Pediatric Dentistry: Non-Pharmacological Behaviour Management

Non-pharmacological Techniques of Behaviour Management

• Non-aversive techniques aim to modify the child's behaviour without causing fear or anxiety.

Behaviour Shaping

• A procedure that develops behaviour by reinforcing successive approximations of the desired behaviour.
• Involve dividing the explanation of the procedure into steps, leading the child through the procedure slowly, and progressing step by step to the goal.
• The time spent on each step depends on the child's behaviour.
• Examples of steps for introducing restorative treatment to an average school-aged child:
  • Examination and prophylaxis
  • Fissure sealant or topical fluoride application
  • Minimal occlusal restoration without local anesthesia
  • Infiltration anesthesia and restoration
  • Inferior dental nerve block and restoration

Tell-Show-Do (TSD)

• A technique used in the educational phase of developing an accepting relaxed child dental patient.
• Involves telling the child about the treatment, showing at least some part of how it will be done, and then doing it.
• Must be followed by praise to ensure smooth continuity through the T-S-D stages.
• Indications:
  • First visit
  • When introducing new dental procedure
  • Fearful child
  • Apprehensive child
• Effective in children more than 3 years of age

Retraining

• For children who display considerable apprehension or negative behaviour due to previous dental visit or improper parental or peer orientation.
• Determine the source of the problem and use a distraction or another technique to retrain the child.
• May be joint with the use of sedation

Modeling

• A technique where individuals learn from observing the consequences of other people's behaviour.
• Models are either live models or videotapes of co-operative patients.
• Better to use same age and sex models to illustrate the rewards for performing appropriately

Reinforcement

• Strengthening a pattern of behaviour that increases the probability of that behaviour being displayed in the future.
• Child's behaviour is a reflection of responses to the rewards and punishment of the environment.
• Positive reinforcement: pleasant consequence follows response.
• Negative reinforcement: withdrawal of unpleasant stimulus after a response.

Distraction

• Attempts to shift attention from the dental setting towards some other kind of situation.
• Distracters, such as cartoons, stories, can be used.

Desensitization

• A three-stage process used to overcome fears:
  • Train the patient to relax
  • Construct a series of fear-producing stimuli related to the patient's principal fear
  • Introduce each stimulus in the series in turn to the relaxed patient, starting with the stimulus that causes least fear

Aversive Techniques

Voice Control

• A controlled alteration of voice volume, tone, or speed to influence and direct the patient's behaviour.
• Objectives:
  • Gain the patient's attention and compliance
  • Avert negative or avoidance behaviour
  • Establish appropriate adult-child roles

Hand Over Mouth (HOM)

• An aversive behaviour modification technique used to modify a negative child's behaviour.
• Should not last for more than 20-30 seconds.
• Must be paired with voice control.
• Indication: normal child exhibits defiant or hysterical behaviour.
• Contraindication: disabled, immature, and medicated children whose understanding of the situation is compromised.

Physical Restraint

• Protective stabilization of the patient is sometimes necessary to diagnose and deliver dental care.
• Indications:
  • Patient requires immediate diagnosis and/or limited treatment and cannot cooperate due to lack of maturity or mental or physical disability.
  • Patient requires diagnosis or treatment and does not cooperate after other behaviour management techniques have failed.
  • Safety of the patient, staff, parent, or practitioner would be at risk without the use of protective stabilization.
• Contraindications:
  • Cooperative non-sedated patient
  • Patients who cannot be safely stabilized due to medical or physical conditions
  • Patients who have experienced previous physical or psychological trauma from protective stabilization (unless no other alternatives are available)
  • Non-sedated patients with non-emergent treatment requiring lengthy appointments.

Mechanical Aids and Protective Stabilization Devices

• Common mechanical aids for maintaining the mouth in an open position:
  • Wrapped tongue blades
  • Open Wide
  • Molt Mouth Prop
  • Rubber bite blocks
• Common protective stabilization devices:
  • Papoose Board
  • Triangular sheet
  • Pedi-Wrap
  • Body straps
  • Velcro straps
  • Towel and tape
  • Extra assistant
  • Head positioner
  • Plastic bowl
  • Extra assistant