BEHAVIOR: – is an observable act. It is defined as any change observed in the functioning of an organism.
CLASSIFICATION OF CHILD’S BEHAVIOUR OBSERVED IN DENTAL CLINICS.
WILSON’S CLASIFICATION (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.
FRANKLE’S CLASIFICATION (1962)
(Frankel’s Behaviour Rating Scale)
| Rating | Behavior |
| Definitely Negative (–) | Refuses Treatment,
cries forcefully, extremely negatively behavior. |
| 2) Negative (-) | Reluctant to accept treatment and displays evidence of slight negativism. |
| 3)Positive (+) | Accepts treatment, but if the child hos a bad experience during treatment, may become uncooperative. |
| 4) Definitely positive (++) | Unique behavior, look forward to and understands the importance of good prevent care. |
LAMPSHIRE (1970)
1) Co-operative: The child is physically and emotionally related. Is cooperative throughout the entire procedure.
2) Tense co-operative: The child is tensed, and co-operative at the same time.
3) Outwardly apprehensive: Avoid treatment initially, usually childes hides behind the mother, avoids looking or talking to the dentist. Eventually accept dental treatment.
4) A 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 WHICH AFFECT CHILDS BEHAVIOUR IN THE DENTAL OFFICE.
| Under the control of Dentist | Out of the control of Dentist | Under the control of Parents |
| Effect of Dental office environment. | Growth and Development | Home Environment |
| Effect of Dentists activity and attitude | Nutritional Factors | Family |
| Presence/Absence of Parents in Operatory | Past Dental experience | Development and peer influence |
| Presence of an older siblings | Genetics | Maternal behavior |
| Dentist attire | School environment | |
| Socio-economic status |
1)Under the control of Dentist
1) DENTAL CLINICS
➤ Dental office should be warm and stimulate a homely environment.
➤ Healthy communication with the child should be established.
➤ Appointment time should be short ie less than 30 min.
➤ Early morning appointments are preferable for younger children.
2) EFFECT OF DENTIST’S ACTIVITY AND ATTITUDES
➤ The dentist should form a good impression on the child.
➤ He/She should avoid jerky, and quick movements and should be fluent in his words and actions.
3) EFFECTS OF DENTIST’S ATTIRE
➤ If a child has previously experienced a stressful situation, which includes the presence of someone in white attire such as physician, the mere presence of a white clotted individual would be sufficient to evoke a negative behavior.
4) PRESENCE OR ABSENCE OF PARENTSIN THE OPERATORY.
➤ This depends on the behavior of the child, parent & dentist. Mother’s presence is essential for a preschool child, handicapped child etc.
5) PRESENCE OF OLDER SIBLINGS.
➤ An older sibling serves as role model in a dental situation. This depends on the age of the patient.
II) Out of control of the dentist
1) GROWTH & DEVELOPMENT
➤ If there is a deficiency in physical growth and development or congenital malformations eg cleft lip, as awareness of the deformity increases it leads to psychological trauma due to rejection by society.
2) NUTRITIONAL FACTORS
➤ Studies have shown that an increased intake of sugar causes an irritable behavior.
➤ Hypoglycemia causes a criminal behavior.
➤ Skipping breakfast leads to an impaired performance.
3) PAST MEDICAL AND DENTAL EXPERIENCES
➤ Any past unpleasant dental experience, prior hospitalization, surgical intervention, sickness, etc are associated with a high degree of uncooperative behavior.
4) GENETICS
➤ Genetics plays a very role in psychological development.
➤ There should be contact interaction between genetic programme of the child and environment for the psychological development of the child.
5) SCHOOL ENVIRONMENT
➤ School affects 50% of the child’s development.
➤ In the school, teachers and peers help to influence the behavior of the younger children.
6) SOCIO-ECONOMIC STATUS
➤ High socio-economic status child may develop normally because the family can provide all the necessary requirements to aid in a normal psychological development. On the other hand this child may also become spoilt if he always gets what he wants.
➤ A low socio-economic status can directly affect the child’s attitude towards the value of dental health as he/she often neglected.
III) Under the control of parents
1) HOME ENVIRONMENT
➤ The home is the first school where a child learns to behave.
➤ Postnatal behavior of the child depends on the prenatal emotion status of the mother.
2) FAMILY DEVELOPMENT AND PEER INFLUENCES
➤ Over indulgence by the parents, can lead to spoilt behavior in the child who may show sudden outbursts and temper tantrums
➤ Internal family conflicts affect children’s behavior.
3) MATERNAL BEHAVIOR
➤ Matemal influence on the children’s mental, physical and emotional development begins before birth.
MATERNAL ATTITIDE AND CHILD’S BEHAVIOR
| MOTHERS BEHAVIOUR | CHILD’S BEHAVIOUR |
| Over protective dominant | Shy, Submissive, anxious. |
| Over indulgent | Aggressive, demanding, display of temper tantrums. |
| Under Estimate | Usually well behaved, but may be unable to cooperate, shy, may cry easily. |
| Rejecting | Aggressive, overactive, disobedient. |
| Authoritarian | Evasive and dawdling. |
BEHAVIOR MANAGEMENT
Behavior Management is defined as the means by which the dental health team effectively and efficiently performs dental treatment and there by instills a
positive dental attitude.
Behavior management can be classified as:-
• Non-pharmacological (psychological approach).
• Pharmalogical.
Non-pharmacological methods of behavior management
1) Communication.
2) Behavior shaping.
Desensitization Tell show do
Modeling
Contingency management.
3) Behavior management.
a. Audio analgesia.
b. Biofeed back.
c. Voice control.
d. Hypnosis.
e. Humor.
f Coping
g. Relaxation.
h. Aversive conditioning-Home and physical restraints.
Pharmacological methods of behavior management
Pre-medication.
a) Sedatives and hypnotics.
b) Anti-anxiety drugs.
c) Antihistamines.
Conscious sedation.
• General anesthesia.
Non-pharmacological method of behavior management
1.COMMUNCATIVE MANAGEMENT
➤ Communication management is used universally in pediatric dentistry with both the cooperative and uncooperative child
➤ Communicative management is the basis for establishing a relationship with a child which may allow the successful completion of dental procedures and, at the same time, may help the child develop a positive attitude towards dental care.
➤ During the course of communicative management child is provided with a playful environment.
2. BEHAVIOR SHAPING
Behavior shaping is the procedure which slowly develops behavior by reinforcing a successive approximation of the desired behavior comes into being Behavior modification involves three techniques.
Desensitization:
➤ Desensitization is accomplished by teaching the child a competing response such as relaxes and then introducing progressively more threatening stimuli.
➤ Systemic desensitization is effectively because the patient learns to substitute an appropriate or adaptive emotional response for an inappropriate or maladaptive response anxiety.
Method popularly used now a days for modifying the behavior by desensitization children is:
1. Tell show do
Tell-show-do is a technique involves:
➤ TELL: verbal explanations of procedures in phrases approximate to the developmental level of the patient.
➤ SHOW :demonstrations for the patient of the visual, auditory, olfactory and tactile aspects of the procedure in a carefully defined, non- threatening setting.
➤ DO: without deviating from the explanation and demonstration of the procedure
2. Modelling:
Introduced by Bandura(1969) developed from social-leaming principle procedure involve allowing a patient to observe one or more individuals(models) who demonstrate a positive behavior in a particular situation. Therefore the patient will frequently imitate the models behavior when placed in a similar situations.
Modeling can be done by:
a) Live models-siblings, parents of child etc.
b) Filmed models.
c) Posters.
d) Audiovisual aids.
3) Contingency management 260
It is a method of modifying the behavior of children by presentation or withdrawal of reinforces. These reinforces can be
a) Positive reinforces is one whose contingent presentation increase the frequency of behavior. (HENRY W FIELDS 1984)
b) Negative reinforces is one whose contingent withdrawal increases the frequency of behavior. (STOKES AND KENNDY 1980)
3) BEHAVIOR MANAGEMENT
A) Audio analgesia or ‘white nose’ 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. Auditory stimulus such as pleasant music has been used to reduce stress and also reduce the reaction to pain.
B) Biofeed back: Involves the use of certain instruments to detect certain physiological processes associated with fear. For e.gif blood pressure is high the instrument gives stimulation and the subject is taught to control the signals, therefore it is useful in anxiety and stress related disorder.
C) Voice control: Voice control is a controlled alteration of voice, volume, tone, or place to influence and direct the patient behavior
Objectives;
1. To gain the patients attention and compliance.
2. To avert negative or avoidance behavior.
3. To established authority.
➤ Voice control is indicated for uncooperative or inattentive children.
D) Humor. Humor helps to elevate the mood of the child, which helps the child to relax.
E) Coping. It is mechanism by which the child copes up with the dental treatment. It is defined as the cognitive and behavioral efforts made by as individual to master, tolerate or reduce stressful situation.
Coping effects may be of two types.
a) Behavioral: are physical and verbal activities in which the child engages to overcome a stressful situation.
b) Cognitive: The child may be silent and thinking on his mind to keep calm.
B) Relaxation: This technique is used to reduced stress and is based on the principle of elimination of anxiety. Relaxation involves a series of basic exercises, which require the patient to practice at home for at least 15 min/day.
C) Hypnosis, is an altered state of consciousness characterized by a heightened suggestibility to produce desired behavioral and psychological changes. When used in dentistry, it can be termed as hypnodontics (Richardson 1980) or psychosomatic or suggestive therapy.
D) Aversive conditioning: Child who displays a negative behavior and does not respond to moderate behavior modification technique falls into the category of frankel’s definitive negative behavior. Two common methods used in the clinical practice are:-
(i) HOME (Hand over Mouth Exercise)
➤ Introduced by Evangeline Jordan (1920)
➤ After determining the child’s behavior, the dentist firmly places his hand over the child’s mouth and behavioral and behavioral expectations are calmly explained close to the child’s ear. When the child’s verbal outburst is completely stopped and the child indicates his willingness to cooperate, the dentist removes his hand. Once the child cooperates, he should be complimented for being quiet and praised for good behavior. It should be noted that the child’s airway is not restricted while performing the technique and the whole procedure should no last for more than 20-30 sec.
Written informed consent from a legal guardian must be obtained and documented in the patient record prior to the use of HOME
Indication
A healthy child who can understand but who exhibits defiance and hysterical behavior during treatment.
Contraindication
Children under 3 years of age.
• Handicapped/Immature child & frightened child.
• Any child with an airway obstruction.
Objectives
• To gain the child’s attention enabling communication with the dentist so that appropriate behavioral expectations can be explained.
• To enhance the child’s self confidence in coping with the annxiety provoking stimuli of dental treatment.
(ii) PHYSICAL RESTRAINTS
➤ Last resort handling uncooperative patients or handicapped patients
➤ Restraints are usually needed for children who are hyper motive, stubborn, or defiant.
➤ The child is seated in the mother’s lap and one of the mother’s hand is placed on the child’s forehead while the other is placed on both the child’s wrists
Types of restraint
a) For body.
Pedi wrap.
Papoose wrap.
Sheets.
Towel and tapes.
b) For extremities
Velcro straps
✔Posey straps
■ Towel and tapes
c) For the head
•Head positioner
•Forearm body support.
d) Mouth
Mouth blocks
Banded tongue blades
Rubber, bite blocks.
Pharmacological management of child behavior
1. SEDATION
The use of sedation is advocated in children lacking cooperative for the short duration procedures.
The various routes of commonly used sedatives are:-
1)Inhalation
Nitrous oxide.
2) Oral
Hydroxyzine
Promethazine
Chloral hydrate
Meperidine
Diazepam
3) Intramuscular
Ketamine
Midazolam
4) Intravenous
Midazolam.
2. CONSCIOUS SEDATION
Some children become anxious in the dental office and can’t relax or sit still long enough for the dentist to treat them. For these children, the dentist may suggest forms of medication that allow the child to relax and/or become sleepy. This is called conscious sedation, since the child is still responsive to conversation or stimulation and all his or her protective reflexes are working. It may involve inhaling gas, taking an oral medication, getting injection or receiving medication intravenously. Conscious sedation also may be used when a child require extensive dental treatment or has special needs.
3. GENERAL ANESTHESIA
General anesthesia is a controlled state of unconsciousness accompanied by a loss of protective reflexes, including the ability to maintain an airway independently and respond purposefully to physical stimulation or verbal command.
The use of general anesthesia sometimes is necessary to quality dental care for the child
Objectives
•To provide safe, efficient and effective dental care.
•To eliminate anxiety in dental patients.
•To eliminate the child’s pain.
Parental or Legal guardian informed consent must be obtained and documented prior the treatment. The patients record should include:
Informed consent.
Indication for the use of particular treatment.
CONCLUTION
Behavior guidance is a continuum of interaction with a child and parent directed toward communication and education, which also ensuring the safety of both the oral health professional and staff and the child’s fear and anxiety about the dental office.
The goal is to provide oral health care in the most comfortable, least restrictive, safest, and most effective manner.
Some behavior guidance techniques are intended to maintain communication, while others are intended to stop uncontrolled or unsafe behavior. Behavior techniques must be selected based on the level of the child’s oral health needs as well as on the child’s ability to understand.
Tips for promoting cooperation in the Dental Office:
•Set the stage for a successful visit by involving the entire oral health team, from the receptionist to the dentist, as well as the parents.
•Arrange for a desensitizing appointment to help the child become familiar with the dental office, staff, and equipment before oral health procedures begins.
•Allow children to bring comfort items such as stuffed animal or a blanket.
•Make appointments short whenever possible, providing only oral health procedures that the child can tolerate.
•Praise and reinforce good behavior, and try to end each appointment on a positive note.