Non pharmacological behavior management in pediatric dentistry

This presentation gives a a comprehensive view on the various non pharmacological behavior management techniques in pediatric dentistry.

1. Good morning! 1

2. NON-PHARMACOLOGICAL BEHAVIOR MANAGEMENT Dr. Pratima Kolekar MDS II 2

3. 3 Mc Elory (1895) wrote : “ Although operative dentistry may be perfect, the appointment is a failure if a child departs in tears.”

4. CONTENTS PART I : Introduction Pedodontic Treatment Triangle Pediatric dental patients Classification of children’s co-operative behavior Fear and Anxiety Psychometric Assessment of dental fear and anxiety Variables influencing children’s dental behavior 4

5. 5 PART II Definitions Fundamentals of behavior guidance Behavior guidance techniques Pre-appointment behavior shaping Basic behavior guidance techniques : Communicative management Tell-show-do Voice control Modelling Contingency management Distractions Memory restructuring Desensitization

6. PART III Advanced behavior guidance Protective stabilization Aversive conditioning Recent advances in behavior guidance Conclusion Previous year question papers References 6

7. INTRODUCTION For optimal management of children, the dental surgeon must understand why certain behavior patterns occur and how to deal with them effectively. The first dental visit of child- full of anxiety for both the parents and the child. 7

8. 8 As the pediatric dentist usually relies on the co-operation of the child for rendering effective treatment, the first appointment is very important for establishing rapport and gaining trust of the child. Behavior management - an integral part of pediatric dental practice.

9. 9 A major difference between the treatment of children and adults is the relationship.

10. PEDODONTIC TREATMENT TRIANGLE 10 1975 2014

11. 11 Vivek Padmanabhan, Dr Kavitha Rai, Dr Amitha M Hegde. Pediatric dentistry treatment triangle - A Review and A New Model Journal of Health Sciences and Research. 2012;3(1):35-6.

12. PEDIATRIC DENTAL PATIENTS 12

13. 13 Stone & Church classification (1975) : Infant (0-15 months) Toddler (15 moths to 2 years) Preschooler (2-6 years) Middle year child (6-11 years) Adolescent (>11years) R. J Mathewson , Robert E.Prismosch.Fundamentals of pediatric dentistry

14. 14 2- year old Self- centred , solitary, easily frustrated, easily distracted and completely dependent on adults Attention span 1-5 minutes Keep appointment times short Special feature Concentrates on one thing at a time. Lives in the present Concentrate only on the child and avoid interruptions from parents or other staff Favourite word No! Avoid asking questions which can have a “no” answer such as “ Would you like me to…..?”

15. 15 3- year-old Exuberant, independent, imitative of adult behavior, curious, imaginative Gain attention by arousing curiosity, describe procedures to the child and ask them to add their own description. Let them “help” Attention span-4-8 minutes Favourite word-Why?

16. 16 4-year-old Dominant, bossy, impatient Engage the child’s “help” Grasps simple reasoning Explain simple procedures ( The filling doesn’t stick if the tooth gets wet)

17. 17 5-year-old Poised, self-confident, aware of rules, likes to act grown-up, less combative Accept authority Should be able to use a hand signal properly Proud of their possessions Show interest in possessions/clothes. Appeal to their vanity( e.g. “A dirty tooth….I’ll clean it and put a pretty filling in it”;”I need you to help me fix it”

18. 18 Adolescents Major emotional, physical and hormonal changes occur during the teenage years- perplexing Moody and sensitive to criticism, so comments about their dental health need to be delivered with care.

19. CLASSIFICATION OF CHILDREN’S CO-OPERATIVE BEHAVIOR Wilson’s classification Frankel’s classification Wright’s classification Pinkham’s classification Lampshire’s classification 19

20. Wilson’s classification (1933) Behavior Description Attitude towards dental treatment Normal or bold Child is confident to face new situations Co-operative & friendly with dentist Tasteful or timid Child is shy Allows dental treatment to be performed without interruption Hysterical or rebellious Child is rebellious Exhibits temper tantrums towards dental treatment Nervous or fearful Child is tense & extremely anxious Interrupts dental treatment 20

21. Frankel’s behavior rating scale(1962) 21 Behavior Rating Description Definitely Negative Rating no.1 Refuses treatment,cries forcefully, extremely negative behavior Negative Rating no.2 Reluctant to accept treatment, displays slight negativism Positive Rating no.3 Accepts treatment Definitely Positive Rating no.4 Unique behavior,establishes rapport

22. 22 Popular research tool Shortcoming - does not communicate sufficient clinical information regarding uncooperative children

23. 23 Modification and adaptation of Frankl’s Behaviour Rating Scale Behavior Rating Symbol Description Definitely Negative Rating no.1 (- -) Refuses treatment,cries forcefully, extremely negative behavior Negative Rating no.2 (-) Reluctant to accept treatment, displays slight negativism Positive Rating no.3 (+) Accepts treatment Definitely Positive Rating no.4 (+ +) Unique behavior,establishes rapport In 1975 Wright proposed a modification of Frankl’s Behaviour Rating Scale.

24. 24 J. Machen and R. Johnson described an adaptation of Frankl’s Behaviour Rating Scale (1991). New version - two independent raters evaluate children’s behaviour in dental setting in the range from definitely positive to definitely negative at five different moments: Separation of the child from the parent First reaction of the child in dental setting Attitude towards the dental staff Behaviour during the treatment Behaviour after the treatment Shindova  MP,  Belcheva  AB.  Behaviour evaluation scales for pediatric dental patients review and clinical experience. Folia Med (Plovdiv). 2014;56:264-70

25. Wright’s classification (1975) 25

26. 26 3. Potentially cooperative Uncontrolled or hysterical- temper tantrums, loud cry, violent movement of extremities Defiant or obstinate- stubborn, resists treatment Tense cooperative- agrees to treatment but is tense, borderline between negative & positive Whining - receives treatment with continuous complaints throughout the procedure Stoic – receives treatment without any expression, physically abused

27. 27 Pinkham’s classification Category I : Emotionally compromised child Category II : Shy, introvert child Category III : Frightened child Category IV : Child who is adverse to authority.

28. Lampshire’s classification (1970) Behavior Description Co-operative Children who remain physically and emotionally relaxed and cooperative throughout the entire visit, regardless of treatment undertaken Tense c o-operative Children who are tense but nevertheless cooperative Outwardly apprehensive Child who hides behind the mother in the waiting room, uses stalling techniques and avoids talking to the dentist. These children will eventually accept dental treatment Fearful Children who require considerable support in order to overcome their fear of dental situation. Modeling is useful for them. 28

29. 29 Behavior Description Stubborn/ Defiant Children who passively resist or try to avoid treatment by using techniques that have been successful for them in other situations Hypermotive Children who are agitated and who adopt procedures such as screaming or kicking as their coping defense mechanism Handicapped Children who are physically, mentally or emotionally handicapped Emotionally Immature This category includes the young children who have not yet achieved sufficient emotional maturity to rationalize the need for dental treatment and to cope with it

30. FEAR AND ANXIETY Fear : reaction to known danger Anxiety : reaction to unknown anticipated stimuli Fear and anxiety toward the dentist and dental treatment - avoidance of dental care. 30

31. 31 Dental anxiety Anxiety associated with the thought of visiting the dentist for preventive care and over dental procedures is referred to as dental anxiety . It has been cited as the fifth-most common cause of anxiety by Agras et al. Anxiety is an emotional state that precedes the actual encounter with the threatening stimuli, which sometimes is not even identifiable.

32. 32 Fear Fear is defined as a painful feeling of impending danger, evil, trouble, etc. ( Delbridge ) It leads to a fight-or-flight situation. Dental fear is a reaction to threatening stimuli in dental situations. Phobia is persistent, unrealistic, and intense fear of a specific stimulus, leading to complete avoidance of the perceived danger.

33. 33 Types of fear :

34. PSYCHOMETRIC ASSESSMENT OF DENTAL FEAR AND ANXIETY Corah’s Dental Anxiety Scale (CDAS) Modified Dental Anxiety Scale (MDAS), Kleinknecht et al’s Dental Fear Survey (DFS) Children’s fear survey schedule-dental subscale (CFSS-DS) Visual analog scale. 34

35. 35 However, none of these existing instruments has been regarded as a gold standard, as they have their own limitations. The CDAS, MDAS, and DFS are the most commonly used questionnaires, and have been shown to be reliable and valid in multiple languages

36. Corah’s dental anxiety Scale (1969) The scale consists of four questions about different dental situations. Each question is scored from 1 (not anxious) to 5 (extremely anxious), so the range of possible scores is 4–20. The cutoff point of more than 15 indicates high anxiety level or possibly phobic. 36

37. 37

38. Modified dental anxiety scale - Humphris et al (1995 ) In 1995, the Corah dental anxiety scale was modified by Humphris et al. to overcome its shortcomings Humphris et al. added a fifth question relating to local anesthetics as it is a major cause of anxiety for many individuals. 38

39. 39

40. Kleinknecht et al’s Dental Fear Survey (DFS) The DFS consists of 20 items concerning avoidance behavior, physiological fear reactions, and different fear objects concerning dental appointments and treatment. This questionnaire also has five response options, giving summed scores from a minimum of 20 to a maximum of 100. A cutoff point for high dental fear has been suggested at 60. 40

41. 41 The scale has three dimensions: avoidance of dental treatment, somatic symptoms of anxiety, and anxiety caused by dental stimuli.

42. Children’s Fear Survey Schedule Developed by Scherer and Nakamura Consists of 80-items on a 5-point Likert’s response high reliability and validity Very cumbersome The Dental Subscale of Children’s Fear Survey Schedule (CFSS-DS) developed by Cuthbert and Malamed consists of 15-items on a 5-point Likert’s response Total range- 15-75 Score of 38 or more- clinical dental fear 42

43. 43 Venham Picture test This scale consists of a series of eight paired drawings of a child. Each pair consists of a child in a nonfearful pose and a fearful pose (e.g. running away). The respondent is asked to indicate, for each pair, which picture more accurately reflects his or her feelings at the time. Scores are determined by summing the number of instances in which the child selects the high-fear stimulus.

44. 44 Facial image scale (FIS) Facial image scale (FIS) has a row of five faces ranging from very happy to very unhappy. Children are asked to point at which face they felt most like at the moment. The face is scored by giving a value of one for the most positive face and five for the most negative face. Faces four and five indicate high dental anxiety.

45. VARIABLES INFLUENCING CHILDREN’S DENTAL BEHAVIOR 45

46. Sociocultural and developmental factors Baseline anxiety Past medical or dental experience School environment and peer influence Growth and development 46

47. Baseline anxiety Unperturbed initial anxiety of a child before any appointment Depends on - psychological strength of child to face new situations and challenges. Efficient parenting - a positive attitude & these children are confident & have less baseline anxiety. High baseline anxiety- overprotected or overindulged children. Children born to women with an increased maternal age or nurtured by a single parent may have high baseline anxiety. 47

48. Past medical or dental experience Any past unpleasant dental experience, prior hospitalisation , surgical intervention, sickness etc., are associated with a higher degree of uncooperative behaviour . Therefore the emotional quality of past visits rather than the number of visits is significant. 48

49. School environment and peer influence Fifty percent of the child’s development is affected by the school and the remaining 50% by the home environment. In school, teachers and peers help to influence the behaviour of the younger children. Also, seniors become role models to the juniors. A child benefited by school dental health programs will have a positive approach towards dental treatment. 49

50. Growth and development Physical growth pattern and development are associated with each other. Some derangement in development can leave a negative attitude in the child’s mind. Deficiency in physical growth and development or congenital malformations, e.g., cleft lip, as awareness of the deformity increases it leads to psychological trauma due to rejection by the society. 50

51. Familial factors 51 Socio-economic factors The mother’s presence Maternal anxiety

52. Socio-economic factors High socioeconomic status child - develop normally because the family can provide all the necessary requirements to aid in a normal psychological development A low socioeconomic status child - develops resentment and is tensed as the child gets little attention and is often neglected. It can also directly affect the child’s attitude towards the value of the dental health. 52

53. The mother’s presence Presence of the mother as a passive observer in the operatory contributes to a greater frequency of positive behavior in preschool children. [Frankl et al. ,1962] It does not enhance the cooperative behaviour of slightly older children, but neither is it deleterious. The mother is usually seated in front and to the right of the dental chair facing the child. This is a good location, since it will usually allow the child an unobstructed view of the mother. 53

54. Maternal anxiety Primary factor influencing a child’s anxiety in the dental office. Highly anxious mother has a negative influence on the child. The mother child relationship falls into two broad categories: autonomy vs control hostility vs love 54

55. Maternal attitude Child’s behavior Overprotection Submissive, shy, anxious Overindulgent Aggressive, spoilt, demanding, displays Temper tantrums Underaffectionate Usually well behaved, but may be unable to cooperate, may cry easily Rejecting Aggressive, overactive, disobedient Authoritarian Evasive 55 By Bayley & Schaefer :

56. Baumrind Parenting Styles (1973) 56 Viswanath S, Asokan S, Geethapriya PR, Eswara K (2020) Parenting Styles and their Influence on Child's Dental Behavior and Caries Status: An Analytical Cross-Sectional Study. Journal of Clinical Pediatric Dentistry 2020; 44(1): 8-14.

57. Factors associated with the dentist/dental operatory 57 Dentist attitude and attire Dental operatory/ environment Length and schedule of the appointment

58. Dentist attitude and attire The dentist’s attire should communicate a ‘security’ symbol as well as an authority figure The attire should be approachable Bizarre and flashy clothes to attract children attention are absolutely inappropriate 58

59. 59 Personality of dentist : Should be impressive. Dentist’s skill and speed : Dentist should be skilled or he will loose child’s confidence. Dentist’s conversation : Keep talking to the child to gain his confidence. Use simple words and answer all questions.

60. Dental operatory/ environment An ideal pediatric operatory should not look like a hospital It should allay anxiety and assist in obtaining cooperative behavior 60

61. Length and schedule of the appointment Short appointment- 30 minutes Long appointment- 45 minutes Early morning appointments - best suited for children as they tend to be more relaxed and cooperative 61

62. Finn summarized the following factors related to the dental office which influence child’s behavior: Waiting rooms – homely environment Comfortable reception room Library with books Simple but sturdy toys for amusement Attractive appointment cards Appealing operating room Avoid having child patient see adults in pain or sight of blood on others 62

63. Good morning! 63

64. NON-PHARMACOLOGICAL BEHAVIOR MANAGEMENT Dr. Pratima Kolekar MDS II 64

65. CONTENTS PART I : Introduction Pedodontic Treatment Triangle Pediatric dental patients Classification of children’s co-operative behavior Fear and Anxiety Psychometric Assessment of dental fear and anxiety Variables influencing children’s dental behavior 65

66. 66 PART II Definitions Fundamentals of behavior guidance Behavior guidance techniques Pre-appointment behavior shaping Basic behavior guidance techniques : Communicative management Tell-show-do Voice control Modelling Contingency management Distractions Memory restructuring Desensitization

67. PART III Advanced behavior guidance Protective stabilization Aversive conditioning Recent advances in behavior guidance Conclusion Previous year question papers References 67

68. DEFINITIONS 68 Behavior management means by which the dental health team effectively and efficiently performs dental treatment and thereby instills a positive dental attitude. (Wright 1975) Behavior guidance i s a conti n u u m o f i n div i dua l iz e d i nteract i on in v ol v i ng the denti st an d patien t dir e cted t o w ar d c o mmunicat i on and education “which ultimately builds trust and allays fear and anxiety”.

69. 69 Behavior modification an attempt to alter the human behavior and emotion in a beneficial way and in accordance with the laws of learning. (Eysenck,1964). Behavior shaping procedure which develops behavior by reinforcing successive approximations of the desired behavior until the desired behavior comes into being.

70. FUNDAMENTALS OF BEHAVIOR MANAGEMENT 70

71. Positive Approach Attitude or expectations of the dentist - affect the outcome of a dental appointment Positive statements chances of success with children More effective than thoughtless questions or remarks 71

72. Team attitude A pleasant smile - tells a child that an adult cares. Children can be made comfortable by : Casual greeting Use of nicknames Noting school accomplishments Hobbies Also helps initiating future conversation . 72

73. Organization Each dental office must device its own contingency plans The entire staff must know in advance what is expected of them Eg . Who summons the patient? The dentist, the dental assistant, the dental hygienist, or the receptionist? Delays and indecisiveness - apprehension in young children 73

74. Truthfulness Unlike adults, most children see things as either “black” or “white” The shades between are difficult for them to discern Truthfulness is extremely important in building trust - fundamental rule for dealing with children. 74

75. Tolerance Dentist’s ability to cope rationally with misbehaviors while maintaining composure. Recognizing individual tolerance levels is especially important when dealing with children. 75

76. Flexibility As children lack maturity - dental team must be prepared to change its plan at times. Treatment of small children may demand a change in operating position. Thus the dental team must be flexible as the situation demands. 76

77. PRE-APPOINTMENT BEHAVIOR MODIFICATION Anything that is said or done to have a positive influence on the child’s behavior before the child enters a dental operatory . The merit - prepares the pediatric patient and eases the introduction to dentistry . 77

78. 78 Several methods of preappointment behavior modification are : Audio-visual aids Films or videotapes The presentation explains in the way the child can understand the dental procedures to take place.

79. 79 Patient modelling : It can be performed with live patient models such as sibilings, other children or parents

80. 80 Wright et al (1973) conducted a RCT that demonstrated the beneficial effect of pre-appointment letter. Pre-appointment mailings / customized web pages

81. 81 Preappointment mailings should be selective . The uncomplicated pre-appointment letter : Welcomes the patient Spells out the basic, first-appointment procedure avoiding dental terminology States the philosophy of good dental health care.

82. 82 Numerous mailings cause a reversal in parental attitude. Overpreparation could confuse a parent or provoke anxiety.

83. 83 Introductory visits – Feigal refers to this examination as ‘preconditioning appointment’ Oral examination should be done .

84. BEHAVIOR GUIDANCE TECHNIQUES Behavior guidance - not an application of individual techniques created to deal with children. R ather a comprehensive, continuous method meant to develop and nurture the relationship between the patient and doctor, which ultimately builds trust and allays fear and anxiety . 84

85. 85 AAPD. The reference manual of Pediatric Dentistry. 2012

86. Basic behavior guidance techniques 86

87. Communicative management Foundation for all basic behavior guidance Prime objective of behavior control. It is universally used in pediatric dentistry with both co-operative and uncooperative child. 87

88. 88 I nitiate conversation with non-dental topics. { Welbury et al ,2005 } Topic of interest to young children - new clothing, pets, television shows and they like to be asked about it. Communication with older children -with reference to school, play activities, sports and friends.

89. 89 Ways to establish communication : Verbal : Spoken language to gain confidence. Nonverbal : Expression without words like welcome hand shake, patting, eye contact

90. KEY POINTS FOR COMMUNICATIVE MANAGEMENT Establishment of Communication : By involving a child in conversation, a dentist not only learns about the patient, but also relaxes the youngster. 90

91. 91 Establishment of the communicator Members of the dental team - be aware of their roles when communicating with a pediatric patient Communication should occur from a single source The same holds true when parents are present in the operatory

92. 92 Message clarity Communication is a complex, multisensory process. The message must be understood in the same way by both the sender and the receiver

93. 93 Very often, to improve the clarity of messages to young patients, dentists use euphemisms to explain procedures Rubberdam Raincoat Airotor Whistle Saliva ejector Straw

94. 94 Tone The manner in which something is said is just as important as what is said. For young children, the tone of our voice is what they hear. A soft, reassuring voice is better than a abrupt, business like voice

95. 95 Multisensory communication Body contact is a form of nonverbal communication Simple act of placing hand on a child’s shoulder conveys a feeling of warmth and friendship

96. 96 When the dentist talks to children, every effort should be made not to tower above them Sitting and speaking at eye level allow for friendlier and less authoritative communication

97. 97 Problem ownership In difficult situations , dentist begin sending “you” messages- “You stop doing that immediately!” “ You” messages - roadblocks to communication- undermine rapport, shatter the child’s self-esteem

98. 98 “ I” messages reflect the practitioner’s experience and disclose the focus of the problem- “ I can’t fix your teeth if you don’t open your mouth wide.” They are honest, clear and inarguable

99. 99 Active listening Listening to spoken word - more important to establish rapport with older children Attention to nonverbal behavior is crucial for younger children Sensitivity to the expressed emotions - reassure the child and encourage genuine communication

100. Tell-Show-Do HK addelston (1959) Desensitizing technique -approach by successive approximations. Attempts made to remove - fear of unknown 100

101. 101 Objectives : Teach the patient important aspects of the dental visit and familiarize the patient with the dental setting Shape the patient’s response to procedures

102. 102 Indications: First visit Subsequent visits when introducing new dental procedures Fearful child Apprehensive child because of information received from parents and peers. Effective in children >3 yrs who can understand

103. 103 The method involves :

104. 104 TSD was the most popular technique for managing children, which was listed by 87% of pediatric dentists. { Crossley and Joshi , 2002 } TSD modifies the behavior of child and aids in achieving the treatment goals effectively in all age groups. { Sharma A and Tyagi R, 2011 } Crossley ML, Joshi G. An investigation of paediatric dentists' attitudes towards parental accompaniment and behavioural management techniques in the UK. British dental journal. 2002 May;192(9):517-21. Sharma A, Tyagi R. Behavior assessment of children in dental settings: a retrospective study. Int J Clin Pediatr Dent. 2011;4(1):35-9.

105. Pattern interrupt TSD not always easy to practice -when child is crying. This stage- ‘pattern interrupt’ plays an important role Interrupting behavior by doing the unexpected. Eg . Lifting the child at height. 105

106. 106 New alternatives to TSD technique Ask-Tell-Ask : ASK : inquiring about patient’s visit & feelings about any planned procedure TELL : Explaining procedures through demonstrations in non-threatening language appropriate to cognitive level of the patient ASK : inquiring if the patient understands and how she feels about the impending treatment

107. 107 Objective : Assess anxiety Teach the patient about the procedures Confirm the patient is comfortable with the treatment before proceeding. Indications : May be used with any patient able to dialogue. Contraindications : None.

108. 108 Tell-play-do : Performing dental treatment on dental imitating toys Child understands the dentist’s frame of reference Feels more comfortable & develops cooperative behavior.

109. Voice control Given by Pinkham in 1985. Voice control is a deliberate alteration of voice volume, tone or pace to influence and direct the patient’s behavior. 109

110. 110 Objectives : Gain the patient’s attention and compliance Avert negative or avoidance behavior Establish appropriate adult-child roles Indications : Uncooperative and inattentive patients Contraindications : Immature children Physically or mentally challenged children

111. 111

112. MODELLING Based on Bandura’s social learning theory Goal is to reproduce the behavior exhibited by model 112

113. 113 The merits of modeling procedures, by Rimm and Masters are as follows: Stimulation of new behaviors Facilitation of behavior in a more appropriate manner Elimination of avoidance behavior. Extinction of fears’s

114. 114 Types of modeling- Audiovisual Live modeling by sibling or parent Types of models- Mastery (cooperative patient who enjoys dental treatment) Coping ( just manages to cope up with the treatment)

115. Contingency management Based on BF Skinner’s operant conditioning The presentation of positive reinforcers or withdrawal of negative reinforcers is termed contingency management 115

116. 116

117. 117

118. Types of reinforcers Positive reinforcers- whose presentation increases the frequency of desired behavior Negative reinforcers - whose contingent withdrawal increases the frequency of behavior 118

119. 119 Materials : stickers, pencils, small toys (preferably not candies and sweets.) Rewards are given after dental procedure. Bribes given before procedure. Bribes should not be given in pediatric dental practice

120. 120 Social praise : Praise, positive facial expression, hand shake, smile etc. Best kind of positive influencer. Activity : opportunity of participating in a preferred activity like a cartoon show, visit to park.

121. DISTRACTION Diverting the patient’s attention from what may be perceived as an unpleasant procedure . Objective : to relax the patient 121

122. 122 C ommonly used distractors - magic tricks, toys, cartoons or movies, music. They can be given either in the waiting room or during dental treatment.

123. 123 Types : Audio distraction : patient listens to audio presentation throughout course of treatment Audiovisual distraction : patient is shown audiovisual presentation through television during the entire treatment.

124. MEMORY RESTRUCTURING B ehavioral approach in which memories associated with a negative or difficult event (e.g. first dental visit) are restructured into positive memories using information suggested after the event has taken place. 124

125. 125 Restructuring involves four components: Visual reminders -- photograph of the child smiling at the initial visit Positive reinforcement through verbalization- - asking if the child had told her parent what a good job she had done at the last appointment Concrete examples to encode sensory details- - praising the child for specific positive behavior Sense of accomplishment -- Child then is asked to demonstrate these behaviors

126. DESENSITIZATION Systematic desensitization - technique popularized by Wolpe . Diminishes emotional responsiveness to a negative, aversive stimulus after progressive exposure to it. Helps to reduce maladaptive fear 126

127. 127 The use of systematic desensitization involves three sets of activities : Encourage the patients to discuss their status of fear and anxiety , from the least to the most anxiety-provoking. Teach the patient relaxation techniques , most commonly used techniques - breathing and muscle relaxation. The final step is to gradually expose the patient to these situations in the hierarchy, from the least to the most anxiety-promoting

128. PARENTAL PRESENCE/ABSENCE C an be used to gain cooperation for treatment Pre-cooperative and fearful children, parents be allowed to be with the child. This prevents separation anxiety in children. A compensatory, overprotective or overindulgent parent can actually worsen the situation . 128

129. 129 REFERENCES Wright GZ, Kupietzky A, editors. Behavior management in dentistry for children. Wiley Blackwell;2014 Jan 21. Dean JA, editor. McDonald and Avery's Dentistry for the Child and Adolescent-E- Book. Elsevier Health Sciences; 2015 Aug 10. Nowak A, Christensen JR, Mabry TR, Townsend JA, Wells MH, editors. Pediatric Dentistry: Infancy through Adolescence. Elsevier Health Sciences; 2018 May 10. Marwah N. Textbook of pediatric dentistry. Jaypee Brothers, Medical Publishers Pvt. Limited; 2018 Oct 31.

130. 130 Vishwakarma AP, Bondarde PA, Patil SB, Dodamani AS, Vishwakarma PY, Mujawar SA. Effectiveness of two different behavioral modification techniques among 5–7-year-old children: A randomized controlled trial. J Indian Soc Pedod Prev Dent 2017;35:143-9. Salah Adeen Mohammed Alrshah et al. Live Modelling Vs Tell- Show-Do Technique for Behaviour Management of Children in the First Dental Visit. Mansoura Journal of Dentistry 2014;1(3):72-77 Sharma K, Malik M, Sachdev V. Relative efficacy of tell-show-do and live modeling techniques on suburban.J Dent Specialities.2016;4(2):178-182 Chadwick BL, Hosey MT. Child Taming: How to manage children in dental practice. Quintessentials , 2003

131. 131

132. Good morning! 132

133. NON-PHARMACOLOGICAL BEHAVIOR MANAGEMENT Dr. Pratima Kolekar MDS II 133

134. CONTENTS PART I : Introduction Pedodontic Treatment Triangle Pediatric dental patients Classification of children’s co-operative behavior Fear and Anxiety Psychometric Assessment of dental fear and anxiety Variables influencing children’s dental behavior 134

135. 135 PART II Definitions Fundamentals of behavior guidance Behavior guidance techniques Pre-appointment behavior shaping Basic behavior guidance techniques : Communicative management Tell-show-do Voice control Modelling Contingency management Distractions Memory restructuring Desensitization

136. PART III Advanced behavior guidance Protective stabilization Aversive conditioning Recent advances in behavior guidance Other behavior guidance techniques Conclusion Previous year question papers References 136

137. 137 Desensitization Modelling Contingency management Distraction Biofeedback Coping Hypnosis Humor Relaxation Voice control Implosion therapy Aversive conditioning Dean JA, editor. McDonald and Avery's Dentistry for the Child and Adolescent-E- Book. Elsevier Health Sciences; 2015 Aug 10

138. 138 Beahvior guidance techniques according to Wright : Getting to know your patient : Using paper & pencil questionnaire for parent/caregiver Direct interviewing the child and parent. Pre-appointment behavior modification : Preappointment contact and modelling Effective communication Non-pharmacological clinical strategies : TSD, Contingency management, modelling, voice control, densitization , parental presence/absence Retraining HOME, restraints

139. SOCIAL LEARNING THEORY Social learning theory was proposed by Albert Bandura in 1963. Bandura believes that behaviour is largely motivated by social needs. Reinforcement is a powerful method for regulating performance of behaviour but is a relatively ineffective method for learning behaviour. 139

140. 140 Principles of social learning theory

141. 141 Observational Learning in Dental Operatory

142. 142 MODELING It is based on Bandura’s social learning theory, which states that one’s learning or behavior acquisition occurs through observation of suitable model performing a specific behavior Modeling is based on the psychologic principle that much of one’s learning or behavior acquisition occurs through observation of a suitable model performing a specific behavior.

143. 143 Mother as a live model can be highly effective regimen while dealing with pediatric patients. (Sharma K , Malik Manvi ,2016) In comparative efficiency of TSD and live modeling on children’s heart rates – children receiving live modeling with mother as model had lower heart rate than those who received with father as model. Karan S,Manvi M ,Vinod S.Relative efficacy of TSD and modeling technique on suburban Indian children during dental treatment based on heart ratev.clinical study.J Dental Specialities . 2016 ; 4:178-82

144. OPERANT CONDITIONING OPERANT :- Any active behaviour that operates upon the environment to generate consequences OPERANT CONDITIONING:- The behaviour is followed by a consequence , and the nature of the consequence modifies the organisms tendency to repeat the behaviour in the future 144

145. Operant conditioning is a method of learning that occurs through rewards and punishments for behaviour. Through operant conditioning, an association is made between a behaviour and a consequence for that behaviour. 145

146. LAW OF EFFECT PRINCIPLE If particular behaviour is powered by desirable consequences or reward it is more likely to happen again. If particular behaviour is followed by an undesirable consequences or punishment that behaviour is less likely to happen again in the future 146

147. VOICE CONTROL It is communicative as well as management technique S udden and firm commands are used to get the child’s attention or to stop the her from whatever she is doing. Once the dentist has the child’s attention, conversation should revert to a quieter tone. 147

148. 148 Chambers (1976) theorized that voice control is most effective when used in conjunction with other communication, such as tapping a child on the chest or clapping the hands loudly . In these cases, it is what is heard that is important because the dentist is attempting to influence behavior directly and not through understanding. The dentist, however, must realize that this technique is not acceptable to all parents.

149. ADVANCED BEHAVIOR GUIDANCE For some children, basic behavior guidance is inadequate to permit safe, high-quality dental care. This may be due to the young age of the child, special health care needs, extreme defiance or fearfulness. 149

150. PROTECTIVE STABILIZATION “Any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely.” It is used to decrease risk of injury during treatment Use of technique with parent consent and if done in positive manner can be very beneficial. 150

151. 151 Active stabilization : The parent, dentist or assistant helps stabilize the patient Typically carried out only for a very short period of time or in times of unexpected, physically uncooperative behavior.

152. 152 Passive stabilization : It is the use of a device to restrict patient movement for patient safety. Devices used commonly are Papoose Board, Rainbow Wraps etc.

153. 153 PART AID FEATURE Mouth Tongue blades Open wide mouth prop Can be used directly to open mouth It has a durable foam core on the outside of a tongue depressor Molt mouth prop Very helpful in the management of a difficult patient for a prolonged period. Disadvantages: possibility of lip and palatal lacerations and luxation of teeth if it is not used correctly

154. 154 PART AID FEATURE Mouth Rubber bite blocks Available in various sizes to fit on the occlusal surfaces of the teeth The bite blocks should have floss attached for easy retrieval if they become dislodged in the mouth Finger guards Used directly to open mouth

155. 155 PART AID FEATURE Body Papoose board Simple to store and use Available in areas to hold both large and small children It has attached head stabilizers Reusable Any restrained patient requires constant attendance and supervision Triangular sheets It allows the patient to upright during radiographic examinations Disadvantages -frequent need for straps to maintain the patient’s position in the chair, difficulty of its use on small patients and the possibility of airway impingement Hyperthermia -during long periods of immobilization Constant supervision required.

156. 156 PART AID FEATURE Body Pedi wrap Allows some movement while still confining the patient Its mesh fabric prevents developing hyperthermia Requires straps to maintain body position in the dental chair Constant supervision to prevent the patient from rolling out of the chair Bean bag insert Developed to help comfortably accommodate hypnotic and severely spastic persons who need more support and less immobilization in a dental environment It is reusable Many patients with physical disabilities relax more in this setting

157. 157 PART AID FEATURE Body Safety belt and extra assistant Useful in controlling movements Extremities Posey straps Velcro straps Towel and tape Extra assistant Fasten to the arms of the dental chair and allow limited movement frequently prevents overreaction by resistant or combative patients Helpful for an athetoid-spastic cerebral palsy patient who tries desperately, but without success, to control body movements Head Head positioner Plastic bowl Extra assistant Used to stabilize head

158. 158 Indications A patient requires immediate diagnosis and/or limited treatment and cannot cooperate because of lack of maturity or mental or physical disability. A patient requires diagnosis or treatment and does not cooperate after other behavior management techniques have failed. The safety of the patient, staff, parent or practitioner would be at risk without the use of protective stabilization.

159. 159 Contraindications A cooperative non-sedated patient. Patients who cannot be safely stabilized due to medical or physical conditions. Patients who have experienced previous physical or psychological trauma from protective stabilization (unless no other alternatives are available). Non sedated patients with nonemergent treatment requiring lengthy appointments.

160. AVERSIVE CONDITIONING Term aversive conditioning by Lencher and Wright Also known as hand-over- mouth exercise (HOME) as described by Dr Evangeline Jordan (1920) 160

161. 161 N ot used routinely but as method of last resort usually with children 3 to 6 years of age having appropriate communicative abilities. Technique fits the rules of learning theory : Maladaptive acts (screaming, kicking) linked to restraint (hand over mouth) Cooperative behavior is related to removal of the restriction and the use of positive reinforcement (praise).

162. 162 Objective : To gain child’s attention enabling communication with dentist so that appropriate behavioral expectation can be explained. To eliminate inappropriate avoidance behavior to dental treatment and to establish appropriate learned response. To increase child’s confidence in coping with anxiety provoking dental stimuli. To assure child safety in delivery of quality dental care.

163. 163 Technique :

164. 164 Indication : A healthy child who is able to understand and cooperate but who exhibits defiant or hysterical behavior to dental treatment. Contraindication : Immature child When it prevents child from breathing When the dentist is emotionally involved with the child.

165. 165 Modifications of HOME : Hand over mouth with airway restricted (HOMAR) Hand over mouth with nose and airway restricted Towel held over mouth only Dry towel held over nose and mouth Wet towel hold over nose and mouth

166. 166 Legality of home technique It has been pointed out that the use of HOME will not subject the dentist to liability by the patient when it is used properly with parental consent. Use of hand over mouth airway restricted (HOMAR) is more nearly objectionable legally and may result in liability of the dentist.

167. RECENT ADVANCES IN BEHAVIOR GUIDANCE The recent technologies such as audiovisual aids, videogames, mobile apps and virtual reality can be used as an adjunct for conventional techniques due to its immersive, interesting and innovational capability in managing children with behavioral problems 167

168. 168 Mobile Dental App In 2017, Patil VH et al. utilized mobile dental app for reducing fear and anxiety in children in the dental set up. An interactive session of using the dental application during the treatment was allowed and the children were virtually made dentists and allowed to provide different treatments through the application. Patil VH, Vaid K, Gokhale NS, Shah P, Mundada M, Hugar SM. Evaluation of effectiveness of dental apps in management of child behaviour : A pilot study. Int J Pedod Rehabil 2017;2:14-8

169. 169 By this technique, the fear towards different dental instruments and its use in children could be reduced and more cooperative behavior could be achieved.

170. 170 Videogame Distraction Videogame as a distraction tool is based on the principles of cognitive- behavioral therapy and neurofeedback mechanism for children with anxiety disorders

171. 171 Virtual reality based distraction The VR equipment contains head mounted display and a tracking device. The head mounted device contains the display screen which provides the view of virtual reality environment in a 360° view.

172. Other Behavior Guidance Techniques 172

173. HYPNOSIS 173 It was first suggested by Franz A Mesmer , a physician in 1773 Hypnosis is a state of mind connected to deep relaxation, narrowed focus and increased suggestibility . When used in dentistry – hypnodontics or suggestion therapy.

174. 174 Hypnodontia was first documented in 1829 to facilitate a dental extraction. By 20th century - hypnotic suggestion became regarded by many dentists as the primary mode of patient management and control. Its relationship with inhalation analgesia began with street ‘professors’, who used to entertain crowds with hypnotic induction and lectures on the wonders of chemistry; they would end a show by demonstrating the effects of nitrous oxide.

175. 175 One night in 1844, a performance was watched by the dentist Horace Wells, who observed a volunteer stumbling around and badly bruising himself after he inhaled nitrous oxide. Afterwards, Mr Wells questioned the volunteer, who said he felt no pain until the gas wore off. The next day, Wells allowed a colleague to extract one of his own teeth under inhalation anaesthesia with nitrous oxide, later proclaiming it as “the greatest discovery ever made!”.

176. 176 Pharmacological sedation is a temporary respite for a single procedure. Hypnosis can achieve both excellent physiological sedation and treatment of anxiety and phobias, and reductions in sedative and analgesic doses. Hypnosis is particularly effective in children ages 8–12 years, although as young as children 4 years of age can be responsive. Hypnosis in modern dentistry: Challenging Misconceptions faculty Dental Journal October 2015

177. 177 Particularly indicated in emotionally disturbed children who require dental work. It is easily accepted by children because they have fewer misconceptions and preconceived ideas about hypnosis. This is because children are often in self-hypnosis state during imaginary play causing them more susceptible to hypnosis than adults.

178. 178 Technique : Patient preparation : It is important to gain informed consent from the parent and child in accordance with the Children Act of 1989. A simple verbal explanation of hypnosis should be given and any questions that the parent or child may have are answered.

179. 179 The hypnotic induction :three parts: Focus the subject’s attention on a stimuli of particular modality, which may be either visual like a focusing light held in an out-stretched hand or body sensation like warmth, cold, tingling. Giving repeated instructions suggestive of relaxation and comfort. The coupling of focussing and suggestion done to develop more powerful effect, e.g. with every breath you feel more relaxed.

180. 180 Deepening : Deepening the hypnotic state involves the sequential use of three or four different inductions. Posthypnotic suggestion : These suggestions given by the clinician during hypnosis are aimed at altering the patient’s feelings, thoughts and behavior afterwards Altering patient after therapy : This is a process of bringing the patient out of the hypnotic state and reorienting to their normal surroundings.

181. 181 Advantages : Extremely useful in relaxation of nervous and excitable patient Useful in eliminating fear and tension making long procedures more tolerable Disadvantages : Time consuming Unpredictable level of effectiveness

182. 182 Contraindications and limitations : Should not be abused by dentist to probe into emotional problems of individual Should avoid exceeding his\her competence in using hypnosis for non-dental purposes.

183. 183 COPING Coping refers to cognitive and behavioral efforts made by individuals to master, tolerate or reduce stressful situations. Stress can act to increase pain perception while coping decrease it by a process called assimilation

184. 184

185. 185 Behavioral coping : Physical or verbal activities in which the child engages to deal with stress Readily visible to dentist e.g. Inquisitive question about the procedure.

186. 186 Cognitive coping : Efforts which involve manipulation of emotions. N ot visible to dentist but play a crucial role in child’s ability to deal with the treatment as well as forming a positive outlook for future. Children taught coping skills like imagery, relaxation, self talk demonstrated less stress during treatment.

187. 187 CONCLUSION Sheller summarizes - “the task of pediatric dentists is the same as it was generation ago: to perform precise surgical procedures on children whose behaviour may range from cooperative to hostile to defiant’ Realistically, the complexities of children’s and dentist’s temperament, parental attitudes, and varying needs make it clear that there will never be a “one size fits all” technique Therefore, the dentist must work towards communication using the best possible techniques and help develop positive oral health care habits in the child

188. Previous years question papers Discuss in detail the various types of behavior and their management. Describe the various types of children based on behavior and factors influencing child behavior. Discuss the management of an emotionally disturbed and anxious child Role of maternal anxiety in he behavior of children in dental clinic 188

189. 189 Define behavior management, behavior shaping and behavior modification. Describe the management of a preschooler throwing temper tantrums in the dental office. Management of emotionally disturbed child Modeling Contingency management

190. 190 REFERENCES Wright GZ, Kupietzky A, editors. Behavior management in dentistry for children. Wiley Blackwell;2014 Jan 21. Dean JA, editor. McDonald and Avery's Dentistry for the Child and Adolescent-E- Book. Elsevier Health Sciences; 2015 Aug 10. Tandon S. Pediatric dentistry.Paras medical publishers;3 rd edition.2018 Marwah N. Textbook of pediatric dentistry. Jaypee Brothers, Medical Publishers Pvt. Limited; 2018 Oct 31.

191. 191 Patil VH, Vaid K, Gokhale NS, Shah P, Mundada M, Hugar SM. Evaluation of effectiveness of dental apps in management of child behaviour : A pilot study. Int J Pedod Rehabil 2017;2:14-8 Karan S,Manvi M ,Vinod S.Relative efficacy of TSD and modeling technique on suburban Indian children during dental treatment based on heart ratev.clinical study.J Dental Specialities . 2016 ; 4:178-82 Hypnosis in modern dentistry: Challenging Misconceptions faculty Dental Journal October 2015

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