Behaviour Management in Paediatric Dentistry

• Behaviour management is necessary:

  • To relax the pt
  • To reduce stress
  • Through effective communication and education create a positive dental attitude
  • Helps to establish a relationship based on trust
  • Reduces dental anxieties that can continue into adulthood
  • To achieve co-operation which is necessary for dental procedures
• The impact of child development - motor:

  • Birth
  • Rolling, sitting, standing
  • Hand-eye co-ordination - important for brushing teeth
• The impact of child development - cognitive:

  • Sensorimotor (lasts until about 2 years)
  • Pre-operational thoughts (from ages 2-7)
  • Ego-centric, unable to encompass another point of view
  • Concrete operations (from ages 7-11)
  • Starting to apply logical reasoning
  • Formal operations (11 years)
  • Different possibilities for actions can be considered
• The impact of child development - perceptual:

  • Concentration skills and selective attention develop gradually so that by the age of 7 years children can determine which messages merit attention
• The impact of child development - language:

  • A lack of the appropriate stimulation will retard a child's learning, particularly language
  • Stimulation is important as language development is a rapid process
  • By the age of 5 most children can use over 2,000 words
  • Dentistry has a specialised vocabulary (jargonistic)
• The impact of child development - social:

  • Babies form specific attachments and are prone to separation anxieties
  • Separation anxiety should therefore be considered by dentists
• The impact of child development - adolescence:

  • End of childhood
  • Warning of parental influence
  • Increasing independency and self-sufficiency
  • Moody
  • Oversensitive to criticism
  • Can be miserable for no apparent reason
  • Emotional turmoil
• The way a dentist interacts with patients will have a major influence on the success of any clinical or preventive care. Children are not 'little adults', they are vulnerable and may be afraid of new surroundings so effective time management is important. Try to see young patients on time and do not stress yourself or the child by expecting to complete a clinical task in a short time on an apprehensive patient.
• Use behavioural principles to inform treatment:

  • Classical conditioning
  • Make the physical and social environment DIFFERENT to situations in which the child is likely to have felt scared, threatened, disregarded and SIMILAR to situations in which the child is likely to have felt safe, in control and listened to
• Use behavioural principles to inform treatment:

  • Operational conditioning
  • Reward the behaviour that you want to see (or moves towards this behaviour)
  • Remember reinforcement can be positive or negative
• Methods to use in behaviour management:

  • Acclimatisation
  • Tell, show, do
  • Distraction
  • Desensitisation
  • Modelling
  • Hand Over Mouth Exercise (HOME)
  • Hypnosis
• Methods to use in behaviour management - tell, show, do:

  • Be positive with your child pt
  • Voice control, alteration of volume, pace or tone can influence behaviour
  • Useful for inattentive but communicative children
  • Can familiarise a pt with a new procedure
• Methods to use in behaviour management - distraction:

  • Try to keep a patter going
  • It helps to shift the pt's attention from a potentially unpleasant procedure
  • Your dental nurse colleagues are invaluable
• Methods to use in behaviour management - desensitisation:

  • Useful for a child who can identify their fear and who can verbally communicate
  • 3 stages:

  1. Training the pt to relax
  2. Building a hierarchy of fear scenarios
  3. Gradually introduce the fearful stimuli

  • May take place over many visits
• Methods to use in behaviour management - modelling:

  • This technique is based on the psychological principle that people learn about their environment by observing
  • In the dental setting, watching a parent or sibling having treatment or even helping
  • The use of videos is an alternative
• Methods to use in behaviour management - Hand Over Mouth Exercise (HOME):

  • Perhaps the most controversial of all behaviour management techniques
  • Recommended by those who advocate it for 4-9 year olds when communication is lost, but parental consent is important
  • We do not advocate it!
  • Importance of the Children's Act
• Methods to use in behaviour management - hypnosis:

  • Including a state of mental relaxation
  • Pt selection is not always predictable
  • Variables including age, intelligence, personality can affect the success
  • Including a semi-hypnotic state is an important element of inhalation sedation
• Cognitive behavioral therapy (CBT) to reduce a child's dental anxiety for ages 9-16:

  • Development of self-help CBT resources
  • Resources developed based on the principles of Cognitive Behavioural Therapy
  • Used child-centred approach
  • Resources for children with accompanying resources for parents and dental professionals
• Cognitive behavioral therapy (CBT) to reduce a child's dental anxiety for ages 9-16:

  1. Challenge unhelpful thoughts
  2. Normalises dental anxiety
  3. Provides information
  4. Enhance control
  5. Message to the Dentist
  6. Stop signal contract
  7. Reflect and plan reward

  
• Sedation - oral:

  • Drugs used to sedate children = Diazepam and Midazolam
  • Convenient to administer but have unpredictable outcomes because of factors that affect absorption
  • Older children have more favourable results
  • Ideally should be administered in the surgery
  • In young children, those with learning disabilities, or very anxious children, oral midazolam is often used as a pre-medication prior to a general anaesthetic - this can help the child enough to be co-operative in theatre
• Sedation - intravenous:

  • The advantage of the intravenous route is that the drug has a rapid effect and is titrated to the individual's needs
  • However as children have such a high metabolic rate it can be unpredictable
• Sedation - inhalational:

  • AKA relative analgesia (RA), happy air (laughing gas), nitrous oxide
  • Relatively insoluble gas that's rapidly taken up by tissues, but also rapidly excreted -> recovery time is rapid
  • Good anxiolytic drug with good analgesic properties
  • Techniques & equipment ensure operator can never administer > 70% nitrous oxide
  • Indicated for the child who wants to co-operate but can be too overwhelmed by fear when accepting treatment
  • The child remains conscious & co-operative
  • Fully recover after only a few minutes
  • No respiratory depression
  • No interactions with other drugs
• Dental anxiety in children and adolescents:

  • Prevalence of dental anxiety in children and adolescents varies according to age, gender and the measure used to assess anxiety
  • Estimates vary from 10% to 29.4%
  • Children with high dental anxiety visit the dentist less and have worse oral health than children with low levels of dental anxiety
  • Although sedation can be a short-term strategy, dental sedation does not lead to any degree of reduced dental anxiety following successful treatment
• Dental anxiety in children and adolescents - it's important to:

  1. Take all possible steps to avoid causing dental anxiety in children and adolescents
  2. Provide care in such a way to minimise and reduce dental anxiety if possible
• Managing dental anxiety:

  • If the potential for a child to experience dental anxiety is a problem, what is the solution...
  • In order to answer this question we need more information. We need to know more about what the child is concerned about in order to be able to put in strategies that will help.
  • Using reflection becomes important because anxiety or fear cannot directly be observed. The particular thoughts, beliefs, evaluations and memories of past relevant experiences also cannot be directly observed.
• Managing dental anxiety:

  • The source of anxiety for one child will not be the same as that for another.
  • Reflective observation, targeted questions, active listening and routine measures will help you to identify the information you need to most effectively manage mild to moderate dental anxiety.
• Asking about dental anxiety:

  • Did you have any concerns about coming today(?)
  • How do you feel about coming for this appointment(?)
  • What questions would you like to ask(?) (not, do you have any questions?)