International Journal of Pharmacy and Biological Sciences

ISSN: 2321-3272 (Print), ISSN: 2230-7605 (Online)

IJPBS | Volume 6 | Issue 3| JUL-SEP | 2016 | 10-15
Review Article – Biological Sciences

BEHAVIOURAL MANAGEMENT TECHNIQUES IN PEDIATRIC CLINIC

J Chandrapooja & Kathiravan Selvarasu

Saveetha Dental College, Poonamalle High Road, Velappanchavadi Chennai-660077

Oral Maxillofacial Surgeon, Saveetha Dental College, 162, Poonamallee High Road, Chennai, Tamilnadu-600077

*Corresponding Author Email: [email protected]

ABSTRACT
The child management behaviour in paediatric clinic is the way by which the dental health care team effectively
and efficiently performs treatment for a child. Management of children in the paediatric clinic is complex
balancing act involving the child, parent and the dentist. To provide dental care for children good communication
skills are necessary. Anxiety is a recognised personality trail, and there are some other factors which were found
to increase the subsistence of behaviour problems during dental procedure. Behaviour management is widely
agreed to be a key factor supplying dental care for children. Certainly, if a child’s behaviour in the dental
surgery/office cannot be managed then it is not easy to hold out any dental care that is needed.

KEY WORDS
child management behaviour, tell show do.

INTRODUCTION listen to one person at a time. Avoid non-dental

The child management behaviour in paediatric clinic conversations with colleagues during procedures. [4]
is the way by which the dental health care team
effectively and efficiently performs treatment for a
child [1]. The aim is to establish a positive dental MANAGEMENT OF CHILDREN
attitude as it is important for all behaviour Management of children in the paediatric clinic is
management techniques [2] . It is not only about the complex balancing act involving the child, parent and
behaviour necessary to complete a given procedure, the dentist. To provide dental care for children good
but also creates a long-term interest on the patient’s communication skills are necessary. A considerable
attitude for ongoing prevention. The dentist must percentage of children do not co-operate in the dental
inculcate a rapport based on trust with the child and chair, causing an obstruction to delivery of quality
their parent complaints allowing proper treatment to dental care. This gives rise to behaviour management
occur and this is called the TREATMENT ALLIANCE [3]. techniques or alternatives to communicative
Children with dental anxiety may refuse treatment, management. Behaviour management of the child
which can lead to dental emergencies. Behavioural patient is an intrinsic component of paediatric dental
management is an essential skill and should be practice. Parents and careers may also play an
acquired by all members of a dental team treating important part in reduce the child's anxiety, allowing
children. Dental surgery staff should be relaxed, the dentist to perform the treatment and manage
welcoming and friendly. Make the child the centre of them. [5]
attention and smile. Use age-appropriate language Goals of behaviour management
and avoid the use of jargon. Decide who will talk to * Communication maintenance
the child and when, as he/she may only be able to * Reduction of fear and anxiety.
* Correct inappropriate behaviour.

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* Elicit behaviour consistent with the need for beside them during the treatment. Rarely, the
successful completion of treatment. presence of a parent has a negative consequence on
the communication between the child and the dentist.
FACTORS INFLUENCING CHILD BEHAVIOR Each clinician has responsible to establish the
Anxiety is a recognised personality trail, and there are communication and support methods that optimize
some other factors which were found to increase the the treatment setting, identifying their own skills, the
subsistence of behaviour problems during dental capability of the particular child, and the wishes of the
procedure. parent involved. [8, 9]
MEDICAL HISTORY: Children who had experienced a FOR CO-OPERATIVE CHILDREN
negative aspect associated with medical treatment TYPES OF CHILD BEHAVIOURAL MANAGEMENT
may be more anxious about the dental procedures, TECHNIQUES
just like that, fear carried from previous unhappy -tell show do
dental visits may also be related to poor behaviour at -Positive reinforcement
upcoming visits. The dentist should include questions -Voice control
about previous medical treatments while taking the -Distraction
medical history and also the child's response to them. -Euphemism
[6, 7] -Live modelling
PARENTAL INFLUENCE -Nonverbal communication
Parent’s anxiety had a major influence on their child’s -Systematic desensitization
behaviour, particularly if they had earlier negative TELL SHOW DO
dental incidents. An anxious or afraid parent may This method is extensively use to familiarise a new
influence a child’s behaviour pessimistically. Educating procedure to the patient [10]. This is the verbal
the parent prior to the child’s first dental visit is explanations of procedures in the way the child could
important. There are office procedures like the early understand (tell); presentation of the visual, auditory,
telephone call, go after by sending office information olfactory and touching aspects of the procedure in a
and a temptation to visit the office website or even an carefully done without threatening (show) and then,
office “pre-visit,” may be supportive in reducing without deviating from explanation and
parental anxiety. demonstration, the procedure has to be done (do).
Parenting styles have changed in recent years. The tell-show-do technique is used with verbal and
Dentists are faced with challenges from the rising non-verbal communication skills and positive
number of children who a lot of times are ill- reinforcement. Other measures will be needed
equipped, the skills and self-discipline necessary to depending on whether the child has communication
deal with novel experiences in the dental clinic. problems or disorders. This technique has been an
Commonly, parental expectations for the child’s effective way for reducing previously formed anxiety
behaviour (e.g., no tears) are impracticable. Some in the child patient [11]. In the tell phase the dentist
parents may even attempt to dictate treatment, gives an explanation about the procedure depending
although their knowledge of the procedure is lacking. upon the age of the patients. The show phase is used
Parents will also be able to predict the associated to illustrate the procedure, example demonstrating
behaviour of their children accurately. with a slow hand piece on a finger.
Practitioners have the same opinion that a good POSITIVE REINFORCEMENT AND BEHAVIORAL
communication is important between the parent, SHAPING
dentist, and parent in building faith and assurance. Positive reinforcement is an effective technique for
Practitioners also assure in the fact that valuable desired behaviours and strengthens the repeated
communication among the dentist and the child is occurrence of those behaviours. All members of the
dominant and requires understanding on both sides. dental team include social reinforce such as positive
Most kids react positively when their parent is there voice modulation, facial expression, verbal praise and

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appropriate physical demonstrations of affection. unpleasant to some other situation. Cartoons have
Some of the non-social reinforces are toys and tokens. been shown to reduce disruptive behaviours in
As most of the dental procedures require quite children when combined with reinforcement, that is
complex behaviours and actions, the patients are to when children knew the cartoon would be switched
be explained and learned, about them. For children off if they did not behave 18]. It has been found that
this should be explained in small clear steps. This is audio tapes may be even more effective than other
called as shaping process. It consists of a well-defined modes of distractions [19]. The dentist distracts with
set of steps towards perfect and complete behaviour words while applying topical paste and administering
[14]. By selective reinforcement this is most easily local anaesthetic. Short term distractors such as
achieved. When the behaviour pattern is diverting the attention by pulling the lip as a local
strengthened it increases the being displayed again in anaesthetic is very useful. The technique is useful for
the future which is called as reinforcements [15]. all patients who can verbally communicate. There are
Anything that the child finds pleasant can act as no contraindications.
positive reinforcers such as stickers and fun labels are LIVE MODELLING TECHNIQUE
used when the appointment was successful. A child In this technique the doctor makes the child to
centred, emotional response giving specific praise observe one or more individuals who demonstrate
such as," Good girl ", " I like the way you have kept positive behaviour in a particular situation. Models
your mouth open". But the latter is shown to be more like a parent or a sibling can be used for this
effective than a general comment previous one. [16] modelling. If a live model is not available filmed
The technique is useful only for all patients who can models like videos [20, 21] or posters can also be used
communicate. for demonstrating.
VOICE CONTROL The technique is based on the psychological principle
The pace, tone and alteration of voice volume, can that people learn about their environment by
influence the child's behaviour. This technique is observing others’ behaviour, by using a model, which
ineffective for children with severe hearing exhibits appropriate behaviour in the dental
impairments. Young children often respond to the environment. This may demonstrate appropriate
tone of voice more when compared to the actual behaviour via a third person, and decrease anxiety by
words. These all techniques aim to improve attention showing a positive outcome to a procedure. For best
and compliance as well as to establish control over effects models should be the same age and should
the child to an extent. However, it is widely used by exhibit appropriate behaviour that of target child.
dentists but may not be acceptable to all parents or They should also be shown entering and leaving the
clinicians [12]. surgery [22].
The technique is useful for communicative children
who are inattentive and is not appropriate for NON VERBAL COMMUNICATION
children who are too young to understand or with Types
emotional impairment. This technique has been -body language
shown to decrease undisciplined behaviour without -smiling
producing long-term negative effects [13]. -eye contact
DISTRACTION -expression of feeling without speaking
This technique diverts the child’s attention from what -by touching the child
may think as an unpleasant procedure. This can be -giving him a pat
done through talking, asking the parent to play with -showing concern
the child, using headphones to play music or allowing -giving him a hug
the child to watch a DVD or some cartoons. This Posture and facial expression and appropriate
approach aims to shift the patient’s attention from contact, are used for reinforcement and guidance of
the dental procedure which can be potentially behaviour. This technique is appropriate for children

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with hearing impairments. Establish contact to calm are used and are taught in advanced paediatric dental
the child; however, some children have tactile programmes.
defensiveness startle reflexes. NITROUS OXIDE OXYGEN INHALATION
SYSTEMATIC DESENSITISATION It is a safe, secure and effective, useful [25] behaviour
This technique focuses on individuals with specific management technique.
fears or phobias to overcome them by repeated Use Nitrous Oxide Oxygen sedation:
contacts. A hierarchy of fear-producing stimuli is * Patients who are anxious.
constructed, and the patient is exposed to them in an * As an adjunct to local anaesthesia.
ordered manner, starting with the stimulus posing the * In a patient whose gag reflexes interfere with
lowest threat. In dental terms, the use of local dental care.
anaesthetic is usually related to a specific procedure * If able to obtain written informed.
which creates fear. The patient is asked to relax first, PHYSICAL RESTRAIN
and in this state he is exposed to each of the stimuli in It includes partial or complete immobilization with
the hierarchy in turn, and progressing to the next dentist, parent or devices to protect the patient from
when they feel able. Several relaxation sessions with a injury during dental treatment. Prior to the procedure
psychologist or dentist who has received training in informed consent must be obtained from the patient.
relaxation or hypnosis techniques may be required for Various types of restraints
true phobias. [2] A 9 hour long sessions with a For the body
therapist is required [23]. However, a similar approach * Pedi wrap
can be used for children who have had a negative * Papoose board
experience in the past [24]. 
The technique is useful * Sheets
for a child who can clearly identify their fear and who * Beanbag with straps
can verbally communicate. * Towels and tapes
EUPHEMISM For the Head
Choices of words, which is used by the dentist ot staff * Head positioner
influence the emotional status of the patient. * Mouth blocks
Therefore, the use of euphemism or reframing is very * Banded tongue blades
important while addressing to the patient. * Beanbag with straps
1. Anaesthetic solution is referred to as water * Mouth props
to put the teeth to sleep Hand-Over-Mouth Technique
2. Caries is referred to as a tooth bug It is another behaviour management technique that is
3. Rubber dam as a rain coat controversial and may be offensive to some parents.
4. Radiograph as tooth picture The child is made to put his hand over his mouth and
FOR HYPERACTIVE CHILDREN behavioural expectations are explained. The hand is
Majority of the children can be managed effectively removed, depending on the behaviour of the child.
using the techniques which are listed above. However, Since there are more potential legal liabilities
children, who occasionally present with behavioural involving this technique it's use is discouraged except
changes like being hyperactive will need more for senior clinicians and paediatric dental consultants.
advanced techniques. Parent consent is more important, and the techniques
These children often cannot cooperate due to lack of should never be used on the children too young to
psychological or emotional maturity and/or mental, understand or with intellectual or emotional
physical or medical disability. The protective impairments [26-28].
stabilization, sedation and general anaesthesia are CONSCIOUS SEDATION
some of the advanced behaviour guidance techniques Sedation is an important technique to guide a child’s
behaviour during dental treatment. Medications
which are being used, help to increase cooperation

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and to reduce anxiety or discomfort associated with CONCLUSION

dental procedures. Sedative medications cause most Behaviour management is widely agreed to be a key
children to become relaxed and drowsy. Unlike factor supplying dental care for children. Certainly, if a
general anaesthesia, sedation is not intended to make child’s behaviour in the dental surgery/office cannot
a patient unconscious or unresponsive. be managed then it is not easy to hold out any dental
Conscious sedation technique is indicated for care that is needed. A wide variety of behavioural
* Patients who are healthy at the time of the management techniques are available to paediatric
appointment. dentists which must be used as appropriate taking
* Patients who cannot cooperate due to disability or into account cultural, philosophical and legal
immaturity. requirements in the country of dental practice of
* Patients who need care is consistently with the risks every dentist concerned with dental care of children,
of sedation and whose care can be completed in solely for the benefits of the child. This also related
one or two appointments. with an important thing called treatment alliance,
GENERAL ANASTHESIA once if a child or parents are comfortable with the
If toddlers are often very frightened of the dentist this treatment of clinician then they will keep on
technique can be used. Even if they do not actually consulting the same clinician.
feel pain, sounds they hear from the dental drill and
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 ISSN: 2230-7605 (Online); ISSN: 2321-3272 (Print)
Int J Pharm Biol Sci.

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*Corresponding Author:
J Chandrapooja
Email: [email protected]

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