Paeds - Behavioural Management

Question 1

What questions do we ask when establishing dental fear in children during history taking? (3)

Answer 1

Ask about previous dental treatment

Ask about past experiences - good and bad

Ask about any problems relating to trust/vulnerability

Question 2

What fears has a 2 year old developed? (4)

Answer 2

Fear of unexpected movements

Fear of loud noises

Fear of strangers

Fear of the dental situation.

Question 3

list the behavioural developments of a 3 year old (3)

Answer 3

Less fear of separation from parents but might not want to be separated
Don’t separate from parent at this age.

Reacts favourably to positive comments (i.e. to behaviour and clothes)

Experience will dictate reaction to experience

Question 4

list the fears and developmental milestones of a 4 year old. (5)

Answer 4

Fear of the unknown and bodily harm

Less fearful of strangers (not always the case)

Will respond well to positive reinforcement if parent is present

Have to be kind but firm with instructions

Assertive - bossy and aggressive

Question 5

list the behavioural developments of a 5 year old. (4)

Answer 5

Less fearful.

Readily separated from parents but wouldn’t until you have established a good relationship

Proud of possessions, this is a way to engage with the parent.

Establish a rapport with comments about clothes

Question 6

List the behavioural developments of a 6 year old (4)

Answer 6

If child develops a sense of inferiority or inadequacy behaviour may regress to that of a younger age

Seeks acceptance - success in this can affect self esteem

Do not belittle (much more important at this age)

Important to chat with the child at this age

Question 7

describe fear in 7 year olds? (3)

Answer 7

Have fears but are better at managing them

Question inconsistencies

Conform to rules of society
i.e. boys want to hide the fear will say they have a sore tummy, need the toilet etc.

Question 8

define dental anxiety.

Answer 8

Occurs without a triggering stimulus and may be a reaction to an unknown danger or anticipatory due to previous negative experience or due to parental preparation or past medical experiences.

Question 9

define dental fear

Answer 9

Normal emotional response to objects to situations perceived as genuinely threatening i.e. needle or sound of the drill.

Question 10

define dental phobia

Answer 10

Clinical mental disorder where there is persistent and extreme fear of objects or situations with avoidance behaviour and interference of daily life.

Question 11

what physiological & somatic sensations are signs of fear? (4)

Answer 11

Breathlessness
Perspiration
Palpitations
Feelings of unease

Tell them that this is a normal response for someone who is worried/nervous

Question 12

what cognitive features are signs of fear?(4)

Answer 12

Interference in concentration

Hypervirgilance (looking around all the time)

Inability to remember certain events whilst anxious

Imagining the worst outcome

Question 13

what behavioural reactions are signs of fear? (3)

Answer 13

Avoidance i.e. postponing or disruptive behaviour to stop the treatment

Escape

Aggressive behaviour (especially common in adolescents if they feel they haven't been listened to. 
Explain that you wont do anything until you have discussed how they are feeling, dentistry comes secondary to their emotions.

Question 14

how would a young child show that they are dentally anxious/fearful?

Answer 14

Delay by asking lots of questions

Question 15

how would school aged children show that they are dentally anxious/fearful?

Answer 15

Complain of stomach aches

Need the toilet frequently

Question 16

how would older children show that they are dentally anxious/fearful? (3)

Answer 16

Complain of headaches and dizziness

Fidgeting

Stuttering

Question 17

what strategies can you use during treatment to overcome dental fear and anxiety? (4)

Answer 17

address the cause of the worry and reassure them.

Rest breaks
Stop signals
Provided them with all the information they require/want

Question 18

what are ways that the dentist can reduce anxiety? (8)

Answer 18

Prevent pain 
Being friendly 
Establish trust 
Work quickly 
Be calm 
Give moral support 
Be re-assuring about pain 
Empathy

Question 19

what expressions should we look out for in terms of children in pain? (4)

Answer 19

Screwing up the eyes

Lowering the eyebrows

Mouth open

Squarish appearance

Question 20

what expressions should we look out for in terms of children who are fearful? (4)

Answer 20

Wide eyes
Raised eyebrows
Mouth open
Tense

Question 21

what is the role of the parent when treating a dentally anxious child? (3)

Answer 21

Children under the age of 4 behave better with a parent present.

Good for parent to see how the child behaves - important if child needs referral

Parents used for knee to knee techniques

Question 22

list behavioural management techniques. (8)

Answer 22

Positive reinforcement

Tell, show, do

Acclimatisation

Desensitisation

Voice control

Distraction

Role modelling

Relaxation/hypnosis

Question 23

define positive reinforcement.

Answer 23

Presentation of a stimulus that will increase the likelihood of a behaviour being repeated

Reinforce positive behaviours by giving praise.

Question 24

what forms of positive social reinforcers can we provide?

Answer 24

Facial expression

Verbal praise has to be specific!!!

Appropriate physical contact

Question 25

what forms of positive non-social reinforcers can we provide?

Answer 25

Stickers

Colouring poster

Clever certificates

Question 26

describe tell, show, do.

Answer 26

used to familiarise the child with a new procedure

T = age appropriate explanation

S = Demonstrate aspects of the procedure in a non-threatening setting

D = initiated with minimal delay

Question 27

define acclimatisation.

Answer 27

A planned, sequential introduction of the clinical environment, people, instruments and procedures.
Gradual introduction.

Question 28

list useful acclimatisation tips. (4)

Answer 28

Introduce 3:1, suction and cotton rolls on the visit before you fissure seal.
(water in a cup and let child use the suction, 3:1)

Introduce topical for one visit before using LA for the first time

Give rubber dam home on the visit before its use.

Use the slow speed on finger nail with a trophy cup, then with a slow speed bur

Question 29

describe the use of voice control.

Answer 29

A controlled alteration of voice volume, tone or pace to influence and direct the patients behaviour.

Gain attention/compliance
To avert negative/avoidance behaviour

Question 30

name examples of distraction techniques. (3)

Answer 30

Pulling the upper lip

Telling a story (i.e. whilst giving LA)

Bringing music to listen to

Question 31

describe the role modelling technique

Answer 31

Having the patient watch a person of similar age (sibling) undergoing similar treatment with ease.

Question 32

what age of child does role modelling work best for?

Answer 32

3-5

Question 33

name types of relaxation exercises that can be used to moderate behaviour. (2)

Answer 33

The Space Exercise:
Get child concentrating on breathing in for 3, out for 5.
Practice yourself

Progressive Muscle Relaxation:
Tensing and relaxing the muscles