious Qs to see if they can be addressed – e.g. why do you not like the chair – might be as of movement
anxiety V behaviour V compliance link
Age 3-8 they will be linked
Older children use way to assess (MCDAS)
dental anxiety
Occurs without a present triggering stimulus and may be a reaction to an unknown danger or anticipatory due to previous negative experiences.
dental fear
Is a normal emotional response to objects or situations perceived as genuinely threatening.
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 – avoid going to dentist
3 components of dental fear and anxiety (DFA)
- physiological and somatic sensations
- cognitive features
- behavioural reactions
physiological and somatic sensations of DFA
Breathlessness
Perspiration
Palpitations
Feeling of unease
cognitive features of DFA
(how changes occur in the thinking process):-
Interference in concentration
Hypervigilance – swivel heads, explain that you will show everything to them before doing anything
Inability to remember certain events while anxious – as mind racing
Imagining the worst that could happen
behavioural reactions of DFA
Avoidance i.e. the postponing of a dental appointment, or with children disruptive behaviour in an effort to stop treatment being undertaken
Escape from the situation which precipitates the anxiety
Anxiety may manifest with aggressive behaviour especially in adolescents who are brought by their parents but do not want to be there.
- Feel not listened to
Explain that you will not do anything until you know how they are feeling, dentistry is second
The dentist should always ensure the safety of patients and staff if this type of behaviour happens.
signs of DFA in children
Some anxious children are easy to spot
Some signs are more subtle
- 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”
facts that influence fear and anxiety
useful to know what is causing it as then able to specifically reassure
- 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.
DFA
dental fear and anxiety
examples of control related items to help pt influence course of treatment
rest breaks
signals to stop
the patients need for information
how control related items can be used to assess child’s DFA
their desire to influence course of tx
need for control and info
health history items to get from pt to assess DFA
ask about previous dental treatment
Ask about past experience
Items relating to trust include attention to the dentist/patient relationship, and perception of vulnerability
good use of precious time
Faces Version of Modified Child Dental Anxiety Scale
Validated age 8+
Likert scale 1-5
Can be given out in waiting room to be done with medical history
- quick & easy to use
different aspects dental experience rated
base line levels of anxiety are established
(Humphries, Morrison & Lindsay 1995)
4 reasons for good dentist/patient communication
Improves the information obtained from the patient
- More you know about them the better the Tx as more adapted to them
Enable the dentist to communicate information to the patient
Increases the likelihood of patient compliance – feel safe, listened to
Decreases patient anxiety
3 components of communication
Verbal Communication (5%)
Paralinguistic (30%)
Non-verbal communication (65%)
ways to reduce patients anxiety
Preventing pain
Being friendly & establish trust
Working quickly
Having a calm manner
Giving moral support
Being re-assuring about pain
Empathy
good way to address pain in DFA
Main fear is pain
Tell them to expect something and it varies from person to person – can they tell you what they feel after
So don’t anticipate pain
5 things that increase fear related behaviours
Ignoring or denying feelings
Inappropriate reassurance
Coercing/Coaxing
Humiliating
Losing your patience with the patient
- If cannot complete Tx, place a dressing and stop so child doesn’t get distressed
what to do if unable to complete Tx in DFA
If cannot complete Tx, place a dressing and stop so child doesn’t get distressed
expression of pain
Screwing up the eyes and lowering the eyebrows with the mouth open in a squarish appearance
Can be seen in drilling with LA failure
expression of fear
Opening eyes widely and raising eyebrows with mouth open and tense
“Letter to dentist” role
Precipitator to conversion
Focuses on why they are worried or fearful of dentist
Parents experience too
Can give information for prior to Tx
Qs
- 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?
role of parent in DFA
Research suggests that the child’s behaviour is unaffected by parental presence or absence
- exception would appear to be children less than 4 years of age who have been shown to behave better with a parent present.
esp when young (knee to knee exam)
benefits of parental presence for infant/toddler
Patient is incapable or unwilling to sit for examination (positioning the child in the lap of the dentist and parent permits the child to be in direct visual and physical contact with the parent – need to knee to knee examination )
Opportunity exists for the parent to witness the behaviour the clinician must contend with
- Can see how child behaves and why may need referred for behaviour
8 behavioural management techniques
positive reinforcement
tell show do
Acclimatisation
desensitisation
voice control
Distraction
role modelling
relaxation / hypnosis
positive reinforcement
The presentation of a stimulus that will increase the likelihood of a behaviour being repeated
Social reinforcers- facial expression, verbal praise & appropriate physical contact
Nonsocial reinforcers- stickers, colouring poster and clever certificates
- Not brave – expected of them but also to do them
social reinforcers
facial expression, verbal praise & appropriate physical contact
non social reinforcers
stickers, colouring poster and clever certificates
- Not brave – expected of them but also to do them
Tell Show Do
Used to familiarise a patient with a new procedure.
The tell involves an age appropriate explanation of the technique.
The show is demonstrating for the patient aspects of the procedure in a non-threatening setting.
The do phase is initiated with minimal delay
E.g. slow speed on fingernail
acclimatisation
e.g., inhalation sedation, new instrument
The planned, sequential introduction of environment, people, instruments and procedures.
- An integral part of the treatment plan
Introduce the 3:1, suction & cotton rolls on the visit before you plan a fissure sealant
Use the slow speed first with a prophy cup, later with a bur and later introduce the high-speed
Introduce topical one visit before using LA for the first time
Give rubber dam home on the visit before you plan to use it
systematic desensitisation
always making sure child is calm and in control
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 of in real-life until no anxiety is produced
- Relaxation techniques taught or strategies like mental maths in head, So child knows able to cope with that so willing to try next stage
e.g. Systematic Needle Desensitisation
voice control
A controlled alteration of voice volume, toneor pace to influence and direct the patient’s behaviour.
- To gain the patients attention & compliance
- To avert negative or avoidance behaviour
distraction
The technique of diverting the patient from what may be perceived as an unpleasant procedure
- pulling the upper lip
- telling a story while giving local anaesthetic
- letting an older child bring in music to listen to
role modelling/imitation of others
sometimes similar age
same/similar treatment
presence of an older sibling is best for children aged 3-5 yrs
see other can cope therefore nothing to be anxious of
relaxation techniques
- Progressive muscle relaxation
- Space exercise
- breathing techniques
Practice yourself so can teach well
hypnosis
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”
The response is experienced by the subject as having a quality of involuntariness or effortlessness.
HOM/HOMAR
HAND OVER MOUTH - unacceptable
problems
- adverse psychological effects
- parental consent
- professional acceptance
- litigation
painless treatment
Care should be taken not to hurt any child.
Restorative care is usually carried out under local anaesthesia.
A painless technique of administering LA is of vital importance with topical an integral part of treatment.
Upper carious teeth are normally restored with L.A. before lower.
which teeth restored first for painlessness
upper before lower
with LA
painless LA administration
topical anaesthetic first
how to approach Tx plan for DFA
gradual introduction of dental equipment and procedures
- E.g. suction from cup first
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
Simple first then complex
- OHI
- Fissure sealants
- Upper before lower teeth restorations
steps in Tx plan for DFA
- 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.
THIS MAY TAKE 1 OR 2 VISITS TO COMPLETE DEPENDS ON THE CHILD
3, Fissure sealants or dressings. 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 & give rubber dam home to play with. (e.g. pulpotomy needed, do before extractions)
THIS MAY TAKE 1 OR 2 VISITS TO COMPLETE DEPENDS ON THE CHILD
- Restore upper teeth with local anaesthesia, using topical prior to injection
- Restore lower teeth with local anaesthesia, again using topical prior to this
- Pulp treatments and then extractions last if patient is pain free
success in treating children needs
The patient, dentist and parent all working as a team are key to ensuring that children are treated at their level in an empathic and caring manner.
how dentist should always act around children and DFA
honest & explain what is happening, using a combination of behaviour management techniques.
Be positive
Tx plan pace
allows for acclimatization at the CHILD’S pace
