Dental behavioural management of paediatric patients Flashcards
Discuss how a safe, comfortable environment can be created
- Creating a good relationship between the child, the accompanying person and dental team
- Take a complete history, keep good clinical notes and review previous notes
- Don’t demand something beyond the young patient’s ability
- No or minimal negative stimuli (pain, bad tastes)
- Encourage a feeling of control
- Set the stage for positive behaviour
- Everyone in the surgery should be transmitting positive, comforting expectations to the patient
- Use of visual distraction in the surgery
- Have age appropriate materials in the waiting room
- Greet child in the waiting room at their height without a mask
- Pace procedures during the appointment, based on how the patient is coping. Introduce new procedures at an appropriate rate
- It is appropriate that parents are able to support their children during treatment
- If parents are unable or unwilling to support their children it may be desirable for them to wait outside the surgery
- Siblings may attend if the child is coping fine with treatment
- Initially work from in front, at eye level
- Provide information in advance about procedures to be performed at next visit
- Be aware of child’s ‘intimate zone’. This zone is approximately 45 cm, but varies with different cultures. We invade, but frequent stopping allow the child to cope
- Involve child in personal discussions
- Conduct less invasive procedures first. It is more tolerable for the patient
- Introduce the child to the office, staff, equipment etc
- Use age appropriate positive language
Explain tell- show- do as a method for behaviour shaping
- The child is first told what will happen, then shown and finally exposed to the procedure
- For example, suction water out of their hand or place Fuji IX on the finger nail
- If the child positively accepts the procedure, it must be reinforced by giving feedback
- If the acceptance is negative, the child should be met with empathy and given more training on the previous step
- If the child is reluctant to get into the chair alone, it should be seated on the parent’s lap
- After the oral examination and prevention steps, the individual treatment need will determine the further
Explain systemic desensitisation as a method for behaviour shaping
Reducing anxiety by first presenting an object or situation that evokes only a little fear, once the child has learnt to cope with this, then progressively introducing other stimuli that are more fear provoking.
List other preventative strategies that may be considered
- Clinic orientation/familiarisation
- Communication - with all parties, OHT/Patient/Parent/DA3
- Paced breathing- is an extremely effective technique for bringing fear reactions down by generating parasympathetic stimulation may be applied with small children by having them blow a windmill toy, a balloon
- Relaxation exercise implies focusing on special muscles or body parts, wriggling toes or alternately contracting and relaxing muscles. It makes the muscles more relaxed and the body less tense
- Distraction is also effective for (ignoring and then directing attention away from a behaviour, thought, or feeling of something else)
- Positive reinforcement- reward in response to a desired behaviour
- Direct observation / role modelling - videos, parent, compliant sibling
- Enhancing control - stop hand
- Voice control - deliberate alteration of voice
- Non verbal communication - physical contact, facial expression, body language
- Descriptive praise - ‘That’s such a wide mouth, well done!’
- Playful humour -using fun labels and suggesting use of imagination
- Other methods - such as story telling, imagery of television programmes, having the child play with the saliva ejector
- Playful humour - using fun labels and suggesting use of imagination, jokes
List the 3 pharmacological techniques that may be used
- Oral sedation (most common: Midazolam)
- Relative Analgesia (nitrous oxide/oxygen inhalation sedation)
- IV sedation (Midazolam, Fentanyl, Propofol)
Describe the characteristics of nitrous oxide
- Colourless, odourless/faint sweet smell
- Reduces discomfort, anxiety, pain
- Safe
- Rapid uptake and onset of action with quick recovery
- Conscious patient
State the 5 indications for nitrous oxide
- Anxious patient
- Strong gag reflex
- Cooperative child requiring lengthy dental procedures
- Reduce pain
- Patients with special health care disabilities
State the 7 contra-indications for nitrous oxide
- Common cold / obstructive pulmonary disease
- Medical problems
- Psychosis
- Pregnancy 1st trimester
- Medication interactions
- Cannot understand the language of operator and no interpreter
- Unwilling patient
Explain what oral sedation is and its associated disadvantages
- “Conscious sedation”
- Provider must be capable of resuscitating the patient or rescuing a patient from a deeper level of sedation than the one intended
- Oral drugs cannot be titrated accurately
- Resuscitation and rescue meds nearby if applicable
Explain what intravenous sedation is
- Requires highly trained team, including an experienced seditionist or specialist anaesthetist and medical nurses
- Controllable and readily reversible, but as most children are frightened of needles, it might seem inappropriate for those anxious ones
List the three instances when general anaesthesia is needed, and state what other things need to be undertaken when GA is administered
Instances
• Multiple carious and abscessed teeth in multiple quadrants in very young, uncooperative children
• Severe facial cellulitis
• Facial trauma
Other requirements
• Child must have sensible tx plan arranged, including home-care instructions, possible dietician’s referral, use of home fluorides and return visits
• Pre-anaesthetic assessment - Medical hx and exam by the anaesthetist is required prior to procedure
List the 6 common side effects of GA
- Nausea
- Headache
- Pain/ bruising
- Sore throat/ dry lips
- Blurred vision
- Problems urinating
