"BEHAVIOUR

MANAGEMENT."
 INTRODUCTION
• Behavioural dentistry is an interdisciplinary science which needs to be
learned, practiced and reinforced.
• The objective is to develop in a dental practitioner an understanding of
interpersonal, intrapersonal, social forces that influence the patients
behaviour.
BEHAVIOUR MANAGEMENT Definition: Wright,
1975

• The means by which the dental health team effectively and efficiently
performs treatment for a child & in the same time instills a positive
dental attitude.
Wright, 1975
BEHAVIOUR SHAPING

• BEHAVIOUR SHAPING:- is the procedure which slowly develops

behaviour by reinforcing a successive approximation of the desired
behaviour until the desired behaviour comes into being.
• BEHAVIOUR MODIFICATION:- is defined as the attempt to alter
human behaviour and emotion in a beneficial way and in accordance
with laws of learning.
TELL SHOW DO,MODELLING
OBJECTIVES OF BEHAVIOUR MANAGANMENT:
• To establish an effective communication with child and parent.
• To gain confidence of child and parent.
• To teach child and parent the positive aspects of preventive dental
care.
• To provide a relaxing and comfortable environment for the dental team
to work in while treating the child.
CLASSIFICATIONS OF CHILD’S BEHAVIOUR
FRANKEL'S CLASSIFICATION(1962) (Frankel's BEHAVIOUR Rating Scale)

• Divided into four categories

a. Rating 1: definitively negative {- -}

Features: Refusal of treatmentCrying forcefullyExtreme negativism
b. Rating 2: negative {–}:
• difficult to accept treatment
• Un co-operative
c. Rating 3: positive {+}:
• Acceptance of treatment.
• Willingness to follow dentists instruction.
• May be hesistant too.
d. Rating 4: Definitely positive{ + +}:
• Good rapport with dentist.
• Will enjoy the procedure.
• ADVANTAGES:Provides doctor with patients history.
• Prepares team to face patient.Is functional scale and easy to learn.
LAMPSHIRE'S CLASSIFICATION(1970)

1. COOPERATIVE
• The child is physically and emotionally relaxed.
• Is cooperative throughout the entire procedure.

2. TENSE COOPERATIVE - The child is tensed, and cooperative at the same time.

3. OUTWARDLY APPREHENSIVE

• Avoids treatment initially

• usually hides behind the mother

• avoid looking or talking to the dentist

• eventually accepts the treatment

4. FEARFUL - requires considerable support so as to overcome the fears of dental treatment.

5. STUBBORN: passively resist treatment by using techniques that have been successful in other situations.

6. HYPER MOTIVE: the child is acutely agitated and resorts to screaming, kicking etc.

7. HANDICAPPED: physically/mentally, emotionally handicapped.

8. EMOTIONALLY IMMATURE:
CLASSIFICATION BY WRIGHT(1975)

• COOPERATIVE (POSITIVE BEHAVIOUR)

• UN-COOPERATIVE (NEGATIVE BEHAVIOUR)

• CO OPERATIVE :

• a) COOPERATIVE BEHAVIOUR: child is cooperative

• LACKING COOPERATIVE ABILITY: usually seen in young child (0-3 yrs.), disabled child,
physical and mental handicap.c)

• POTENTIALLY COOPERATIVE: has the potential to cooperate but because of the inherent fears
(subjective/objective) the does not cooperate.
• a) UNCONTROLLED/HYSTERICAL: usually seen in
UN-COOPERATIVEa) UNCONTROLLED/HYSTERICAL:usually seen inpreschool children
at their first dental visittemper tantrums i.e physical lashing out of legs & arms, loud crying
and refuses to cooperate with the dentistb) DEFIANT/OBSTINATE BEHAVIOUR:can be seen
in any age groupusually in stubborn childrenthese children can be made cooperativec) TENSE
COOPERATIVE:in the borderline between positive and negative BEHAVIOURdoes not resist
the treatment but is tensed at mindSuggestive and immitative fear

• 12 d) TIMID BEHAVIOUR/TIMID:
seen in over protective child at first visitis shy but cooperativee) WHINING TYPE:
complaining type of BEHAVIOUR allows for treatment but complaints through out the
proceduref) STOIC BEHAVIOUR: seen in physically abused children. they are cooperative &
passively accept all treatment without any facial expressions.
BEHAVIOUR MANAGEMENT
NON PHARMACOLOGICAL METHODS OF BEHAVIOUR MANAGEMENT
CLASSIFICATION
1. COMMUNICATION.
2. BEHAVIOUR SHAPING
a.) DESENSITIZATION
b.) MODELLING
c.) CONTINGENCY MANAGEMENT
3. BEHAVIOUR MANAGEMENT
a.) AUDIO ANALGESIA
b.) BIO FEEDBACK
c.) VOICE CONTROL
d.) HYPNOSIS
e.) HUMOUR
f.) COPING
g.) RELAXATION
h.) IMPLOSION THERAPY
i.) AVERSIVE CONDITIONING
HOW TO COMMUNICATE:
• should Be comfortable and relaxed.
Language should contain words that express pleasantness,
friendship and concern.Voice that is used should be constant and
gentle.Tone of voice can express empathy and firmness.Sitting and
speaking at the eye level allows for a friendlier atmosphere

• 16 USES OF EUPHEMISMSEuphemisms are substitute word which

can be used in the presence of children.For e.g.:Anesthetic solution is
referred as water to put the teeth to sleep.Caries is referred as a tooth
bug.Rubber dam as rain coat.Radiograph as tooth picture.Airotor as
whistle.
BEHAVIOURAL SHAPING:
• It is based on the stimulus –response theory and principles of social
learning. The child is taught how to
behave.1.DESENSITIZATION:JOSEPH WOLPE(1975) Used to
remove fears and tension in children who have had previous
unpleasant dental experience or negative BEHAVIOUR.It is an
effective method for reducing a maladaptive BEHAVIOUR.Method
used now a days for modifying the BEHAVIOUR by desensitization in
children is:“TELL SHOW DO TECHNIQUE”
• TELL SHOW DO TECHNIQUE:
ADDLESLON(1959).Tell and show every step and Instrument and
explain what is going to be done.By having verbal (tell) and nonverbal
show and do interactions, available, one can overcome the many small
dental related anxieties of any child.INDICATION:first
visit.subsequent visit when introducing new dental procedure.fearful
child.
• 2.MODELLING: BY BANDURA(1969)
Learning principle procedure involves a patient to observe one
or more individuals who demonstrate a positive behaviour in a
particular situation.MODELLING CAN BE DONE BY:a.) Live
models- siblings,parent of child etc.b.) Filmed modelsc.)
Postersd.) Audiovisual aids.
• 3.CONTIGENCY MANAGEMENT
It is the management of modifying the behaviour of children by
presentation or reinforcers. This reinforcers may can
be:POSITIVE REINFORCERS: Is one whose contingent presentation
increases the frequency of behaviour.NEGATIVE REINFORCERS: Is
one whose contingent withdrawal increases the frequency of
behaviour.In the process of establishing desirable patient behaviour, it
is essential to give appropriate feedback. Positive reinforcement is an
effective technique to reward desired behaviours and thus strengthen
the recurrence of those behaviours.
• TYPES OF REINFORCEMENT:
SOCIAL: for e.g. positive voice modulation, positive facial
expression, shaking hand, verbal praise and appropriate physical
demonstrations of affection by all members of the dental
team.MATERIAL: may be given in the form of
toys,games.ACTIVITY REINFORCERS: involving the child in some
activity like watching TV show
2 BEHAVIOUR MANAGEMENT
• AUDIO ANALGESIA:
Or “white noise” is a method of reducing pain by sound stimulus of such intensity that the
patient finds it difficult to attend to anything else. For e.g. playing pleasant
music.BIOFEEDBACK:Involves the use of certain instruments to detect certain
physiological processes associated with fear.For e.g. if blood pressure is high the instrument
gives stimulation and the subject is taught to control the signals, therefore useful in anxiety
and stress related disorders.

• 23 HUMOR:Helps to elevate the mood of the child, which helps the child to relax.Functions of
humor:Social: forming and maintaining relationship.Emotional: anxiety relief in the child, parent
and doctor.Informative: transmits essential information in a non-threatening way.Motivation: it
increases the interest and involvement of the child.Cognitive: distraction from fearful stimuli.
• COPING:It is defined as the cognitive and behavioural efforts made by an individual to master,
tolerate or reduce stressful situations.TWO TYPES:behavioural:are physical and verbal activities
in child engages to overcome a stressful situationCognitive:The child may be silent and thinking
in his mind to keep clam. Cognitive coping strategies can enable the children to:Maintain realistic
perspective on the events at hand.Perceive the situation as less threatening.Calms and reassures
themselves that everything will be all right.

• 25 VOICE CONTROL:Voice control is a controlled alteration of voice volume, tone, or pace to

influence and direct the patients BEHAVIOUR. Parents unfamiliar with this possibly aversive
technique may benefit from an explanation prior to its use to prevent
misunderstanding.Objectives:Gain the patients attention and compliance.Avert negative or
avoidance BEHAVIOUR.Establish appropriate adult-child roles.Indications: may be used with
any patientContraindications: patients who are hearing impaired.
• RELAXATION:This technique is used to reduce stress and is based on the
principle of elimination of anxiety. Relaxation involves a series of basic
exercise, which may take several months to learn, and which reguire the
patient to practice at home for at least 15 min per day.HYPNOSIS:Hypnosis
is an altered state of consciousness characterized by a heightened
suggestibility to produce desirable behavioural and physiological changes.
When used in dentistry it is known as hypnodontics or psychosomatic.
Benefit: reduce anxiety and painIMPLOSION THEORY:Sudden flooding
with a barage of stimuli which have affected him adversely and the child has
no other choice but to face the stimuli until a negative response disappears.
Implosion therapy mainly consist of HOME, voice control and physical
restraints.
• AVERSIVE CONDITIONING:
Aversive conditioning can be safe and effective method of
managing extremely negative BEHAVIOUR.TWO COMMON
METHODS ARE:HOME (Hand Over Mouth Technique)PHYSICAL
RESTRAINTS.
• HOMEIntroduced by Evangeline Jordan in 1920.INDICATION:A healthy child who
can understand but who exhibits defiance and hysterical BEHAVIOUR during
treatment.3-6 years old.A child who can understand simple verbal
commands.Children displaying uncontrolled
BEHAVIOUR.CONTRAINDICATIONS: Child under 3 years of age.Handicapped
child/immature child, frightened child.Physical, mental and emotional handicap.

• TECHNIQUE:After determining the child the child’s BEHAVIOUR, the dentist

firmly places his hand over the child’s mouth and behavioural expectations are calmly
explained close to the child’s ear.When the child’s verbal outbrust is completely
stopped and the child indicates his willingness to co-operate, the dentist removes his
hand. It should be noted that the child’s airway is not restricted while performing the
technique and the whole procedure should not last for more than seconds.
• PHYSICAL RESTRAINTSRestraints are usually needed for children who are
hyper motive, stubborn or defiant.Physical restraint involve restriction of
movement of child’s head, hand, feet or body.It can be:Active: restraints perform
by the dentist staff or parent without the aid of restraining device.Passive: with
the aid of restraining deviceTYPES OF RESTRAINT:Head positionerForearm
body supportVelcro strapsPosey straps.Towel and tapesPedi wrapPapoose
boardSheetsBeanbag with strapTowel and tapes

• 30 MOUTH:1.mouth block2. banded tongue blade3. mouth props – it is used at

time of local anesthesia . It is used for:- physical/mental handicapped child.-
young child who cannot keep themouth open for long time.- child becoming
fatigues because of long appointments and frequently close his mouth.
• PHARMACOLOGICAL MEANS OF BEHAVIOUR
MANAGEMENT
PHARMACOLOGICAL MEANS OF
BEHAVIOUR MANAGEMENT
• INTRODUCTION
• THE USE OF PHARMACOLOGICAL MEANS HAS MADE DENTAL
TREATMENT ACCEPTABLE TO LARGE EXTENT.THESE
PROCEDURES CAN BE CARRIED OUT IN THE NORMAL
CIRCUMSTANCES WITH THE HELP OF BEHAVIOUR SHAPING
TECHNIQUES .

• PHARMACOLOGICAL MEANS
CLASSIFICATION:-CONCIOUS SEDATION
• DEEP SEDATION
• GENERAL ANAESTHESIA
• DEFINITION(AAPD-1993)CONSCIOUS SEDATION-[SEDATION]A
minimally depressed level of consciousness, that retains the patient’s
ability to maintain an airway independently and respond appropriately
to physical stimulation and verbal command.DEEP SEDATION-A
controlled state of depressed consciousness, accompanied by partial loss
of protective reflexes, including inability to respond purposefully to a
verbal command.GENERAL ANESTHESIA-A controlled state of
unconsciousness, accompanied by partial or complete loss of protective
reflexes, including inability to maintain an airway independently and
respond purposefully to physical stimulation or verbal command.
Contra indicated
Long-term exposure (more then 24 hours) can produce transient
bone marrow depression.

Patient’s inability to perform nasal respiration because of

obstruction from a cold, deviated septum, enlarged adenoids
prevents its use.
PREGNANCY Fetal resorption
- Congenital abnormalities
- Fetal growth retardation
Long surgical procedure
(more then 30 min)
DURING TREATMENT 1.The practitioner should be trained in the use of conscious sedation methods. 2. Two members of the dental team should be present. 3. Blood
pressure, heart, and respiratory rates should be continuously monitored by trained personnel and intermittently recorded. 4.Child’s color should be visually checked,
especially oral mucosa and nailbeds for cyanosis. 5. Head position should be evaluated constantly41 POSTOPERATIVE CARE 1. Vital signs should be recorded at
intervals after the procedure. 2. Discharge of patient should occur only when a vital signs are stable and patient is alert, can talk, and can sit up unaided.
Patient with certain physical, mental, or medically compromising condition.
Patient wherein local anesthesia is not effective or allergic to it.
Fearful, uncooperative, anxious patient with no expectation that behaviour will improve.
Patients who have sustained extensive orofacial trauma.
PREANESTHETIC EVALUATION AND PROCEDURES-APD 1985

Instruction to patients

Preoperative health assessment

Clinical examination

Doctors order

INSTRUCTION TO PARENTS

The practitioner should provide verbal and written instruction to the parents. It should include explanation of potential/ anticipated postoperative behaviour and
limitation of activities along with dietary precautions.

45 PEROPERATIVE HEALTH ASSESMENT It should be done within 2 days prior to procedure to be reviewed at the time of treatment. CLINICAL EXAMINATION
VITAL SIGNS -Pulse and BP to be recorded LABORATORY INVESTIGATION- BLOOD-TC,DC,HB,PS,ESR,HIV,HBS,ELISA. URINE- urea and keratinine.
TEMPERATURE AND BODY WEIGHT CHILD PHYSICIAN- Name and address of child’s physician. DOCTOR’S ORDERS 1. To parents 2. TO ASSISTANT- To inform
the OT, Anesthesian, Pradiatrition. Premedication with a systemic background Patient with subacute bacterial endocarditis and abscess – antibiotic prophylaxis is
needed.
PRE-MEDICATION (in a normal child)
OBJECTIVES
-To block unwanted autonomic reflexes.
-To prevent excessive secretions.
-To produce sedation & allay anxiety.
-To facilitate induction of anesthesia & to supplement & reduce the amount of the same to be administered.
RUGS USED FOR PRE-MEDICATION
D

ANTICHOLINERGICS Atropine Glycopyrrolate SEDATIVES

Benzodiazepines Barbiturates ANTI-EMITICS Hydroxyzine
Metaclopromide
48 SEDATIVE DRUGS & DOSAGE
Chloral Hydrate: mg/kg/dose PO, PR
Clonidine: mg/kg PO (Max 0.1 mg)
Diphenhydramine: mg/kg/dose IV q4-6h;
or 1.25 mg/kg/dose q6h (Max 400 mg/d)
Etomidate: 0.3 mg/kg IV
Haloperidol: mg/dose
Ketamine: 1-2 mg/kg IV;
3-6 mg/kg PO;
6-10mg/kg PR; 3 mg/kg intranasal
Methohexital: 1-2 mg/kg/dose IV;
30-40 mg/kg PR
Midazolam: mg/kg IV, IM;
Infusion: 0.4 mcg/kg/min PO: mg/kg PR: mg/kg Intranasal: 0.2 mg/kg
Pentobarbital: 2 mg/kg IM, IV, PO
Propofol: 2-3 mg/kg IV;
Maintenance: mcg/kg/min
Thiopental: 3-7 mg/kg IV
PR: mg/kg
GUIDELINES FOR USE D BEFORE G A TREATMENT
1. Verbal and written instruction should be given to parents about preoperative and postoperative care.
2. No milk or solid foods should be eaten after midnight before procedure. [NPO]
3. Only clear liquids should be ingested up to 4 to 8 hours before appointment, depending on age.
4. Vital statistics should be recorded (weight and height).
5. Medical history should be completed.
6. Status of airway should be confirmed.
7. Vital signs, including pulse and blood pressure, should be recorded.
POST OPERATIVE PERIOD
Procedure performed should be explained to patient.
The presence of any bleeding from the oral cavity, extra oral
swelling should be checked for.
The patient can de start of with analgesic if pain is present.
The child should be evaluated for the various system like
cardiovascular function.
Any instructions regarding the restorative procedure performed
should be given.
Do not drive an automobile. Bike or use any machinery.
Do not drink any alcohol or take any medicine that is not prescribed by the doctor.
Do not take any complex or legal decision.
Start with liquid and advance to other food.
You feel groggy, dizzy and tired for 24 hours.