PEDODONTICS 1-2 Dr. Abdullah Abumoamar

Behavior Management 1

Behavior Management Child age classification: 1-Newborn: birth to one month. 2- Infants: one month to 12 months. 3-Toddlers: one year to 2-3 years. 4- Preschool: three to six years. 5- School age: six to 11/12 years. 6- Adolescent: /20 years.

Behavior Management Consent: 1- Consent to examination, investigation or treatment is essential to the provision of dental care. 2- If dentist and parent do not share a common language an interpreter is essential.

Behavior Management The aim of behavior management is to promote positive dental attitudes, it does not imply just the behavior necessary to complete a given task, but includes creating a long-term interest on the patient's part for ongoing

Behavior Management To do this the dentist must establish a relationship based on trust with the child and parents to ensure compliance with preventive regimes and allow treatment to occur.

Behavior Management Behavior Management of children in the dental practice can be achieved by two methods: I- Non-pharmacological methods II- pharmacological methods

Non-pharmacological methods -A major difference between the treatment of children and adults is the relationship. -Treating adults generally involves a one-to-one relationship, that is, a dentist-patient relationship. -Treating a child usually relies on a one-to-two relationship among dentist, pediatric patient and parents or guardians.

Non-pharmacological methods Factors influencing child's behaviors: A-Factors involving the child. B-Factors involving the parents. C-Factors involving the dentist.

Factors involving the child 1-Medical history: -Children who have bad negative experiences associated with medical treatment may be more anxious about dental treatment. -When taking a medical history the dentist should include questions about previous hospital/medical contact/treatment and the child's response to them.

Factors involving the child 2-Past dental experience: Fear sustained from previous painful or unhappy dental visits has also been related to poor behavior at subsequent visits.

Factors involving the child 3-Growth and development: -Normal children go through different psychological developmental stages as they grow up. -The child's psychological age may not always correspond to his chronological age, but most children demonstrate emotional maturation along with their physical growth. -Positive relationship exists between intelligence quotient (IQ) and acceptance of dental treatment.

Factors involving the child 4-Awareness of dental problem: -Children who know they have a dental problem are more likely to exhibit negative behavior at the first dental appointment. 5-Position of the child in the family: -Arrangement of the children in the family offers their behavior.

Factors involving the parents: 1-Parent-child relationship 2-Maternal Anxiety 3-Attitude of parents to dentistry:

Factors involving the parents: 1-Parent-child relationship: characteristics of parent-child relationship that may influence children behaviors in dental clinic are: a) Over protective/over anxious parents: -These parents do not allow their children to experience and learn to cope with the problems and anxieties of life. -Over protection may relate to the previous history of miscarriage, death of other sibling or serious illness of the child. -As a result child is frequently very shy, fearful of new situations and lacking self-confidence.

Factors involving the parents: b) Over indulgent: -Parent often gives the child whatever he asks. -Child manipulates his parents into satisfying all of his wants and tend to act superior, bossy, and demanding. -Typically, he follows the same type of behavior during dental visit and are often called ''spoiled'' child.

Factors involving the parents: C ) Over Authoritative: -Such parents do not support their children anxieties but constantly criticize or punish them. -They may compare them with older siblings and demand the same behavior. -Those children will be submission, coupled with resentment and commonly are delaying tactics in an attempt to avoid the dental procedures.

Factors involving the parents: d) Under affection : -This includes parental behaviors that range from mild lack of interest to overt rejection or physical abuse. -The lack of affection and attention to their children may result in severe emotional problems. -The child usually develop resentment and non- responsive to painful procedures or might also be loud, crying easily and aggressive seeking the attention that is missing at home.

Factors involving the parents: E) Rejection: Abuse Child syndrome

Factors involving the parents: 2-Maternal Anxiety: -Highly anxious parents tend to affect their child's behavior negatively. -Children under the age of 4 years are affected greatly by mother’s anxiety and may increase the child's own anxiety. 3-Attitude of parents to dentistry: -Parents with positive dental attitude will develop the same in the child whereas, Conversely

Factors involving the dentist: 1-Appearance of the dental office: -Since the child may enter the dental office with some fear, the first objective of the dentist is to put the child at ease. -To achieve this, the reception room should be made as comfortable and warm as possible. -Cartoon characters, coloring books and magazines should be placed. -Try to avoid children seeing adults in pain.

Factors involving the dentist: 2-Personality of the dentist: -Children are not small adults, thus an understanding of child development is crucial if behavior management techniques are to be used effectively. -Also the reaction of the child is not a fixed pattern but differs from time to time and from child to another. -The dentist should be able to modify his approach and language with the child to match their abilities and understanding.

Factors involving the dentist: 2-Personality of the dentist: -It is extremely important that the dentist learn to mask his emotional reactions toward situations and never lose his temper as this will create a feeling of success in the mind of the child and will ruin the child for all future dental visits. -The dentist can help the child to display good behavior by permitting him to express their feeling and listen to him.

Factors involving the dentist: 2-Personality of the dentist: -Dentist must be calm, smile and show friendly attitude and may well express disapproval to the unacceptable behavior without losing personal control. -The child should always be called by his or her nick name or at least the first name. -All conversation should be directed towards the child and the dentist should not talk in a loud voice or shake hands vigorously.

Factors involving the dentist: 3-Dental team skill and speed: -Dental treatment should be performed in a pre-planned manner to avoid loss of time. -A child can endure discomfort if he knows it is late going to end. -Four-handed assistant with excellent communication skills is important in the management strategies.

Factors involving the dentist: 4-Time and length of appointment: -Children cannot sit in one position for long time and their threshold of tolerance is very low, therefore they should not be kept in the chair for periods longer than half an hour. -Children should not be given appointment during their naptime or soon after some emotional experience such as birth of a sibling or death of someone close.

Factors involving the dentist: 5-Avoiding the use of fear promoting words: -The use of fear promoting words such as needle, injections etc. should be avoided, and alternatively other words can be used ex. Needle prick → Mosquito bite fluoride → cavity fighter Rubber dam → Rain coat suction → vacuum cleaner Sealant → tooth paint hand piece → motor cycle.

Factors involving the dentist: 6-Use of flattery, praise and reward: -One of the most important rewards sought by the child is the approval of the dentist. -In praising a child, it is better to praise the behavior than the individual. -Tiny gifts such as alphabet erasers, tiny gold stars, toys or stickers make good gifts.

Factors involving the dentist: Role of the dentist in the emotional conditioning of children toward dentistry: A- Parent education/reduction of maternal anxiety: B- Psychological growth of children:

Factors involving the dentist: A- Parent education/reduction of maternal anxiety: 1-Advise the parents never to use dentistry as punishment to the child. 2-Discourage parents from bribing their child to go to the dentist as this will signify to the child that there must be danger ahead. 3-Stree to the parent the value of regular dental care, not only in preserving the teeth but also in the formation of good dental patient.

Factors involving the dentist: A- Parent education/reduction of maternal anxiety: 4-Advise the parents not to talk about their own fears of dentistry in front of their children. 5-Parents should not promise the child that the dentist will not hurt or what dentist is not going to do.

Factors involving the dentist: B-Psychological growth of children: -It is important to note that children vary in their development and that chronological and psychological ages do not always correspond, thus the dentist must consider both when planning management techniques.

Psychological growth of children: 1-First Year: -In this period the infant is a stranger in a new world and totally dependent on others to nature him and meet his needs. -His tension is secured by serving food and sucking. -The infant is incapable of rational response in the dental situation and difficult to communicate with. -Short and fast procedure must be used and techniques to manage infants utilizing the assistance of parents are important.

Psychological growth of children: 2-Two Years: -At this age the child has limited vocabulary, like to feel and touch objects to understand their meaning -The dental situation with its unusual sounds, smells, bright lights and tilting chair can produce fear in the child. -Keep procedures short and invite the parent to accompany the child during treatment to provide him with security and reassurance.

Psychological growth of children: 3-Three Years: -The child is able to speak in sentences, has very active imagination like stories and is capable of communicating in the dental office. -He remains closely attached to his parent and praise for routine behavior is important during management.

Psychological growth of children: 4-Four Years: -The fourth year can be a very difficult one for the child, his fear of the unknown is at its peak, and he becomes more aggressive but can be easily separated from his parents. -Management includes kind understanding and firmness directions.

Psychological growth of children: 5-Five Years: -Five years marks’ ending of early childhood, the child is now able to accept community experience and group activities. -He is readily separated from parents and his fears usually diminished. -Praise and compliments such as positive comments about the child's clothes or personal appearance are very effective in establishing rapport.

Psychological growth of children: 6-School-period (6-12): -The child has irrational fear of objects, people and bodily harm; he may still experience anxiety but will tend to hide it with false bravado or stoic silence. -Management needs understanding without overindulgence, deals on intellectual level but maintained firmness, tell-show-do.

Classification of children's behavior patterns: 1)Frankel behavioral Rating scale: -Rating One: Definitely Negative -Refuses treatment, immature, uncontrollable, crying forcefully, fearful.

Classification of children's behavior patterns: -Rating two: Negative -Reluctant to accept treatment, uncooperative, immature, timid and whining. -Rating three: Positive -Accept treatment, willing to comply with the dentist with reservation but follows the dentist's directions cooperatively.

Classification of children's behavior patterns: -Rating four: Definitely Positive -has good rapport with the dentist, interested in the dental procedures, laughs and enjoys the situation.

Classification of children's behavior patterns: 2) Wright's Classification: - Cooperative behavior: -Reasonably relaxed, have minimal apprehension and can be treated by a straight forward behavior shaping approach. -Have or develop good rapport with the dentist and are interested in the dental procedures. -Laugh and enjoy the situation. -Allow the dentist to function effectively and efficiently.

Classification of children's behavior patterns: 2) Wright's Classification: -Lacking cooperative behavior: -Unable to communicate with the dentist and understand the procedures. -Includes very young (< 2.5) or with specific debilitating or handicapping conditions. -Management best accomplished through the use of sedation or general anesthesia.

Classification of children's behavior patterns: 2) Wright's Classification: Potentially Cooperative: -Includes children aged three through teens and unable to express their fears and anxieties. -Their behavior is essentially reflection of their inability to cope with their anxiety and show some adverse reaction such as timidity, whining or defiant behavior.

Reactions of the child to dental experience: -Potentially cooperative children have a combination of several reactions to the dental experience which make the problem more complex. Children with the following behaviors require behavior modification procedures.

Reactions of the child to dental experience: 1-Fear: The infant fears are primitive responses trying to escape from harm or fight, and when the child's mental age increases these responses can be controlled. -Types of fear: A-Fear of the unknown: Native fear is one of the primary emotions, it is a protective mechanism and present in every human being, and any unknown situation is fearful until experienced.

Reactions of the child to dental experience: B-Fear of strangers: 1-Objective fear: -They are produced by direct physical stimulation, they are the responses to stimuli that are felt, seen, heard, smelt or tasted and are not liked or accepted. -A child who has a bad dental experience will naturally wish to avoid treatment. -They fear white uniform and smell of certain drugs and chemicals in hospital.

Reactions of the child to dental experience: 2-Subjective fear: -Subjective fear may be acquired by imitation and may be transmitted from parents. -Also fear may be suggested to the children from friends or from materials such as books, T.V, radio or cartoons.

Reactions of the child to dental experience: C-Fear of separation: -Separation anxiety and distress may be developed when the child is separated from the parents and young children are best treated with a parent present.

Reactions of the child to dental experience: 2-Anxiety: -Anxiety or insecurity is increase in tension, apprehension and uneasiness due to unknown causes; it is closely related to fear of new experiences. -The child's reaction may be aggressive such as temper tantrum in dental office. -The dentist must determine whether the reaction is one of acute fear or a tantrum.

Reactions of the child to dental experience: 3-Resistance:(uncontrolled behavior ) - preschool age -It is a manifestation of anxiety or insecurity, the child may display temper tantrum, head beating or may develop vomiting habits, and withdrawal is another manifestation of anxiety.

Reactions of the child to dental experience: 4- Defiant behavior -All age -School age -Spoiled child

Reactions of the child to dental experience: 5 -Timidity: -Timid or shy behavior is often expressed by young children, particularly at the initial dental visit. -Child tries to hide behind his mother or looks to the floor and another direction, once the child gains his confidence he becomes an excellent patient.

Reactions of the child to dental experience: 6 -Stoic behavior: -The child is cooperative, sits quietly and passively and accepts all dental treatment including the injection without protest or any sign of discomfort. -Children of these characteristics may be physically abused.

Reactions of the child to dental experience: 7 -Tense cooperative behavior: -The child wants to cooperate but is obviously afraid; his eyes follow the movement of the dentist and assistant. -He accepts the treatment but is extremely tense; clenching his hands and may cry during the injection.

Reactions of the child to dental experience: 8 - Whining behavior:

Crying as a diagnostic tool: - Crying like all other emotional manifestations of human behavior is a mode of expression of the personality traits of the individual. -There are four types of crying:

Crying as a diagnostic tool: 1-Obstinate Crying: Characterized by loud crying, temper tantrum, kicking, biting, usually no lacrimation. This child is termed spoiled -Management: firmness and hand-over-mouth technique to gain quiet, listening and compliance from the child. Use sedation as last option.

Crying as a diagnostic tool: 2-Frightened Crying: Characterized by profusion of tears, constant wailing sound, convulsive and rasping without temper tantrum. -Management: attempt to deal with the emotion and explanation, kindness and understanding. use sedation when all fails.

Crying as a diagnostic tool: 3 -Hurt Crying: Characterized by lack or less tears without another manifestation, respiration may be affected if child hold his breath. Management: relief pain, use of topical anesthetic before injection.

Crying as a diagnostic tool: 4 -Compensatory Crying: Characterized by whining sound that is not loud but consistent, no tears, child allows treatment to be provided but he whines throughout the procedures. -Management: make no attempt to stop the whining as long as the child is cooperative.