CHILD MANAGEMENT 2/3

Dr. Yosra Abdelfatah Ali

Behavior management can be achieved basically by two methods:
•Non-pharmacological methods.
•Pharmacological methods.
Non-pharmacologic management of children’s behaviors.
•Behavior Shaping
•Behavior guidance
Basic Behavior Guidance
Modern alternative techniques
Advanced Behavior Guidance
Behavior Shaping
•This is the process of influencing the child’s behavior towards a
desired ideal behavior towards dentistry.
•Desired ideal: maintaining good oral hygiene, sensible diet control,
being relaxed and co-operative during operative procedures.
Defined as a series of steps on the path to the desired behavior, and then to
progress step by step to the goal.
1. State the general goal
2. Explain the necessity for the procedure
3. Divide the explanation for the procedure
4. Give all explanations at a child’s level of understanding
5. Use successive approximations
6. Reinforce appropriate behavior
7. Disregard minor inappropriate behavior
Behavior guidance
•The process by which practitioners help patients identify appropriate
and inappropriate behavior, learn problem solving strategies, and
develop impulse control, empathy, and self-esteem.

•Behavior guidance should never be punishment for misbehavior,

power assertion, or use of any strategy that hurts, shames, or
belittles a patient.
Behavior guidance
Goals are to:
•Establish communication
•Alleviate fear and anxiety
•Deliver quality dental care
•Build a trusting relationship between dentist/staff and child/parent
•Promote the child’s positive attitude toward oral health care.
Basic Behavior Guidance • Memory restructuring
• Positive pre-visit imagery • Retraining
• Direct observation • Systemic desensitization
• Tell-show-do • Communication techniques for parents
• Ask-tell-ask • Hand Over Mouth (HOM)
• Voice control Modern alternative techniques
• Nonverbal communication • Magic tricks
• Positive reinforcement and descriptive praise • Child-centered care
• Distraction • Hypnosis
• Changing control/temporary escape Advanced Behavior Guidance
• Parental presence/absence • Protective stabilization
Basic Behavior Guidance
 Positive pre-visit imagery
Description: Patients are shown positive photographs or images of dentistry and
dental treatment in the waiting area before the dental appointment
Objectives:
•Provide children and parents with visual information on what to expect during the
dental visit
•Provide children with context to be able to ask providers relevant questions
before dental procedures are initiated.
Indications: May be used with any patient.
Contraindication: None.
 Direct observation (Modeling)
Description: Patients are shown a video or are permitted to directly observe a
young cooperative patient undergoing dental treatment.
Objectives:
•Familiarize the patient with the dental setting and specific steps involved in a
dental procedure
•Give the patient and parent an opportunity to ask questions about the dental
procedure in a safe environment.

Indications: May be used with any patient.

Contraindications: None.
 Tell-show-do
•Description: The technique involves verbal explanations of procedures in
phrases appropriate to the developmental level of the patient (tell)
•Demonstrations for the patient the visual, auditory, olfactory, and tactile
aspects of the procedure in a carefully defined, nonthreatening setting (show)
•Then, without deviating from the explanation and demonstration, completion
of the procedure (do).

•The tell-show-do technique is used with communication skills (verbal and

nonverbal) and positive reinforcement.
 Tell-show-do
Objectives:
•Teach the patient important aspects of the dental visit and familiarize the
patient with the dental setting
•Shape the patient’s response to procedures through desensitization and well-
described expectations.

•Indications: May be used with any patient.

Contraindications: None.
 Ask-tell-ask
•Description: Inquiring about the patient’s visit and feelings toward or
about any planned procedures (ask)
•Explaining the procedures through demonstrations and non-threatening
language appropriate to the cognitive level of the patient (tell)
•Again inquiring if the patient understands and how she/he feels about the
impending treatment (ask).
•If the patient continues to have concerns, the dentist can address them,
assess the situation, and modify the procedures or behavior guidance
techniques if necessary.
 Ask-tell-ask
Objective:
•Assess anxiety that may lead to noncompliant behavior during
treatment
•Teach the patient about the procedures and how they are going to
be accomplished
•Confirm the patient is comfortable with the treatment before
proceeding.
Indications: May be used with any patient able to dialogue.
Contraindications: None.
 Voice control
Description: Voice control is a deliberate alteration of voice volume, tone, or pace to
influence and direct the patient’s behavior.
The Use of an assertive voice may be considered aversive to some parents unfamiliar
with this technique. An explanation prior to its use may prevent misunderstanding.
Objectives:
•Gain the patient’s attention and compliance
•Avert negative or avoidance behavior
•Establish appropriate adult-child roles
Indications: May be used with any patient.
Contraindications: Patients who are hearing impaired.
Nonverbal communication
Description: Nonverbal communication is the reinforcement and
guidance of behavior through appropriate contact, posture, facial
expression, and body language.
Objectives
•Enhance the effectiveness of other communicative management
techniques
•Gain or maintain the patient’s attention and compliance.
Indications: May be used with any patient.
Contraindications: None.
Positive reinforcement and descriptive
praise
Description: In the process of establishing desirable patient behavior,
it is essential to give appropriate feedback.
Positive reinforcement rewards desired behaviors thereby
strengthening the likelihood of recurrence of those behaviors.
Social reinforcers include: Positive voice modulation, facial
expression, verbal praise, and appropriate physical demonstrations of
affection by all members of the dental team.
Positive reinforcement and descriptive
praise
Descriptive praise emphasizes specific cooperative behaviors
Nonsocial reinforcers include Material e.g. toys or Activity e.g.
Watching a TV show .

Negative reinforcement: Withdrawal of unpleasant stimulus after a

response. (different from punishment).
Positive reinforcement and descriptive
praise
Objective:
•Descriptive praise is to reinforce desired behavior.

Indications: May be used with any patient.

Contraindications: None.
 Distraction
Description: Diverting the patient’s attention from what may be perceived as an
unpleasant procedure. Giving the patient a short break during a stressful
procedure can be an effective use of distraction.
Objectives:
•Decrease the perception of unpleasantness
•Avert negative or avoidance behavior.
Indications: May be used with any patient.
Contraindications: None.
Distraction technique includes :
1) Guided imagery
2) Reading
3) Listening to audio
4) Watching videos
5) Practicing relaxation
6) Self talk
Changing control/temporary escape
It allows the patient to have some degree of control over their
situation and the ability to communicate when the patient requires a
rest, is in pain, or needs the dentist to stop.
Memory restructuring/ Retraining/
Systemic desensitization
Memory restructuring
Description: Behavioral approach in which memories associated with a negative
or difficult event (e.g., first dental visit, local anesthesia, restorative procedure,
extraction) are restructured into positive memories using information suggested
after the event has taken place.
Restructuring involves four components:
(1) Visual reminders
(2) Positive reinforcement through verbalization
(3) Concrete examples to encode sensory details
(4) Sense of accomplishment.
Memory restructuring
Objectives:
•Restructure difficult or negative past dental experiences
•Improve patient behaviors at subsequent dental visits.

Indications: May be used with patients who had a negative or difficult

dental visits.
Contraindications: None.
Retraining
Children who require retraining approach the dental office displaying
considerable apprehension or negative behavior.
The demonstrated behavior may be the result of a previous dental
visit or the effect of improper parental or peer orientation.
•Determining the source of the problem is helpful because the
undesirable behavior can then be avoided through another
technique or deemphasized, or a distraction can be used.
 Systemic desensitization
Aims to reduce anxiety through the gradual presentation of anxiety or fear-
inducing stimuli while the child is either in a relaxed state or in the
presence of a neutral or positive stimulus, thus modifying child’s response.
4 steps:

1- Identify the problem

2- Introduce relaxation technique

3- Create a ranked inventory of fear- or anxiety-inducing stimuli

4- Expose the patient to stimuli from the inventory while practicing

relaxation techniques
•Dentist should not move to the next stimuli unless behavior has
improved.

•The technique requires time

•Requires psychologist (sometimes)

Communication techniques for parents
(and age appropriate patients)
Successful bi-directional communication between the dentist/staff
and the parent is essential to assure effective guidance of the child’s
behavior.
Socioeconomic status, stress level, marital discord, dental attitudes
aligned with a different cultural heritage, and linguistic skills may
present challenges to open and clear communication.
Communication techniques such as ask-tell-ask, teach back, and
motivational interviewing can reflect the dentist/staff’s caring for
and engaging in a patient/ parent centered-approach.
 Hand Over Mouth (HOM)
•Aversive conditioning
•Controversial (Rarely used /old technique)
•The dentist place his or her hand over the mouth of a hysterically
crying child and speak clearly but firmly into the child's ear,
explaining that the hand will be removed as soon as the crying stops.
•Should not last for more than 20 – 30 seconds .
•Used to intercept tantrums or other fits of rage.
•It has to be paired with voice control.
• It is not intended to scare the child, but it reframes the seriousness of a
previous request.
• Critics suggest it may be aggravating to the child.
• Indicated in the normal child who is old enough to understand the
directions of the dentist and to cooperate but who exhibits defiant or
hysterical behavior.
• Contraindications include disabled, immature, and medicated children
whose understanding of the situation is compromised
Modern alternative techniques
Magic tricks
Show the child a trick to reduce his level of anxiety and encourage a
positive behavior.
It may make a child feel at ease in an unfamiliar scenario
 Child-centered care
•Creation of a positive and friendly environment focusing on the
individual child.

•Decorating the dental room with age-appropriate

themes using movies, toys, books, and video games

in waiting rooms.
Hypnosis
Hypnosis is the formalized process of suggestion and visualization,
which may be useful for children during uncomfortable procedures.
Advanced Behavior Guidance
Protective stabilization

Any manual method physical or mechanical device, material, or

equipment that immobilizes or reduces the ability of a patient to
move his or her arms, legs, body, or head freely or A drug or
medication when it is used as a restriction to manage the patient’s
behavior or restart the patient’s freedom of movement and is not a
standard treatment or dosage for the patient’s condition.
Consent
The ideal characteristics of a mechanical restraining device:
• Easily used.
• Appropriately sized for the patient.
• Soft and contoured to minimize potential injury to the patient.
• Specifically designed for patient stabilization (i.e., not improvised
equipment).
• Able to be disinfected.
The following are commonly used for
protective stabilization:
Body
•Papoose Board
•Triangular sheet
•Pedi-Wrap
•Beanbag dental chair insert
•Safety belt
•Extra assistant
 The following are commonly used for
protective stabilization:
Extremities
•Posey straps
•Velcro straps
•Towel and tape
•Extra assistant
Head
•Forearm-body support
•Head positioner
•Plastic bowl
•Extra assistant
 Aids for maintaining the mouth in an
open position
•Wrapped tongue blades
•Disposable mouth props
•Open Wide mouth prop
•The Molt Mouth Prop
•Rubber bite blocks
Monitoring
•Ongoing awareness/assessment of the patient’s physical and
psychological well-being during the dental procedure must be
performed.
•Tightness
•For a patient who is experiencing severe emotional stress or
hysterics, protective stabilization must be terminated as soon as
possible to prevent possible physical or psychological trauma.
•Assess the patient’s level of cooperation.
Indications
• A patient requires immediate diagnosis and/or urgent limited treatment
and cannot cooperate due to emotional and cognitive developmental
levels, lack of maturity, or medical and physical conditions.

• Urgent care is needed and uncontrolled movements risk the safety of the
patient, staff, dentist, or parent without the use of protective stabilization.

• A previously cooperative patient quickly becomes uncooperative during

the appointment in order to protect the patient’s safety and help to
expedite completion of treatment.
• An uncooperative patient requires limited (e.g., quadrant) treatment and
sedation or general anesthesia may not be an option because the patient
does not meet sedation criteria, there is a long operating room wait time,
financial considerations, and/or parental preferences after other options
have been discussed.

• A sedated patient requires limited stabilization to help reduce untoward

movements during treatment.

• A patient with SHCN exhibits uncontrolled movements that would be

harmful or significantly interfere with the quality of care.
Contraindications:

• Cooperative non-sedated patients.

• Patients who cannot be immobilized safely due to associated medical,
psychological, or physical conditions.
• Patients with a history of physical or psychological trauma due to
immobilization (unless no other alternatives are available).
• Patients with non-emergent treatment needs in order to accomplish full
mouth or multiple quadrant dental rehabilitation
• The practitioner’s convenience
Risks:
•Consider the patient’s emotional and cognitive developmental levels and be
aware of potential physical and psychological effects of protective stabilization.
•Minor bruises and scratches
•Overheat
•A rigid stabilization board may not allow for complete extension of the neck
and, therefore, may compromise airway patency.
•Significant release of adrenal catecholamines may exist in patients who
experience increased agitation when restrained by staff members or
protective stabilizing equipment. Excessive catecholamine release may
sensitize the heart and cause rhythm disturbances.
Documentation
The patient’s record must include:
• Indication for stabilization.
• Type of stabilization.
• Informed consent for protective stabilization.
• Reason for parental exclusion during protective stabilization (when applicable).
• The duration of application of stabilization.
• Behavior evaluation/rating during stabilization.
• Any untoward outcomes, such as skin markings.
• Management implications for future appointments.