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Child Behaviour

Management in Dentistry
BDS,MSc (Comm.Dent),DDPH RCS(England)
Categorizing Behavior
Variables influencing Child behavior:
Parental influences:
Overprotective Parents: Take excessive care of the children.
Such children are submissive , shy & anxious, fear new
situations & lack self confidence
Overindulging parents: Give children whatever they want Overindulging parents: Give children whatever they want
without any restraint. The child becomes spoilt & is used to
getting his own way.
Under affectionate parents: Child is devoid of love &
affection. Children are shy, indecisive but well behaved.
Response when treated with love.
Authoritarian parents: Try to instill a high level of verbal
discipline in the form of physical punishment & verbal
ridicule. Such children show a heightened gradient of
avoidance , & try to avoid or delay response
Rejecting parents: Face situation when parents have an
unwanted child, unhappy marriage etc. Such children are
anxious, overactive, disobedient & most difficult to deal.
Past Medical & dental influences:
Children who have pleasant past medical experiences are
more likely to be co-operative , & those with experience of
pain & fear will be co-operative.
Home Environment: Home is the first place where the child
learns to behave. Children from broken home will feel
insecure, inferior & depressed. insecure, inferior & depressed.
Position of child in the family:
First Child- Uncertainty, mistrustfulness, insecurity
Second Child- Independent, Aggressive, Extrovert
Middle child Aggressiveness, inferiority
Last child Secure, confident, immature, envy
Sibling Rivalry:
Rivalry & jealousy between siblings for the affection
of parents influence childs behavior.
Socioeconomic status:
High authority of parents in low socioeconomic
status is observed compared to the medium & the status is observed compared to the medium & the
Clinic Set up
1. Ambience of the clinic: The clinic environment
should relax the patient & keep him engaged till
treatment begins. Should be equipped with toys,
playroom, tape recorder, cartoons , Aquarium,
cartoon etc.
2. Personality of the dentist
Casual, confident, friendly, total command of situation, never
loose temper, encourage the child etc.
3. Time & length of appointment:
The duration of appointment should not be more than half an
No appointment to be scheduled during naptime
The appointment to be kept in the morning time
4. Use of Euphemisms (Substitute words)
The use of fear promoting words should be avoided . Use
substitute words that are less provoking. Eg: Needle prick as
a mosquito bite
5. Use of flattery , Reward & praise
The use of Tiny gifts, after the treatment have a great
influence on the child's behavior. Praising a child or a pat
the back helps him/her to gain confidence
6. Parent counseling: The parents should keep the following
points in mind.
1. Not to voice their own fears
2. Not to use dentistry as a threat
3. Mothers presence reduces the fear of the child
Child & parent separation Vs parental presence
Disadvantages of parental presence
Repeat the orders of the dentist, annoyance
Inject orders
Dentist unable to use voice control
Child attention is divided
Dentists attention is divided Dentists attention is divided
Can be supportive in communicating
Child below 2-3 years
Behavior Management
Behavior management can be 2 types:
Non-Pharmacologic Behavior management
Pharmacologic Behavior management Pharmacologic Behavior management
Non Pharmacologic Behavior management:
Communicative Management:
Most basic form of behavior management & first step in
treating the child.
The objective develop rapport with the patient & gain trust
The types of communication include:
Non verbal may be in the form of patting, smile
acknowledging good behavior
2.Systematic Desensitization:
Involves gradual exposure of the child to least stressful objects
to the most stressful object.
Done in 2 steps:
1.Gradual exposure of the child to his or her fear 1.Gradual exposure of the child to his or her fear
2.Induced state of incompatibility with his or her fear
3.Tell Show do (TSD)
Dentist first explains to the patient in easy terms (Tell)
Demonstrates procedure to the patient . Eg: using mouth mirror
or probe.
Continues with performing the procedure (Do)
-Developed by Bandura (1969)
-Learning occurs only as a result of direct experience
-Witnessing the behavior and the outcome of that behavior for
other people
Types of models:
Live Models: The other children in the clinic who are Live Models: The other children in the clinic who are
undergoing treatment (Best live models- siblings)
Filmed Models- Posters, or cartoon characters (Mickey
mouse brushing teeth) or famous star taking treatment
Modeling is the most beneficial compare to other means for
dentally uneducated child.
5. Voice Control:
Controlled alteration of voice volume. Allows dentist to
inuculate more authority into his/her communication.
It must indicate that I am in charge here (facial
expressions have an important role to play
6.Contingency Management: 6.Contingency Management:
Its a method where a childs behaviour is altered by
presenting or withdrawing a reinforcer.
Positive reinforcement: childs behaviour is encouraged or
praised by patting on the back
Negative reinforcement: Withdrawing a toy from the child
on performance of an undesirable behaviour
Helpful in reducing anxiety & increasing pain threshold
It is an altered level of consciousness characterized by a
heightened suggestibility to produce desirable behavioral &
physiological changes
8. Aversive Conditioning (Kramer 1974) 8. Aversive Conditioning (Kramer 1974)
Techniques used in the management of non-cooperative
They are physical restraints & HOME. Consent is necessary
for these procedures
They include active & passive. Divided based on the area of
Body- Papoose board,pedi wrap
Extremities- Velcro straps, bean bag
Head- Head positioner
Mouth- Bite blocks, props
Others, eg: chair straps
Physical Restraint:
Others, eg: chair straps
2. Hand Over Mouth Exercise (Levitas 1974)
Gain attention of highly co-operative child who is not willing
to receive any sort of communication from dentist
Not be used for children above 4-6 years of age or who do
not have any handicapping conditions
Papoose board restraint
A hand is placed over the childs mouth & behavioral
expectations are explained. The hand is removed or
reapplied depending on the behavior of the patient
Use of HOME is indicated for a healthy child who is able to
understand & co-operate but exhibits defiant or hysterical
avoidance behavior.
HOME is contraindicated if it causes occlusion of nasal HOME is contraindicated if it causes occlusion of nasal
passages & restricts breathing, unable to obtain informed
consent, unable to understand & co-operate due to age,
disability or medication.
Pharmacologic Behavior management (Conscious
sedation & General anesthesia)
Used only when the patients lack co-operative behavior or a
systemic condition requires it.
Conscious Sedation:
Minimally depressed level of consciousness that retains the Minimally depressed level of consciousness that retains the
patients ability to maintain an airway independently & respond
appropriately to physical stimulation & verbal command (ADA
Useful for nervous & apprehensive child requiring extensive
Nitrous oxide oxygen combination is the drug of choice
Conscious sedation
Patient is unconscious & unable to maintain
respiration independently & loses all protective reflexes.
Indicated when the patient is mentally or physically
handicapped, too young to co-operate
All other behavioral management technique has failed
Patient requiring extensive/immediate dental treatment
which would otherwise require multiple appointments
Contraindications indicate systemic conditions where
use of anesthesia is not advisable. In both conscious
sedation & general anesthesia written parental consent
is a must