Child behaviorChild behavior

Are we managing our children’s Are we managing our children’s behavior or just treating dental caries behavior or just treating dental caries

??

Behaviour: Is an observable act, which can be described

in similar ways by more than one person.

”It is defined as any change observed in the functioning

of the organism.”

Behavioural pedodontics:- It is a study of science which

helps to understand development of fear, anxiety and

anger as it applies to child in the dental situations

Normal behaviour :-Normal behaviour :-Ps

ycho

mot

or

Emotional Development

Environmental Influences

Personality Traits

Emotion is a state of mental excitement characterized by physiological, behavioral changes and alterations of feelings.

Commonly seen emotions in a childCommonly seen emotions in a child

Cry (Elsbach 1963)

Obstinate cry,Frightened cry ,Hurt cry, Compensatory cry

AngerAnger

FearFearIt may be defined as an unpleasant emotion or effect

consisting of psycho-physiological changes in response to realistic threat or danger to one's own experience.

Innate fear Subjective fear Objective fear:

Fear Evoking Dental Stimuli…

Factors Causing Dental Fear

1. Fear of pain or its anticipation.

2. A lack of trust or fear of betrayal.

3. Fear of.1oss of control.

4. Fear of the unknown.

5. Fear of intrusion.

SIGNS AND SYMPTOMS OF FEAR

AnxietyAnxiety

Is an emotion similar to fear arising without any objective source of danger. Is a reaction to unknown danger.

It is often been defined as a state of unpleasant feeling combined with an associated feeling of impending doom or danger from within rather than from without.

It is a learned process being in response to one's environment. As anxiety depends on the ability to imagine, it develops later than fear.

 

Types of anxietyTypes of anxiety Trait anxiety temperament feature. These children are

generally jittery, hypersensitive to stimuli.

 Free floating anxiety- persistently anxious mood

Situational anxiety- Seen only to specific situations or objects.

State anxiety-

General anxiety -a chronic pervasive feeling of anxiousness whatever the external circumstances.

 

Anxiety ScaleAnxiety Scale

Phobia:Phobia: Defined as persistent, excessive, unreasonable fear

of a specific object, activity or situation that results in a compelling desire to avoid the dreaded object.

Simple Situational Social

Behavior managementBehavior management

Behavior managementBehavior management

Behavior managementBehavior managementBehavior management is the means by

which the dental health team effectively and efficiently performs treatment for a child and, at the same time, instills a positive dental attitude.

The fundamentals of behavior management center on the attitude and integrity of the entire dental team.

FUNDAMENTALS OF BEHAVIOR MANAGEMENTFUNDAMENTALS OF BEHAVIOR MANAGEMENT

Positive approach- Positive statementsTeam attitude- Friendly and caringOrganization- Well organized dental team and

treatment Truthfulness- Black or White ,nothing grayTolerance- Ability to rationally cope with the

misbehaviors Flexibility-as situation demands

CLASSIFYING CHILDREN'S BEHAVIORCLASSIFYING CHILDREN'S BEHAVIOR

Wright's clinical classification (1975)

  Cooperative

Lacking in cooperative ability

Potentially cooperative

.

Potentially cooperativePotentially cooperative

Uncontrolled/Hysterical, Defiant/obstinate, Tense-cooperative, Timid/shy, Whining, and Stoic behavior

Frankel’s Behavioral Rating Scale. Frankel’s Behavioral Rating Scale. (1962)(1962) Rating 1: Definitely Negative. Refusal of treatment,

forceful crying, fearfulness, or any other overt evidence of extreme negativism.

Rating 2: Negative. Reluctance to accept treatment, uncooperativeness, some evidence of negative attitude but not pronounced.

Rating 3: Positive. Acceptance of treatment; cautious behavior at times; willingness to comply with the dentist, at times with reservation, but patient follows the dentist's directions cooperatively.

Rating 4: Definitely Positive. Good rapport with the dentist, interest in the dental procedures, laughter and enjoyment.

Wilson's classification (1933)Wilson's classification (1933)

a) Normal or bold: The child is brave enough to face new situations, is co-operative, and friendly with the dentist.

b) Tasteful or timid: The child is shy, but does not . interfere with the dental procedures.

c) Hysterical or rebellious: Child.is influenced by home environment - throws temper-tantrums and is rebellious. d) Nervous or fearful: The child is tense and

anxious, fears dentistry.

Lampshire Classification (1970)Lampshire Classification (1970)1. Co-operative: The child is physically and emotionally relaxed. Is

cooprative throughout the entire procedure

2. Tense cooperative: The child is tensed, and cooperative at the same time.

3. Outwardly apprehensive: Avoids treatment initially, . usually hides behind the mother, avoids looking or talking to the dentist. Eventually accepts dental treatment.

4. Fearful: Requires considerable support so as to overcome the fears of dental treatment.

5. Stubborn/Defiant: Passively resists treatment by using techniques that have been successful in other situations.

6. Hypermotive: The child is acutely agitated and resorts to screaming kicking etc.

7. Handicapped: Physically/mentally, emotionally handicapped.

8. Emotionally immature

Factors affecting Childs Factors affecting Childs behavior behavior

Under the control of dentistUnder the control of parents

– Maternal anxiety and attitudes [Overprotective, Overindulgent, Under affectionate, Rejecting, authoritarian]

Others [socioeconomic status, nutritional,past dental experience]

Behavior Management techniques can be Behavior Management techniques can be broadly classified as:broadly classified as:

Non-Pharmacological Techniques.

Pharmacological Techniques

Non-pharmacological methods1. Communication2. Behavior shaping (modification)

a. desensitizationb. modellingc. contengency management

3. Behavior managementa. audioanalgesiab. biofeedbackc. voice controld. hypnosise. humorf. copingg. relaxationh. implosion therapyi. Aversive conditioning

CommunicationCommunication

CommunicationCommunication Verbal [establishment of communication,

establishment of communicator ,message clarity,tone]

Nonverbal [Multi sensory Communication]

Problem Ownership –Use “I” messages,

Active Listening

Appropriate Responses to the situation

DENTAL TERMINOLOGY WORD SUBSTITUTES

rubber dam rubber raincoat rubber dam clamp tooth button  rubber dam frame coat rack sealant tooth paint topical fluoride gel cavity fighter air syringe wind gun water syringe water gun suction vacuum cleaner Alginate pudding  study models statues high speed whistle low speed motorcycle

Behavior shapingBehavior shaping

By definition, it is that procedure which very slowly develops behavior by reinforcing successive approximations of the desired behavior until the desired behavior comes to be.

: Stimulus – response (S-R) theory

Systematic Desensitization Systematic Desensitization ..exposure to ..exposure to hierarchy of fear producing stimuli hierarchy of fear producing stimuli

Desensitization : (joseph Wolpe)Desensitization : (joseph Wolpe)

Systematic Desensitization Systematic Desensitization ..exposure to ..exposure to hierarchy of fear producing stimulihierarchy of fear producing stimuli

Tell-show-do[ Addelston]Tell-show-do[ Addelston] The technique involves verbal explanations of procedures in

phrases appropriate to the developmental level of the patient (tell);

demonstrations for the patient of the visual, auditory, olfactory, and tactile aspects of the procedure in a carefully defined, non threatening setting (show);

and then, without deviating from the explanation and demonstration, completion of the procedure (do).

The tell-show-do technique is used with communication skills (verbal and nonverbal) and positive reinforcement.

Tell-show-doTell-show-do Objectives:1. teach the patient important aspects of

the dental visit and familiarize the patient with the dental setting;

2. shape the patient’s response to procedures through desensitization and well-described expectations.

Acclimatisation…getting Acclimatisation…getting familiarizedfamiliarized

Modelling Modelling

Bandura (1969)

– Live– Filmed – Posters – Audiovisuals

ModelingModeling

Allowing the patient to observe one or more individuals [models]

Patient frequently imitates the models

Contingency managementContingency management

Positive reinforcerNegative reinforcers

– Social– Material– Activity

Positive reinforcementPositive reinforcement to give appropriate feedback. to reward desired behaviors and thus

strengthen the recurrence of those behaviors. Social reinforcers include positive voice

modulation,facial expression, verbal praise, and appropriate physical demonstrations of affection by all members of the dental team

Nonsocial reinforcers include tokens and toys.

Objective: Reinforce desired behavior..

3. Behavior management3. Behavior management

a. audioanalgesia: white noise

b. biofeedback: detect physiological processes

c. voice control

d. hypnosis: altered state of consciousness

e. humor:

f. coping: signal system

g. relaxation:

h. implosion therapy

i. Aversive conditioning

Enhancing control..STOP SIGNALEnhancing control..STOP SIGNAL

Voice ControlVoice Control Voice control is a controlled alteration of

voice volume, tone, or pace to influence and direct the patient’s behavior.

Objectives:1. gain the patient’s attention and

compliance;2. avert negative or avoidance behavior;3. establish appropriate adult-child roles.

RetrainingRetraining

To review and retrain the response to a given set of stimuli

DistractionDistraction

Diverting the patient’s attention from what may be perceived as an unpleasant procedure.

MusicVideoTalkingWhite noise….HypnosisBreathing

DistractionDistraction

Objectives:1. decrease the perception of

unpleasantness;2. avert negative or avoidance behavior.

Indications: May be used with any patient.

Contraindications: None.

AVERSIVE CONDITIONING

Informed consentInformed consent

All management decisions must be based on a subjective evaluation weighing benefit and risk to the child.

It is important that the dentist inform the legal guardian about the nature of the technique

Communicative management, requires no specific consent.

HOMEHOME Redirect inappropriate behavior.

Hand is gently placed over the child’s mouth and behavioral expectations are calmly explained.

Maintenance of a patent airway is mandatory.

Upon the child’s demonstration of self-control and more suitable behavior, the hand is removed and the child is given positive reinforcement.

HOMEHOME.Indications:

A healthy child (Able to understand and cooperate), but who exhibits hysterical avoidance behaviors.

Contraindications:1. children who, due to age, disability,

medication, or emotional immaturity are unable to verbally communicate, understand, and cooperate;

2. any child with an airway obstruction.

Several variations of home:Several variations of home:

HOMAR: HOM with airway restricted HOM and nose with airway restrictedTowel held over mouth onlyDry Towel held over mouth and noseWet Towel held over mouth and nose

Physical Restraints Physical Restraints

Considerations:-Informed consentType of restraint usedIndication for restraint

Oral Oral

At the time of injection For stubborn child/ defiant child Mentally handicapped child Very young child who cannot keep its mouth open

for long time

Bite blocksBite blocks

Mouth props Mouth props

WRAPPED/PADDED TONGE BLADEUse, disposable, inexpensive

OPEN-WIDE MOUTH PROPEasy to use, disposable , different sizes, expensive

Molt Mouth propsMolt Mouth props

Restrains - BodyRestrains - Body

Restrict the pt movements Used frequently in pt < 2yrs of age

Papoose board:-Advantages: Store / use Size(3) Reusable

Body Restrains Body Restrains

Triangular sheet with leg straps:- Mink – bed sheet / triangular sheet technique Advantage:

– sit upright

Disadvantages: Need of straps Difficult for small children Airway impingement hyperthermia

Body RestrainsBody RestrainsPedi wrap:- Has nylon sheet

No head supports/ back

board

Various sizes

Movement

Mesh fabric – ventilation(

no hyperthermia)

Requires straps

Restrain : ExtremitiesRestrain : ExtremitiesAttach to the dental unit restraint a pt at the chest

waist, legs.Mentally / physically handicapped Prevent the pt from getting injured himselfPrevent from interfering in the dental procedure.

– Posey straps– Velcro straps– Towel & tape– Extra assistant

Head Head Supports the head Protects the pt from getting injured himself & pt.

Types: Fore body support Head protector Extra assistant

Practical Considerations Practical Considerations of of BEHAVIOR MANAGEMENTBEHAVIOR MANAGEMENT

Dental Clinic setupDental Clinic setup

Convenience of the childConvenience of the dentistPEER grouping

SchedulingScheduling

Parental Parental presence/absencepresence/absence

The parent often repeats orders, injects orders,

The dentist is unable to use voice

intonation, divides attention between the parent and child.

The child divides attention between the parent and dentist.

  "performing with an audience."

Parental presenceParental presence A parent can be a major

asset in supporting and communicating with a disabled child,

Very young children (those who have not reached the age of understanding and full verbal communication) have a close symbiotic relationship with parents; consequently, they usually are accompanied by them.

Need of Pharmacological Need of Pharmacological intervention intervention

GoalsGoals

To facilitate the provision of quality careMinimize extremes of disruptive behaviorTo promote a positive psychologic response

to treatmentTo promote patient welfare and safety

Patient Physical Status Patient Physical Status ClassificationClassification

ASA I - A normal healthy patient. (ASA = American Society of Anesthesiologists) ASA II - A patient with mild systemic disease. ASA III - A patient with severe systemic disease. ASA IV - A patient with severe systemic disease that is a constant threat to life. ASA V - A moribund patient who is not expected to survive without the

operation. ASA VI - A declared brain-dead patient whose organs are being removed for

donor purposes. E - Emergency operation of any variety (used to modify one of the above

classifications, i.e., ASA III-E).

STAGES OF ANESTHESIA STAGES OF ANESTHESIA

I stage of analgesiaII stage of deliriumIII stage of surgical anesthesiaIV stage of respiratory paralysis

Conscious sedation ASDA Conscious sedation ASDA 19851985

Minimally depressed level of consciousness that retains the patient’s ability to independently and continuously maintain an airway and respond appropriately to physical stimulation and verbal command, produced by pharmacologic and nonpharmacologic methods alone or in combination

Deep sedation Deep sedation

A controlled state of depressed consciousness accompanied by a partial loss of protective reflexes including inability to respond purposefully to a verbal command, produced by pharmacologic and nonpharmacologic methods alone or in combination

General anesthesiaGeneral anesthesia

A controlled state of unconsciousness accompanied by partial or complete loss of protective reflexes including inability to maintain airway independently and respond purposefully to physical stimulation or verbal command, produced by pharmacologic and nonpharmacologic methods alone or in combination

Ambulatory out-patient or day Ambulatory out-patient or day care anesthesiacare anesthesia

Levels of Conscious SedationLevels of Conscious Sedation

Indications of C.SIndications of C.SObjectives Indications Contraindications

mood alteration patient should be conscious respond to verbal stimuliIntact reflexesVital signs stable and normalPain threshold increasedamnesia

uncooperative patientsCannot understand definitive treatment lack of psycho-logical or emotional maturity fearful & anxious

COPD Epilepsy bleeding disorders prolonged surgery

Pre-requisitesPre-requisites

Knowledge about the agentDocumented rationaleInformed consentOffice facilitiesMobile emergency medical facilitiesPatient selection and preparationMedical history and patient evaluation

Patient Assessment Prior To Patient Assessment Prior To Conscious SedationConscious Sedation

The physician, dentist, or independent practitioner responsible for overall conduct of the conscious sedation is generally required to do the following within 30 days prior to procedural sedation:– perform a history and physical exam– assign an American Society of Anesthesiologist (ASA)

health class– document a sedation plan– document NPO status and interval changes if H&P not

done immediately prior to procedure.

Focused History and ExamFocused History and Exam

History should focus on factors that may increase– patient sensitivity to sedatives/analgesics– patient risk of respiratory/cardiopulmonary

complications– difficulty in managing complications

Preprocedural Fasting Guidelines Preprocedural Fasting Guidelines To Minimize Aspiration RiskTo Minimize Aspiration Risk

ROUTES OF ADMINISTRATIONROUTES OF ADMINISTRATION

Inhalation Enteral [ oral and rectal]Parenteral [ IM, IV, IN, Submucosal, sub

cutaneous,]

InhalationInhalationIndications Contraindications Advantages Disadvantages

AnxietyMedically compromised patientsGagging

Severe behavioral problemsAcute respiratory conditionsCOPDPregnancy

Rapid onsetPeak clinical actionsTitration permittedDepth of sedation can be alteredRapid recovery

CostSpace PotencyTraining of staffOccupational hazard

Nitrous oxide and oxygenNitrous oxide and oxygen

sp gr 1.53,low solubility in blood, rapid onset , no bio transformation,excreted by lungs

Adverse effects [ N2O Entraped in gas filled spaces]

Oral routeOral routeAdvantages Disadvantages

Universally acceptedEasyLow costLow incidence of reactionsNo pricksNo equipmentsNo special training

RelianceProlonged latent periodErratic & incomplete absorptionInability to titrateProlonged duration of action

Rectal Rectal Indications Advantages Disadvantages

Unwilling to take orallyNausea & vomittingPatient objecting injectionPost-op control of pain

Low costEasyNo pricksAbsorb directly into systemic circulationBypassing entero hepatic circulation

InconvenienceVariable absorptionInability to reverseInability to titrate

Intra muscular routeIntra muscular routeAdvantages Disadvantages Complications

Rapid onset:15mMaximum clinical effect :30mMore reliable absorption

Inability to titrateInability to reverseProlonged durationInjection neededPossible injury

Nerve injuryIntra-vascular injectionAir embolismPeriostitisHematomaAbscessCystNecrosis

INTRA NASAL/ INTRA NASAL/ SUBMUCOSAL subcutaneousSUBMUCOSAL subcutaneous

Common agents used for Common agents used for sedationsedation

Common agents used for sedationCommon agents used for sedation Gases Antihistamines

[Hydroxyzine ,Promethazine,Diphenhydramine] Benzodiazepines

[Diazepam , Midazolam, lorazepam] Benzodiazepines Antagonist [Flumazenil] Sedative Hypnotics [Barbiturates ,Chloral Hydrate] Narcotics [Meperidine ,Fentanyl] Narcotic Antagonist [Naloxone] Dissociative agent [Ketamine] Others [Propofol]

AntihistaminesAntihistaminesDiphenhydramine Promethazine Hydroxyzine

Dosage: oral/IM/ IV1 to 1.5mg/kgMax dose = 50mg

Dosage : oral/ IM – 0.5 to 1.1 mg/kg. SC not recommended. Max. recommended dose is 25mg

Supplied tablet syrup and injectable form

Dosage :Oral : 1-2mg/kg

IM : 1.1mg/kg

Supplied : Tabs 10, 25, 50, 100mg

Syrup 10mg/ 5ml

Injectable 25 or 50mg/ml

BenzodiazepineBenzodiazepine

Diazepam Midazolam

Dosage : 0.2 to 0.5mg/ kg ;

max single dose 10mg;

IV 0.25mg/kg

Dosage : 0.25 to 1mg/kg

max single dose 20mg

IM 0.1 to 0.15mg/kg

max 10mg;

IV - manufacturer's recommendation

Sedative HypnoticsSedative Hypnotics

Barbiturates Chloral hydrate

Limited value for pediatric patients

Must be individualized for each

Recommended 25-50mg/kg to a max of 1g supplied in the form of oral capsules 500mg

Oral solution 250 and 500mg/ 5ml

Rectal suppositories 324 and 648mg

NarcoticsNarcotics

Meperidine Fentanyl

Oral/ SC/ IM – 1 to 2.2mg/kg not to exceed 100mg

Supplied : oral tablets 50 and 100mg

Oral syrup 50mg/ 5ml

Parenteral solution 25, 50, 75 and 100mg/ ml

0.002 to 0.004mg/ kg

Supplied 0.05mg/ ml in 2 and 5ml ampules

Reversal AgentsReversal Agents-,

Ketamine [ Dissociative agent]Ketamine [ Dissociative agent]

Derivative of the street drug phencyclidine. This drug carries an increased risk of deep sedation

and should be used only by those with hospital privileges in deep sedation.

Induces a functional dissociation between the cortical & limbic systems to create a sensory isolation and “trance-like” state.

A potent pain reliever as the drug prevents cortical interpretation of noxious stimuli.

KetamineKetamine

Produces CNS stimulation & inhibits catecholamine uptake, so direct myocardial depressant effects are overcome.

While producing sedation, amnesia, & analgesia, ketamine may also produce dreams & delirium. This is minimized by co-administering small doses of midazolam.

1 TO 4.5mg/kg IV over 1min

PropofolPropofolThis drug carries an increased risk of progression to

deep sedation and should be used only by those with hospital privileges in deep sedation.

no analgesic properties but does produce sedation and amnesia.

widely distributed in the body and is eliminated via hepatic & pulmonary systems.

DOSE 1mg/kg /iv followed by 3 to 4.5 mg /kg/hr

The Lytic CocktailThe Lytic Cocktail

A fixed combination of meperidine, promethazine, and chlorpromazine.

Long history of use in pediatric sedation. Commonly called DPT, an acronym for demerol,

phenergan, and thorazine. Its use is strongly discouraged; equivalent or

superior sedation may be achieved with single agents or individualized combinations of sedatives & narcotics.