Behavioural Management Techniques in Paeds Flashcards
Why may a child bite?
Only way to stop us being in their mouth
What is out goal with anxious pts?
To ensure pt and parent feels engaged and knows how to improve OHI
Ease any fear and anxiety
Promote understanding for need for good dental health
What is communication between dentist and pt built on?
Dialogue
FAcial expression
Voice tone
What is important about 2 years olds?
Afraid of unexpected movements, loud noises and strangers
dentist is strange and unexpected - we can produce fear at this age as fear is part of evolution to stop children running away
What is important about 3 years?
nursery
child wants to be accepted so likes praise on clothes and behaviour
not as scared to be separated from mum and dad
When are solo visits okay if mum and dad stay in waiting room?
7-8 years old
What is important about 4 year olds?
May be starting school
assertive - tell use what’s happening
fear of unknown, can fear strangers but less if parent present
introduce child to what we are doing in friendly manner
What happens at age 5?
Primary school
spends time away from parents, less fears
proud of possessions - good way to engage child
What happens at age 6?
Child wants to be accepted - don’t belittle
engage with the child - they know what they want and don’t want so if we cooperate then tx will be easier
If a child won’t open mouth or get on chair how can we manage this?
We want to find out why and understand the reasons they don’t want to
Why are you not wanting to sit on my chair?
Would it help if I put back the chair first the you got on?
What happens at age 7-12?
Children are growing up - they may be scared but are better at managing
What can anxious boys often do?
They may hide
say can’t be bothered
have sore tummy
need toilet
often just avoidance strategies - don’t want to show fear
What 3 things are related?
Anxiety, behaviour and compliance
if pt is anxious it affects behaviour which affects compliance
What is dental anxiety?
This is what occurs without a present triggering stimulus
may be a reaction to unknown danger or anticipatory danger due to previous bad experiences
What is dental fear?
Normal emotional response to objects or situations perceived as genuinely threatning
- sound of drill, needle
What is a phobia?
Clinical mental disorder
pts display persistent and extreme fear of objects or situations with avoidance behaviour and it interferes with daily life
What are the physiological aspects of fear?
Out of breath
sweating
palpitations
feeling uneasy - tries to avoid situation
Its important pt knows these are all very normal ways to feel however we can help change this
What do cognitive features of DFA do?
They change the way we think - instead of thinking rationally out subconscious brain always thinks of the worst and is unable to remember certain events
How can we manage the cognitive features of DFA?
Ensure pt feels in control, let them know nothing will be done without them okaying it!
What are some behavioural aspects of DFA?
Avoidance
Escaping situation
being aggressive
How may a pt avoid dentistry?
Cancel appt, act disruptively to prevent tx being carried out (Biting, not opening, constant chatter, running out surgery)
If a pt acts aggressive what do we do?
Take a step back
inform them that the dentistry isn’t important right now - lets discuss how you feel, I need you to feel comfortable before I start to help you!!
What can subtle DFA present like?
Pt asking lots to delay tx
complain of stomach aches or needs toilet lots
headaches, dizzy, fidget, cba
What factors influence DFA?
fear of choking
fear of injections
fear of drilling
fear of unknown
past med and dent experiences
dental exp of friends and fam
attitudes of parents towards dental experience
prep at home before dental visit
Childs perception that something is wrong with their teeth
How do we calm DFA?
Give control back to pt
How do we give control back to pt?
Stop signals
rest breaks
answer any qs pt has
How do we establish if a pt has dental fear?
Ask about previous dental tx, experience they had, how they feel about dentistry now
What is the MCDAS?
This is a quick easy to use questionnaire that a pt completes about how they feel towards different aspects of dentistry - the ratings are of different faces - ranging from relaxed to very worried (covers elements of coming to dentist all the way to a needle, being put to sleep etc)
What are the advantages of MCDAS?
Quick
Easy to use
allows pts to rate diff aspects of dental tx
we can establish base line levels of anxiety
What does good dentist/pt communicate allow for?
Improved info form the pt about how they are etc
enables us to build rapport with pt, we can listen and hear them which inc compliance
decreased anxiety
inc likelihood of compliance
What are the 3 components of communication?
verbal
paralinguistic
non verbal
What is the role of the dentist/pt?
reduce pt anxiety
- prevent pain
- establish trust
- work quickly
- be calm
- provide moral support
- reassure about pain
- emapthetic
When putting topical LA what can we say to pt to address the way they may feel?
Going to put a little bit of spray in your gum
you may feel some light pressure
Id be interested t see what you feel
What will increase fear related behaviours?
Ignoring or denying feelings - telling kids they are being silly and won’t feel anything (MUST ACKNOWLEDGE THEY WILL FEEL SOMETHING!)
humiliating pts
losing patience - if we feel like happening take a step back and don’t continue
What is the problem with children and pain?
They may not be able to communicate with us that they feel pain - we must monitor expressions for this
What will pain expressions look like?
Screwing up eyes
lowering brows
mouth in square appearance
What does expression of fear look like?
Eyes wide open
raised brows
mouth open
tense
What is MTD?
This is known as message to dentist and the pt takes this away with them and fills it out
it allows them to fill in how worried they are and how painful they think dental tx will be and what they want to happen and what stop signal they want
this allows us to discuss why the pt feels this way and how we can help them cope
Is a Childs behaviour affected by parental presence or absence?
No - no evidence to suggest this
When would Childs behaviour be better with parental present?
4 OR UNDER
Why is parental presence important?
So they can see pt misbehave and not comply with tx - will understand when we refer
Why is the parent useful at dental appointments?
If child is too young or won’t sit for examination we can do knee to knee exam
parents can witness behaviour that we are dealing with
What is a knee to knee exam?
Child head in dentist lap and parent holds babies legs on their lap so we can get look inside mouth - baby has contact with parent and can see them
What are some BMTs?
8
Positive reinfircement
tell show do
acclimatisation
desensitisation
voice control
distraction
role modelling
relaxation/hypnosis
What is positive reinforcement?
This is when we reinforce positive behaviours by either social or non social reinforcers
the use of this increases chances of behaviour being repeated
What can we use for pos reinforcement?
Facial expression - smile
Verbal praise - well done
What is important about verbal reinforcement?
It must be specific or child doesn’t know what they are being praised for
ie
well done! that was wonderful when u opened so wide I could see all ur teeth
What are some non social reinforcers?
Stickers
colouring posters
clever certificates
When may we tell a child they are clever v giving clever certificate?
Clever - if they do something we expect of them and we want them to repeat this behaviour
certificate - if v worried and manage an xla
What is the tell show do technique used for?
Used to familiarise pt with a new procedure
tell - explain the technique in age appropriate manner
show - show them the procedure - ie slow speed on finger nail, suction in cup of water
do - carry out technique soon after show (I would now like to do this on ur tooth, is that okay?)
What is acclimitisation?
This is where we gradually introduce pt to environment, people, instruments and procedure - done slowly to help get them used to environment and reduce anxiety
How do we acclimatise for fissure sealant placement?
Introduce 3 in 1 - hairdryer
introduce suction
introduce cotton wools
How should we acclimatise LA?
Introduce topical one visit before LA
What is systematic desensitisation?
This is based on assumption that repeated non distressing exposure to anxiety provoking stimulus will eventually reduce anxiety
How do we do systematic desensitisation?
Reassure child they are in control
do it in ordered manner from what they perceive as least anxiety provoking to most anxiety provoking until no anxiety is produced
What is voice control?
Not used often
when e change voice come tone or pace to influence and direct pts behaviour
- gian pts attention and compliance
avert neg or avoidance behaviour
What is distraction?
This is where the divert pts attention from what may be an unpleasant procedure
What are some distraction techniques?
pulling upper lip
telling story whilst giving LA
music
you will fell im holding ur lip (inject la as you say this)
What is role modelling?
This is where we have presence of sibling with no DFA who is similar age and getting similar tx to act as a coping model
What are two relaxation techniques?
Progressive muscle relaxation
Space exercise - in for 3 out for 5
What is hypnosis?
This is where we try influence subjects perception, feelings, thinking and behaviour by asking them to concentrate on ideas and images
When building a tx plan what should we consider?
slow gradual introduction of dental equipment and procedures in a predetermined planned manner
we must incorporate behaviour management into everything we do
How do we ensure child has painless tx?
Care takem to avoid hurt to child
carry out tx under LA - children feel pain!
painless technique to administer LA - such as wand
upper carious teeth restored with la before lower
What teeth do we restore with LA first?
upper carious teeth before lowers
What is the first part of a tx plan when we build ir for kids?
Simple exam
OHI
Diet
F varnish application
radiographs
explanation of next visit
What would happen on second visit (tx plan)?
Brush teeth demo using kids brush
diet check
radiographs
polish and dry teeth
introduction of slow speed and air syringe
fissure sealant process explained
What can we do on the 3rd visit?
Fissure sealants
saliva ejector introduction
What tx can we do as we progress with tx plan?
Remove carious tissue with hand excavator if immediate temporisation is req
use slow speed drill
introduce topical
give rubber dam home
if immediate temporisation is req what do we do?
remove carious tissue with hand excavator
As child gets more comfy what can we do?
- restore upper teeth with la, topical
- restore lower teeth with la and topical
7, pulp tx, xla
