NON-PHARMACOLOGICAL

BEHAVIOR MANAGEMENT

Definitions

Behavior management : is defined as the means by which the dental health team effectively and efficiently performs dental treatment and thereby instills a positive dental attitude.

(Wright,1975)

DefinitionsBEHAVIOR SHAPING: Is a procedure which slowly develops behavior

by reinforcing successive approximations of

the desired behavior until the desired behavior

comes into being.

Given by Lenchner & Wright, (1975).

BEHAVIOR MODIFICATION: It is defined as the attempt to alter human

behavior & emotion in a beneficial way & in

accordance with the laws of learning.

GOALS OF EFFECTIVE BEHAVIOR MANAGEMENT

• Establish rapport, trust and communication

• Gain child’s and parent confidence

• Teach the positive aspects of dental care.

• Provide a relaxing and comfortable environment

• Facilitates quality dental care

Classification of child’s behavior observed in dental clinic

• Normal/bold: brave enough to face the situation, cooperate & friendly with dentist

• Tasteful/ timid: shy, does not interfere with dental procedures

• Hysterical/ rebellious: influenced by home environment , throws temper tantrum, rebellious

• Nervous / fearful: tense & anxious, fear of dentistry

Wilson’s classification 1933

WRIGHT CLASSIFICATION(1975)

A COOP ERATIVE (POSITIVE)

a Cooperativeb Lacking

cooperative abilityc Potentially cooperative

B UNCOOPERATIVE(NEGATIVE)a. Uncontrolled/Hysterical/

Incoorrgibleb. Defiant/Obstinate behaviorc. Tense Cooperatived. Timid Behaviore. Whining typef. Stoic behavior

A. CO-OPERATIVE-(Positive behavior)

I cooperative behaviour

• Relaxed, minimal apprehension, can be R/ by

behavior shaping

• Develop good rapport, interested in the dental

procedure

• Laugh & enjoy the situation

• Allow the dentist to function efficiently &

effectively

Wright classification (1975)

II. Lacking co-operative behavior:

Contrast to co-operative child

0 to 3 years

disabled child, physical and mental handicap

III. Potentially cooperative behavior:

potential to cooperate. But because of the inherent fears the child does not cooperate.

B) UNCOOPERATIVE (Negative

Behaviour)

1. Uncontrolled behavior:

• in preschool children

• Temper tantrums even in the reception area.

• Tears, loud crying, physical lashing out of the

hands & legs

2. Defiant behavior:

• Elementary school group.

• Stubborn or spoilt child

• Highly cooperative – once won over

3. Timid behavior:• Mild but highly anxious• Shy but do not cry hysterically.• Overprotective in home.• Needs to gain self confidence.

4. Tense cooperative:• Do not resist treatment, extremely tense.• Border line behavior.

5. Whining behavior: • Allows treatment but complains

throughout the procedure• Extremely frustrating to treat.

6. Stoic behavior:• Cooperative• Sits quiet ,passively receives R/ including LA.• Does not talk readily• Seen in physically abused child

FRANKEL’S BEHAVIOR RATING SCALE(1962)

Rating

1. DEFINITELY NEGATIVE(--)

2. NEGATIVE (-)

3. POSITIVE (+)

4. DEFINITELY POSITIVE(++)

Behavior

• Refuses treatment, cries forcefully, extremely negative behavior associated with fear

• Reluctant to accept treatment& displays evidence of slight negativism

• Accepts treatment, but if had a bad experience ,may become uncooperative

• Unique behavior, looks forward to &understands the importance of good preventive care.

Non- Pharmacological Method of BehaviorManagement

a. Preappointment behavior modificationb. Communicationc. Behavioral shaping– Tell-show-do technique– Desensitization– Modeling– Contingencyd. Other methods– Distraction/Audio analgesia– Voice control– Hypnodontics– Coping– Relaxation– Aversive conditioning techniques—HOME,implosion therapy.

PHARMACOLOGICAL METHODS OF BEHAVIOR MANAGEMENT

1.Premedication a) Sedatives & Hypnoticsb) Antianxiety drugsc) Antihistamines

2. Conscious sedation3. General anesthesia

Preappointment Behavior Modification

• It is aimed at preparing the child for a dentalvisit. Various methods used for preappointment behavior modification includesaudiovisual aids, letters, films and vidotapes.Children are explained the importance ofmaintaining the teeth in health. Video clippingmay include other children undergoing dentaltreatment so that the child will feel thesimilarity and reproduce the behaviorexhibited by the model.

Universally used in pediatricdentistry with both co-operative anduncooperative child.

Fundamental form of behaviormanagement.

Communication

TYPES OF COMMUNICATION Verbal Communication

Non Verbal Communication(Multisensory

Communication)

• Body language

• Smiling

• Eyecontact

• Expression of feelings without speaking

• Showing concern

• Giving him a pat

• Giving him a hug

Both

How to communicate

• Communication should make the child comfortable

and relaxed

• Chosen language should be understandable, show

concern

• Voice control

• Multisensory communication that involves

a transmitter, the spoken word,(medium)

and the pediatric patient(the receiver)

• Best for children above 3 yrs of children

• Active listening

• Communication should be

from a single source to avoid

confusion

• Try to call by nick name, Give compliments about his good behavior

• Using animation Explain about the procedure briefly (tooth sleeping, worms in tooth)

• Keep the patient occupied in your conversation through out the procedure.

• Use of euphemisms• For example:

• Mosquito bite --------------------------- needle prick

• Rain coat ----------------------------------rubber dam

• Tooth button ------------------------------rubber dam clamp

• Coat rack----------------------------------- rubber dam frame

• Tooth paint--------------------------------- sealant

• Cavity fighter------------------------------- fluoride

• Wind gun------------------------------------ air syringe

• Vacuum cleaner---------------------------- suction

• Pudding--------------------------------------- alginate

• Motor cycle ----------------------------------hand piece/bur

TELL SHOW DO

TECHNIQUEBy ADDLESLON 1959

The technique involves verbal explanations ofprocedures in phrases appropriate to the developmentallevel of the patient (tell); demonstrations for the patientof the visual, auditory, olfactory, and tactile aspects ofthe procedure in a carefully defined, nonthreateningsetting (show); and then, without deviating from theexplanation and demonstration, completion of theprocedure (do)

INDICATIONS:

First Visit

Subsequent visits when introducing new dental procedure

May be used with all patients.

Can be used to deal with pre-existing anxieties and fears, or with patients facing dentistry for the first time

First visit

Objectives

To allow the child to learn about and

understand dental procedures in a way that

minimises anxiety.

Used with rewards, to gradually shape the

child’s behaviour towards

acceptance of more

invasive procedures.

Desensitization by Joseph Wolpe

It is a training procedure or steps taken to reduce thesensitivity of the patient to a particular anxietyproducing situation or object. Each situation or objectis then introduced progressively starting from the leastfear producing to more threatening stimuli.

Technique involves three stages---------1. Training the patient to relax2. Constructing a hierarchy of fear producing stimulirelated to the patient’s principal fear.3. Introducing each stimulus in the hierarchy in turn tothe relaxed patient, starting with the stimulus thatcauses least fear and progressing to the next onlywhen the patient no longer fear that stimulus.

Example-If the child is frightened of the restoration, desensitization might include successive introduction of the child to the:• Reception• Dentist• Dental chair• Oral examination• Oral prophylaxis• Restoration

This technique requires many appointments and visits.

MODELING BY BANDURA 1969

Procedure involves allowing a patient to observe one or more

individuals (models) demonstrate a positive behavior in a particular

situation.

It is indirect learning, i.e. learning from others, who may be parents,

teachers, peers, siblings or the media.

Modeling can be done by

• Live models----siblings, parents etc.

• Filmed Models

• Posters

• Audiovisual Aids

Learning through modeling is effective when:

• Observer is in the state of arousal

• When the model is more mature than the child

• When there are positive consequences associated with model’s

behavior

Improve the child’s beh. who had previous bad dental experience

Live modeling requires no extra expenses

Contingency Management

The presentation or withdrawal of reinforcers to modify a child’s behavior is termed contingency management.

Positive ReinforcerWhose contingent presentation increases the frequency of behavior e.g.: giving reward to the child After behaving in a desired manner.

• Negative Re-inforcer is one whose contingent

withdrawal increases the frequency of behavior. It is

usually the termination of an aversive stimulus.

Types of reinforcers• Social:

praise, positive facial expression, patting shoulder

• Material:

toys,games

• Activity reinforcer:

watching TV show or cartoon movie

Distraction

• Distraction is the technique of diverting the patient’s attention from what may be perceived as an unpleasant procedure. Thus it helps to decrease the perception of unpleasantness and avert negative or avoidance behavior. Music in the back ground, television in front of the child may act as affective distractors.

Audio Analgesia Or `White Noise’ is a method of reducing pain. This technique consists of providing a sound stimulus of such intensity that the patient finds it difficult to attend to anything else.

Voice Controlmodification of the intensity and pitch of one’s ownvoice in an attempt to dominate the interactionbetween the child and the dentist. It reminds thechild that the dentist is an authority Figure to beobeyed.

Objectives

To control disruptive behaviour.

To gain the child’s attention.

Hypnodontics

• Use of hypnosis in dentistry is known ashypnodontics. Hypnosis is defined as aparticular state of mind which is usuallyinduced in one person by another—a state ofmind in which suggestions are not only morereadily accepted than in the waking state, butare also acted upon more powerfully thanwould be possible under normal conditions.

COPINGCognitive and behavioral efforts made by an individual to master, tolerate or reduce stressful situations.

Patients differ not only in their perception and responseto pain but also in their ways of dealing or coping withthe stress associated with painful experiences. Different coping mechanisms are:1. Distraction or displacement of attention away from the threat is an ideal method of coping. This can be achieved by constantly talking and asking interesting questions to the child.2. Allowing the child to verbalize fears to the dentist makes the child feel secure.3. Allowing parents to be in the operatory. The child feels secure with the parent.

Relaxation:

• Relaxation usually involves a series of basic exercise that may take several months to learn and which require the patients to practice at home for at least fifteen minutes each day.

• This technique is used to reduce stress and is based on the principle of elimination of anxiety.

Humor:helps to elevate the mood of the child

FUNCTIONS:

• SOCIAL: forming and maintaining relationship

• EMOTIONAL: anxiety relief in the child, parent and

dentist

• INFORMATIVE: transmits essential information in a

non-threatening way

• MOTIVATION: it increases the interest and

involvement of the child

• COGNITIVE: distraction from fearful situation

Implosion Therapy:

Sudden flooding with a barrage of stimuliwhich have affected him adversely and thechild have no other choice but to face thestimuli until a negative response disappears.It mainly comprises of Home, Voice Controland Physical Restraints.

Aversive Conditioning: It is a method of managing extremely negative behavior.

HOME(Hand over mouth exercise)

• It was introduced by Evangeline Jordan in the year 1920.

• The purpose of the Home technique is to gain the attention of a child so

that communication can be achieved.

INDICATIONS

--3 TO 6 YRS OLD.

--Healthy child who can

understand but who exhibits

defiance and hysterical

behavior during treatment.

--A child who can understand

simple verbal communication.

--Children displaying

uncontrollable behavior.

CONTRAINDICATIONS• Child under 3 years of age.

• Handicapped/Immature Child.

• Physical, mental and emotionally handicap.

.

• Variations-

• - Hand over mouth with airway restricted.

• - Hand over mouth & the nose & airwayrestricted

• - Dry towel over mouth

• - Dry towel over nose & mouth

• - Wet towel over nose & mouth

PHYSICAL RESTRAINTS

• Last resort for handling uncooperative/handicapped patients

• Restraints are usually needed for children who are hyper motive, stubborn or defiant.

Indications:

• It should only be used when absolutely necessary,

• The least restrictive alternative should be chosen,

• It should not be used as punishment,

• It should not be used solely for the convenience of the dental team,

• Staff should closely monitor its use.

Mouth props with

suction tips

Pappose board in use

Immobilization for control of body & extremities

(Patient in a pedi-wrap)

Head positioner

Physical Restraints involve restriction of movement of the child’s head, hands, feet or body.Active : restraints provided by the dentist, staff or parent without the aid of restraining device.Passive: with the aid of restraining device.

Immobilization for the extremities(Posey strap on wrist)

Immobilization aids for head stabilization( Proper positioning of the dentist’s hands, forearm & body)

Immobilization for control of body &

extremities

(Patient lying in a beanbag dental chair

insert)

References

1. TEXTBOOK OF PEDIATRIC DENTISTRY- NIKHIL MARWAH.

2. PRINCIPLES AND PRACTICE OF PEDODONTICS- ARATHI RAO.

3. TEXTBOOK OF PEDODONTICS – SHOBHA TANDON.

Thank You