Non pharmacological behaviour

management

Contents
Part I Introduction
Age related behaviour patterns of child
Emotional development
Common emotions of a child

 Anxiety rating scales

Classification of child according to behaviour patterns
Factors affecting childs behaviour in dental office
Maternal influences on childs behaviour in dental office.

Learning objectives
At the end of the seminar the listener should be able to
Describe the Age related behaviour patterns of child
Describe the emotional development & Common emotions of
a child
Should know anxiety rating scales and should be able to

classify child according to behaviour patterns

Introduction
Behavioural pediatric dentistry is described as the science that
understands the development of fear, anxiety and anger of a child in
a dental clinic.
The behaviour of a child cannot be dictated, the pedodontist can try
to understand, analyse and manipulate it with few strategic
techniques.
The technical skills of a pedodontist and his ability to acquire and
maintain the cooperation of child decide the success of dental
treatment delivered to the child.

Definitions
Behavior
Any activity that can be observed recorded or measured.
It is an observable act or any change in the functioning of an
organism.

Behavior management (Wright 1975)

Means by which the dental health team effectively and
efficiently performs dental treatment and thereby instills a
positive dental attitude.

 Behavior shaping
Procedure which slowly develops behavior by reinforcing a
successive approximation of the desired behavior until the
desired behavior comes into being.

Behavior modification
The attempt to alter human behavior and emotion in a
beneficial way and in accordance with the laws of learning.

 Behavior guidance
Continuum of interaction involving the dentist, the dental
team, the patient and the parent directed towards
communication and education which ultimately build trust
and alloys fear and anxiety.

Behavioral pedodontics
Study of science that helps to understand development of fear,
anxiety, anger and associated acts as it applies to child in the
dental situation.

 Pediatric treatment triangle

Age-related psychosocial traits and skills for

2 to 5 year old children
Two years

Geared to gross motor skills

Likes to see and touch
Very attached to parent
Plays alone; rarely shares
Has limited vocabulary; shows early sentence formation
Becoming interested in self-help skills.

 Three years
Less egocentric; likes to please
Has very active imagination
Remains closely attached to parent

Four years

Tries to impose powers

Participates in small social groups
Shows many independent self-help skills
Knows thank you and please

 5 years

Undergoes a period of consolidation, deliberate

Takes pride in possessions
Relinquishes comfort objects such as blanket and thumb
Plays cooperatively with peers.

 6 12 years

Learns about the outside world

Develop a close circle of friends
Independent of parents and peer group influence is more
Potential to resolve fears regarding the dental situations
Tolerance towards unpleasant situation is increased

Emotional development
Emotion is a state of mental excitement characterised by
physiological, behavioral changes and alteration of
feelings.
Elements physiological, cognitive, cultural

Physiology of emotion
Development of emotions depends on maturation
Nervous
endocrine system.

Differences in emotional responsiveness

children and adults appear to be due to
Cortical immaturity
Difference in endocrine output

between

 At birth
Cortex development is completed
Frontal lobe is immature
Has little influence on functions of the lower parts of brain
resulting in unbalanced emotions

 In 2-5 years and 11-12 years

Adrenal glands gain weight rapidly
Liberation of adrenaline in blood is vigorous
As a result preschooler is highly emotional and emotional
outbursts are prolonged too
Giving rise to physiological signs of emotional disturbance.

 As emotion subsides, parasympathetic energy-conserving

system takes over and returns the organisation to normal.
Hypothalamus and other parts in nervous system directly
influence muscles and internal organs to initiate body
changes.
Indirectly stimulating adrenal hormones to other body
changes and preparing the body for fight or flight response

Theories of emotion

Commonly seen emotions in a child

Cry

Cry or distress
Defined as a multimodal behaviour consisting of tears, nonverbal vocalization(wails, sobs) and facial expressions of
distress
At birth
Primary emotion present at
birth with vigorous body expressions.

 At 6 months
Greatly replaced by a milder
expression of fussing or vocalization

During preschool
Only for the reasons of physical pain

 During school years

Pressure helps him to outgrow crying
habit which decreases rapidly.

In young adult
Limited quiet crying in private only for
reason of grief or other intense
emotions.

Different types of cries seen in children

Obstinate cry

Throws temper tantrum to thwart dental treatment

Loud, high-pitched
Characterized as a siren like wail
This form a belligerent cry, represents the childs external
response to anxiety

 Frightened cry
Accompanied by a torrent of tears
Convulsive breath-catching sobs
Usually the child emitting this type of cry has been
overwhelmed by the situation

Hurt cry
Frequently accompanied by a small whimper

 Compensatory cry

Not a cry
Sound that child makes to drown out the noise
Cry sound is slow, monotone
Sort of coping mechanism to unpleasant auditory stimuli,
finding himself uncomfortable in the situation

Anger
Outburst of the emotion is caused by the
childs lack of skill in handling situation
Infants and young children respond in anger in a direct and
primitive manner
As they develop the responses become violent and more
symbolic

 15 months by throwing objects

2 years attack other children with an intention to hurt
4 years through begging
5 years less expression of anger
6 years renewal of violent methods of expression of anger

 7 years displays less aggressiveness, though kicking,

throwing objects is observed

8-9 years through feelings

10 years become violent , may be expressed physically.
12 years express verbally
14 years may take out his anger on someone else

Fear
Reaction to the known danger
Defined as an unpleasant emotion or effect
consisting of pshychophysiological changes
in response to realistic threat or danger to
ones own experience.

Development of fear
Birth to 2yrs
Primary response at birth
With age becomes aware of fear producing stimuli

 Pre-schooler(2-5years)
Fear of animals or being left alone
More apprehensive about failures

Early schooler
Fear of the dark, staying alone
Fear of supernatural powers like ghosts and witches,
imaginary objects and situations such as fear of war, spies,
beggars.

 Late schooler
Fear of bodily injury
Fear of failure, not being liked, competition, fear of
punishment

Adolescent
Fear of social rejection and fear of performance

Fear of dental situation

Innate fear
Without stimuli or previous experience
Also dependent on the vulnerability of an individual

 Objective fear
Acquired objectively or
Produced by direct physical stimulation of the sense organs,
but not of parental origin
Fears from previous unpleasant contact with dentistry
Unrelated experiences

 Subjective fears
Based on the feelings and attitudes suggested to child by
others without the child personally experiencing them.
May be due to family experiences, peer, information media.
These are
imaginative
Suggestive
Imitative

Significance of fear
Protective mechanism
Keeps the child away from dangerous situation
Fear of being punished or parental disappointment is an
important factor that reinforces discipline in a child
Fear should never be eradicated
Rather should be channalized towards situations, where
danger really lies.

Fear in dental office

Lowers the pain threshold
Hence any discomfort or pain produced by any procedure is
magnified
Fear towards dental clinic should be eliminated by proper
counseling
Dental clinic or procedure should never be used as a threat or
punishment.

Fear assessments
The childrens dental fear picture test (Klingberg, 1994)
A sentence completion task

 The pointing pictures

Contains a set of five pictures showing a human child in 5
different dentally related situations

Just before going to the dentist

The dentist examining the mouth
The dentist giving an injection
The dentist drilling
Lying in bed about to fall asleep/dreaming about dentists

 A sentence completion task Contains 15 incomplete sentences, which are read to the child
consecutively
The child is instructed to complete the sentences by saving the
first word or words that come to the mind.

Anxiety
Defined as a state of unpleasant
feeling combined with an associated
feeling of impending danger from
within.
Learned process being in response to
ones environment.
Develops later than fear

 Types of anxiety
Trait anxiety
Life-long pattern of anxiety as a temperament feature
Children are generally jittery, skittish and hypersensitive to
stimuli
State anxiety
Acute situational-bound episodes of anxiety
Do not persist beyond the provoking situation

 Free floating anxiety

Condition of persistently anxious mood
Cause of emotion is unknown
Situational anxiety
Seen in specific situations
General anxiety
Chronic pervasive feeling of anxiousness, whatever may be the
external circumstances

Anxiety rating scales

The childrens fear survey schedule dental subscale (CFSSDS)
Dental fear schedule subscale short form (DFSS-SF)
Dental anxiety scale (DAS) and modified DAS
Modified child dental anxiety scale (MCDAS)

 Facial image scale (FIS)

Venham picture scale (VPS)
Dental fear survey (DFS, 20-item version) and modified
version of the DFS
Smiley faces programme (SFP)

The childrens fear survey schedule dental

subscale (CFSS-DS)
Dental-specific measure that
requires children to rate how
frightened they are in
response to 15 dental-related
situations/ treatments.

Dental fear schedule subscale (DFSS-SF)

The measure is a shorter version of the CFSS-DS measure
containing eight items and asks children to rate how
frightened they would feel in response to eight specific dentalrelated situations/treatments.
Advantages - the reduced number of items
items which are not highly relevant to dentistry (e.g. doctors)
have been removed from this shortened questionnaire.

Dental anxiety scale (DAS)

Modified dental anxiety scale(MDAS)

Modified child dental anxiety scale (MCDAS)

Contains eight questions, four of which are based on the
original DAS.
The additional anxiety-provoking dental situations assessed
by the MCDAS include dental injections, general anaesthesia,
extraction and sedation.

Facial image scale (FIS)

The FIS comprises one item with a response set of five faces
(ranging from a very sad to a very smiley face)
Children are asked to indicate which of the faces they feel
most like at that moment
Thus, it is a state measure of anxiety.

Venham picture scale (VPS)

The VPS is a pictorial measure of
dental anxiety
Incorporates eight pictures with
each depicting two cartoon boys
displaying contrasting emotions.
The participant is required to
indicate which of the boys, within
the eight pictures, most accurately
reflect their feelings at that time.

Dental fear survey and modified version of the

DFS
The Dental Fear Survey was originally a 27-item questionnaire
Was later revised to a 20-item measure of dental anxiety
Used to assess childrens responses to a variety of dental
situations and general fear of dentistry.

Smiley faces programme

A computerised measure of dental anxiety called the Smiley
Faces Program has been developed (Buchanan, 2005).
For each of the four stimulus scenarios is followed by a set of
seven faces to select from:

Phobia
Defined as a persistent,
excessive, unreasonable fear of
specific feared object, activity or
situation that results in a
compelling desire to avoid the
dreaded object.

 Characteristics
Being out of proportion to the stimulus or situation
Cannot be reasoned with
Being out of voluntary control
Persistent and inadequate

 Types(Shehan 1982)
Exogenous

 Other causes
Simple phobia
Isolated fear of a single object or
situation leading to avoidance of the
object or the situation
Situational phobia
Popularly interpreted as fear of open
space
Usually refers to cluster of complaints

 Social phobia
Phobia due to fear of being looked
at and the concern about appearing
shameful or stupid in presence of
others.
Types public speaking, fear of
eating, fear of blushing

Phobia in childhood
Fear of animals
Phobia of darkness
School phobia
In 12 years children of both sexes,
previous
aversive
dental
experiences are more closely
related to dental phobia than
general fear.
Adolescents fear of being
looked at.

Classification of behaviour
Wilsons classification of child behaviour
Behaviour

Description

Attitude toward dental

treatment

Normal or bold

Child is confident to Cooperative and friendly

face new situations

Tasteful or timid

Shy

Allows dental treatment

without interruption

Hysterical or rebellious

Rebellious

Unacceptable behaviour
temper tantrums

Nervous or fearful

Tense & anxious

Interrupts
treatment

dental

 Frankels behavior rating scale

Rating

Behaviour

1. Definitely negative(--)

Refuses treatment, cries forcefully,

negative behaviour associated with fear

2. Negative(-)

Reluctant to accept treatment

evidence of slight negativism

3. Positive(+)

Accepts treatment, but if the child has a bad

experience during treatment, may become
uncooperative

4. Definitely positive(++)

Unique behaviour, looks forward to & understands

the importance of good preventive care

and

extremely
displays

 Lampshire
Behaviour

Description

Cooperative

Emotionally & physically relaxed child

Tense cooperative

Emotionally anxious & tense

Outwardly apprehensive

May hide behind parents or avoid talking to the

dentist initially

Fearful

Child is unable to concentrate on the situation or

communicate receptively

Stubborn/defiant

Child does not want to cooperate and firmly resist

establishment of communication

Behaviour

Description

Hypermotive

Anxiety of the child is expressed as a fear of

impending death and associated with violent
movement of extremities

Handicapped

A physically challenged child can be treated as

any other child. A mentally handicapped child
needs special care

Emotionally immature

Very young child not able to follow instructions

 Wright
Cooperative (positive behaviour)
1. Cooperative behaviour
child is cooperative, relaxed with minimal apprehension
2. Lacking cooperative ability
usually seen in young child(0-3yrs), disabled child, physical
and mental handicap.
3. Potentially cooperative
has the potential to cooperate, but because of inherent fears
the child does not cooperate

 Uncooperative (negative behaviour)

1. Uncontrolled/hysterical/incorrigable
Preschool children at their first dental visit
Temper tantrums

2. Defiant/obstinate
Can be seen in any age group
Usually in spoilt and stubborn children
Can be made cooperative

3. Tense cooperative
Borderline between positive and negative behaviour
Does not resist treatment but the child is tensed at mind

4. Timid/shy
Seen in overprotective child at first dental visit
Shy but cooperative

5. Whining type
Complaining type of behaviour

6. Stotic behviour
Seen in physically abused children
.

 Garcia-Godoy
1. Fearful resist entering treatment room, cries, screams.
2. Timid enters treatment cautiously, thoughtful with eyes on
floor.

3. Spoiled enters clinic with arrogant and proud behaviour,

neglects treatment and states preferences on treatment.

 Aggressive screams, does not open the mouth, kicks. Sits on

dental chair and neglects treatment.
Adopted combination of spoiled and fearful behaviour.
Could present with timid characteristics.
Handicapped will need special care and this will manifest in
behaviour
Cooperative cooperate with treatment

Factors affecting childs behaviour in

dental office
Under the control of
dentist

Out of control of the

dentist

Under the control of

parents

Effect of dental office

environment

Growth and development

Home environment

Effect of dentists activity

and attitude

Nutritional factors

Family development &

peer influence

Dentists attire

Past dental experiences

Maternal behaviour

Presence/absence of
parents in the operatory

genetics

Presence of an older
sibling

School environment
Socioeconomic status

Under the control of the dentist

Dental clinic
Should be warm and simulate a homely environment.
Operating environment should be made colorful and lively
with posters
TV and videogames for children and a separate waiting room
which should contain toys, story books and comics
Dental auxillary should be kind to children

 Appointment should always be short i.e not more than 30

mins.
Early morning appointments
No long appointments
Preparation by use of telephone/letter/pamphlets

 Effects of dentists activity and attitude

methods

Features

Outcome

Data gathering &

observation

Collecting data about the child and

parents through questionnaire
Keen observation of the child as he
steps into the dental clinic

Helps to judge the

behaviour expected

Structuring

Preparing by explaining the procedure Child knows what to

Establishing guidelines
expect and how to react

Externalization

Childs attention is focused away from Reduces fear and anxiety

the sensation associated with the
treatment by distraction or involvement

Empathy & support

Allowing the child to express his

feelings and reassuring

Gains confidence

Flexible authority

Compromises made by the dentist to

meet the needs of the patient

Gains trust and

confidence

Education &
training

Educating the parent and patient on

the need for maintaining good oral
health

Motivates the patient

 Effect of dentists attire

Previous unpleasant experience - mere presence of white
clothed individual will be sufficient to evoke a negative
behaviour

Presence or absence of parents in the operatory

Mothers presence is essential for preschool child,
handicapped child.
An older child does not require mothers presence
Dentists are usually relaxed and comfortable when the parents
are in the reception room

 Presence of an older sibling

Older sibling serves as a role model in a dental situation

Depends on the age of the patient
Little effect on the behaviour of a 3 year old patient
Most noticeable effect among 4 year old patient
No effect on a 5 year old patient

Out of control of the dentist

Growth and development
Deficiency in physical growth and development or congenital
malformations leads to psychological trauma due to rejection
by the society.
Mental retardation, epilepsy, cerebral palsy failure of
cognitive development and therefore variations in the
behaviour are encountered.

 Nutritional factors
Skipping breakfast can lead to an impaired performance

Past medical and dental history

Past unpleasant dental experience, prior hospitalization,
surgical intervention, sickness are associated with high degree
of uncooperative behaviour.

 School environment
In the school, teachers and peers help to influence the
behaviour of the younger children
Seniors become role models to the juniors

Socioeconomic status
High socioeconomic status child develops normally
This child may also become spoilt
Low socioeconomic status child develops resentment and is
tensed.
Directly affects the childs attitude towards the value of dental
health

Under the control of the parents

Home environment
All the home individuals influence the childs behaviour but
none so much as the mother
One-tailed relationship
Postnatal behaviour of child depends on the prenatal status of
mother.

 Family development and peer influence

Position of the child, status of the child in the family, parental
attitudes can influence the childs behaviour
Overindulgence by parents spoilt children
Younger child follows the model of the older siblings.

 Maternal behaviour
Maternal influence begins even before birth
Somatic development nutritional status of mother
Neurohormonal system of mother transfers emotion to the
fetus
Postnatal behaviour of the child is linked to prenatal
emotional status of the mother

Maternal influences on personality

development

 Overprotective mother
Close relationship between the
mother and child
Exaggeration of this love and affection
leads to overprotection
Harmful to the normal psychological
development of the child

 Features
Child is not permitted to use his own initiative
or make decisions for himself
Mother takes active part in his social activities
Child is submissive, anxious, shy and fears new situations
Cooperative but difficult to create a good rapport.
Polite, obedient, disciplined

 Overprotective-overindulgent mother
Features of the child
Aggressive, demanding, displays temper tantrums
Expect constant attention and services
Obstinate, stubborn, spoilt
Dominate over the dentist and are demanding
Well behaved and well adjusted but difficult to establish a
good rapport.

 Underaffectionate mother
Features
Well behaved and well adjusted
Shy and difficult to establish good rapport
May be uncooperative to dental treatment
Through affection & love the child may be made to respond

 Rejecting mother
Features
Over reactive, revolting, aggressive, disobedient
Tries to gain attention of other by showing overt behaviour
Constantly criticized, nagged, torture
with displays of displeasure.
Lack of self-esteem
Most difficult to deal in the clinic

 Authoritarian mother
Features Submission with resentment and
later evasion
Evasive, dawdling child, obeys
command slowly and with delay
Parents are not supportive to child
and often criticize them
Heightened avoidance gradient and seek to evade or delay the
response.

Mothers
behavior

Childs behavior

Over protective
dominant

Submissive, shy
anxious

Overindulgent

Aggressive, demanding;
displays temper tantrums

Under
affectionate

Usually well behaved, but

may be unable to cooperate:
shy, may cry easily

Rejecting
Authoritarian

Aggressive, overactive,
disobedient
Evasive & dawdling

Effect of maternal anxiety

Attitudes and experiences of ones family towards dentistry
seem to be the most important factor in determining how an
individual will react to dentistry.
People who come to the dentist conditioned to reponse with
tension and fear do so chiefly because of the way dentistry is
presented to them at home.
The mothers reaction to dental treatment has a profound
influence on the childs attitude towards dentistry.

Conclusion
Emotional expressiveness through bodily movements, facial
expressions and vocalizations are within a human being.
Home environment is an important factor in development of a
childs personality
Pattern of mother- child relationship during early childhood
exerts a profound influence on the development of personality
of a child

References
Dentistry for the child & adolescent , Mc Donalds
Management of Children in Dental Office- Louis Ripa
Child Behaviour in dental Office Wright
Textbook of pedodontics Shobha Tandon

 Illustrated paediatric dentistry, PR Chokalingam

Manual of paediatric dentistry, Sridhar Premkumar
Assessing childrens dental anxiety: a systematic review of
Current measures Community Dent Oral Epidemiol 2013; 41;
130142

Questions
Discuss step by step management of a 7 year old child with a
previous painful dental experience.(RGUHS, Oct 2008)

Non pharmacological behaviour

management

Contents
Pre-appointment behaviour modification
First dental visit
Techniques for non pharmacological behaviour management

Learning objectives
At the end of the seminar the listener should be able to
describe
Methods for pre-appointment behaviour modification in child
First dental visit
Various techniques for behaviour management in children.

Emotional development
Early infancy (birth to 6 months)
Between six and ten weeks, a social smile emerges.
As infants become more aware of their environment, smiling
occurs in response to a wider variety of contexts.
Laughter, which begins at around three or four months,
requires a level of cognitive development.

Child and Adolescent Development - WILLIAM DAMON

 Late infancy (7 12 months)

During the last half of the first year, infants begin
expressing fear, disgust, and anger because of the maturation
of cognitive abilities.
Anger, often expressed by crying, is a frequent emotion
expressed by infants.
Fear also emerges during this stage as children become able to
compare an unfamiliar event with what they know

 One of the most common is the presence of an adult stranger,

a fear that begins to appear at about seven months.
A second fear of this stage is called separation anxiety

 Toddlers (1-2 years)

During the second year, infants express emotions of shame or
embarrassment and pride.
These emotions mature in all children and adults contribute to
their development.
During this stage of development, toddlers acquire language
and are learning to verbally express their feelings.

 Preschoolers(3-6years)
Children's capacity to regulate their emotional behavior
continues to advance during this stage of development.
Parents help preschoolers acquire skills to cope with negative
emotional states by teaching and modeling, use of verbal
reasoning and explanation.
Beginning at about age four, children acquire the ability to
alter their emotional expressions

 Beginning at about age four or five, children develop a more

sophisticated understanding of others emotional states

 Middle childhood years (7-11 years)

Children ages seven to eleven display a wider variety of selfregulation skills.
Sophistication in understanding and enacting cultural display
rules has increased dramatically by this stage, such that by
now children begin to know when to control emotional
expressivity
Children at this age also demonstrate that they possess
rudimentary cognitive and behavioral coping skills that serve
to lessen the impact of an emotional event

 Adolescence years (12 18 years)

Adolescents have become sophisticated at regulating their
emotions.
They have developed a wide vocabulary with which to discuss,
and thus influence, emotional states of themselves and others.
Acute self-awareness and self-consciousness as they try to
blend into the dominant social structure.

Introduction
Behaviour management techniques in pediatric dentistry are
directed towards the goals of communication and education.
The relationship between the dentist and the child is built
through a dynamic process of dialogue, facial expression and
voice tone.
The goals of behaviour management are to achieve good
dental health in the child and to help develop the childs
positive attitude towards dental health

Definition
Behavior management (Wright 1975)
Means by which the dental health team effectively and
efficiently performs dental treatment and thereby instills a
positive dental attitude.

Behavior shaping
Procedure which slowly develops behavior by reinforcing a
successive approximation of the desired behavior until the
desired behavior comes into being.

 Behavior modification
The attempt to alter human behavior and emotion in a
beneficial way and in accordance with the laws of learning.

Goals
To establish a proper communication with the child and the
parent
Deliver quality dental care
To alleviate anxiety and fear
To impart a positive attitude in the child and the parents
towards maintaining good oral health

Fundamentals of behaviour management

Positive approach

Positive statements are more effective

with children

Team attitude

A friendly and caring attitude of entire

team has a positive effect on the
childs behaviour

Organization

Organized treatment plan and

execution

Truthfulness

Important for building the basic trust

Tolerance

Rationally cope up with the childs

misbehaviour

Flexibility

In all aspects from treatment positions

to treatment execution

Preappointment behavior modification

Anything that is said or done to positively influence childs
behaviour before the child enters a dental operatory.
Prepares the pediatric patient and eases the introduction to
dentistry.
Crucial in formation of childs attitude towards dentistry

 METHODS
Films, video tapes developed to provide model for a young
patient
Live patient models- siblings, other children, parents
Preappointment parental education via mailings, prerecorded
messages or customized web pages
Letters & pamphlets

 The pre appointment letter reduced mother's anxiety about the

child's first dental visit (Wright and co-workers).
Effects of pre appointment preparation on maternal anxiety and
child behavior (Pinkham and Fields)
lower anxiety scores for mothers who participated in the
preoperative preparation program compared to mothers who did
not.
no significant difference between the behavior of the participating
and the nonparticipating children at their first visits.

120

First dental visit

A smooth first appointment with no unpleasant experiences ,
makes the child positive towards dental care
Childs first dental visit be made no later than three to four
years of age.
The child should be warmly greeted and attended to by the
receptionist and members of the dental team.

 The clinic environment should reduce the anxiety of the child

for the effectiveness of the first dental visit.
Communication with the child should be emphasised for the
following reasons
To understand the childs baseline anxiety
To develop trust in the childs mind
To reduce fear and anxiety

Procedures that may be done at the

first dental visit

Procedures to be avoided at the

first dental visit

clinical examination

Restorations of dentinal lesions

Radiographical examination

Endodontic procedures

Oral prophylaxis

Extractions

Sealant application
Fluoride application
Restoration of enamel carious lesion
Rubberdam application

Children reaction towards sequential visit

Behavior of approximately 60% to 65% of the 61 children

remained unchanged as care progressed from the examination
to the restorative phase of treatment

App 20% - deterioration in behavior

20% showed improvement (Koenigsberg and Johnson, 1975)

125

Non-pharmacological methods of
behaviour management
1. Communication
2. Behavior shaping(modification)

Desensitization
Modelling
Contingency management

3. Behavior management
Audio analgesia
Biofeedback
Voice control
Hypnosis
Humor
Coping
Relaxation
Implosion therapy
Aversive conditioning

Communication
Imparting or exchanging thoughts, opinions or information
Primary strategy of behaviour management
Multisensory process
A thorough understanding of the childs cognitive
development and vocabulary is necessary to effectively
communicate with the child.

 Verbal communication
Ideal approach for children more than
3 years of age.
Gentle and constant voice
Tone firm and express empathy and support
The words and expressions should be comfortably understood
by the child.

 Used of euphemism or word substitutes can influence the

behaviour
Dental terminology

Word substitute

Rubber dam

Rain coat

Rubber dam clamp

Tooth button

Sealant

Tooth paint

Topical fluoride gel

Tooth fighter

Air syringe

Wind gum

Suction

Vaccum cleaner

Study models

Statues

Alginate

Pudding

 Non-verbal communication
Eye-to-eye
Physical
Facial
Voice
quality
expression
contact
contact

Behavior Shaping

It is a procedure which slowly develops behavior by

reinforcing successive approximation of the desired behavior
until the desired behavior comes into being .

Desensitization
Introduced by joseph wolpe in 1975
Works on the principle of classical conditioning
Employed in dental clinic to remove fears and tensions in
children who have had previous unpleasant experience.

 Procedure -

 Dentally fearful patients completing a systematic

desensitization programme showed greater fear reduction and
an improvement in mood after receiving dental treatment
compared to those patients pre-medicated with diazepam
prior to dental treatment
Hakeberg and colleagues
The process of exposure can be further systematized by using
video-based exposure.
A computer-based systematic desensitization programme
named CARL (Computer-Assisted Relaxation Learning) has
been developed to help reduce fear of dental injections.

Tell show do
Closely related to desensitization
Introduced by Addlestone in 1959
Behaviour shaping technique and should be employed in all
patients in the first visit and the subsequent visits for
explaining a new procedure.

 Objectives
To allow the child to learn about and understand dental
procedures in a way that minimises anxiety.

Used with rewards, to gradually shape the childs behaviour

towards acceptance of more invasive procedures.

 Indications May be used with all patients.

Can be used to deal with pre-existing anxieties and fears

With patients facing dentistry for the first time.

Effective in children more than 3 years of age

Modelling
Introduced by Bandura in 1969
Encompasses the principle of his observational learning
Works on the principle that when a child is allowed to observe
one or more individuals who demonstrates a positive
behaviour in a particular situation, the child imitates the
model when placed in a similar situation.

 Stages of modelling
1. Acquisition
The child observes the behaviour of the model and tries to
imitate him under similar circumstances
Basic requirements attention, retention, reinforcement,
motivation.

2. Performance
Reproduction of the behaviour of the model

 Advantages
Reduces the anxiety and improves the behaviour of an
apprehensive child.
Extinction of fear
No additional equipment or alterations in the dental routine
are required

 Audiovisual modeling resulted in highly significant reduction

of fear toward dentists, doctors in general, injections, being
looked at, the sight, sounds, and act of the dentist drilling, and
having the nurse clean their teeth.
The reduction of fear may be due to the observation of a
filmed model who depicted positive behavior during dental
treatment .
Exposure to the modeling film may have familiarized the
children to the sights, sounds, and procedures that they will be
subjected to.

Childs dental fear: Influence of audiovisual modeling

Journal of Indian Society of Pedodontics and Preventive Dentistry | Oct-Dec
2013 | Vol 31| Issue 4 |

Contingency management
A method of modifying the behavior of children by
presentation or withdrawal of reinforcers
Uses principle of operant conditioning

 Positive reinforcement
The contingent presentation increases the frequency of
behaviour
The reinforcer or a pleasant stimuli is presented after a dental
procedure if the behaviour of the patient is acceptable.

Negative reinforcement
Withdrawing an aversive stimuli reinforces a positive
behaviour.

Social

 Objectives
- To strengthen desired behaviours.

Indications.
- Can be used with all patients

Behaviour management
The means by which the dental health team effectively and
efficiently performs treatment for a child and at the same
time instills a positive dental attitude.(Wright,1975)

Audio analgesia
Audioanalgesia or white noise is a method
of reducing pain and associated stress by a
sound stimulus.
The intensity of the sound is so high that the patient finds it
difficult to listen to anything else.
It works on the principle of distraction or displacement of
attention from the source of stress

 The effect seems to result from stimulus distraction,

displacement of attention, and a positive feeling on the part of
the dentist that it can help.
Completely effective in 65% of 1,000 patients who previously
required nitrous oxide or local anesthetics to accomplish
comparable procedures (Gardner et al )
Effective in 76% of 1,200 dental patients during cavity
preparation or scaling of teeth. In addition, extractions were
performed on 115 children and 200 adults' with the aid of
topical anesthesia and audioanalgesia (Schermer)

Distraction
A technique of shifting the attention of the anxious patient
away from the anxiety-provoking stimulus.
Distraction is probably most effective when anxiety is mild.
Several types of distraction have been reported in the
literature, including the use of video-taped cartoons,
audiotaped stories and video games

Non-Pharmacological Approaches to Behaviour Management in

Children, Dent Update 2013; 30: 194199

 Techniques for distraction include the use music, brief

relaxation, storytelling, audio
presentation through
headphones or audiovisual story presentation on television,
and presentation of videotaped material or a video game.
More recently the use of audiovisual video eyeglasses have
been introduced as promising techniques.
AVD using eyeglasses facilitates cooperative behavior and
achieves a high level of patient satisfaction for most children
(Diana et al)

Audiovisual video eyeglass distraction during dental treatment in children

Quintessence Int 2010;41:673679

Biofeedback
System that obtains signals from physiological functions such
as electromyographic activity, heart rate and blood pressure.
The system intimates any increase in anxiety, stress,
discomfort and pain.
The responses are intimated to the dentist as a visual or
auditory signal.
The dentist in turn reassures the patient and helps in reducing
the anxiety of the patient

 Beneficial effects of biofeedback were reported in the

reduction of bruxism (Feehan and Marsh 1989), and
myofascial pain of temporomandibular joint (Scott and Gregg
1980)
Encouraging results in the application of biofeedback in
paediatric dentistry
The children are taught to recognise the symptoms of anxiety
and are told to respond with techniques that reduce arousal
like breathing exercises, guided imagery and various other
relaxation methods.

Disadvantages
It is labour intensive

Requires motivation and multiple reinforcements

Requires complex cognitive processing and sustained

attention that may be beyond the abilities of younger children.

The equipment used is not cost-effective

Eur Arch Paediatr Dent (2014) 15:97103

Voice control
Controlled alteration of voice volume, tone or pace to
influence and direct the patients behaviour.
Used in children of 3-6 years who cries loudly
Done when the child is uncontrollable and other forms of
communicative management cannot be employed.
The intensity and pitch of the voice is modified as an attempt
to dominate the interaction between the dentist and the child

 Voice control - a therapeutic punishment procedure

Greenbaum et al (1990)
When used contingent upon a childs disruptive behaviour, it
suppressed that behaviour very effectively, within two seconds,
and the effect lasted throughout the two-minute period of
observation.
Modulation of tone can be equally effective in encouraging a
particular behaviour, as weakening or eliminating a behaviour
May be less accepted by parents due to aggressive tone

Parental acceptance of pediatric behavior management techniques

Journal of Indian Society of Pedodontics and Preventive Dentistry, Vol. 30, No. 3, JulySeptember, 2012

 Objectives
To avert the negative behaviour
Gain the attention of the child

Hypnosis
An altered state of consciousness characterized by a
heightened suggestibility to produce desirable behavioural and
physiological changes.
When used in dentistry, it can be termed as hypnodontics
(Richardson 1980) or psychosomatic or suggestion therapy.
One of the most effective non-pharmacological therapies that
can be used with children for a number of different procedures
(Ramanson 1981)

 Hypnosis can control some of the patients negative responses

to dental treatment, such as movement and behaviour during
administration of LA (Braithwaite 2005)
Hypnosis is the most promising intervention which help
children by reducing the pain and distress that accompany
needle-related procedures (Uman 2006)
Hypnosis is probably most effective in those patients who are
willing to co-operate with treatment (Kent and Croucher )

Hypnosis for children undergoing dental treatment (Review), The Cochrane

Library2010, Issue 8

Humor
Helps to elevate the mood of the child which in turn helps the
child to relax
Functions: Social : Forming and maintaining relationship
Emotional: Anxiety relief in the child
Information : Transmission of essential information in a
non threatening way
Motivation: Increases the interest and involvement of
the child
Cognitive: Distraction from fearful stimuli

Coping
It is defined as the cognitive and behavioral efforts made by an
individual to master, tolerate or reduce stressful situations
(Lazaue 1980)
Types :
Behavioral :
Physical & verbal activities in which the child engages to over
come a stressful situation
Cognitive :
Child may be silent & thinking in his mind to keep calm

 Signal system
Generally used as a part of coping
The child is asked to raise his hand when it hurts
(Musslemann, 1991)
Normal coping mechanisms utilized by dentists to reduce pain
and tension are friendliness, support & reassurance

Relaxation
Effective in reducing anxiety & fear
Involves series of basic exercises which may take several
months to learn & practice
Which patient requires to practice at home for atleast 15
mins
per day

Implosion therapy
Sudden flooding with a barrage of stimuli which have affected
him adversely & the child has no other choice but to face the
stimuli until negative response disappears
Mainly
comprisesVoice control

Aversive conditioning
Child who displays a negative behavior and does not respond
to moderate behavior modification technique falls into the
category of Frankels definitive negative behaviour.

Parental consent necessary prior to its use

It can be safe and effective method of managing extremely

negative behavior

 Common methods used in clinical practice

HOME(Hand Over Mouth Exercise)

Introduced by Evangeline Jordan in 1920
Purpose is to gain the attention of the child so that
communication can be achieved.

 Technique
After determining the childs behaviour, the dentist firmly
places his and over the childs mouth
Behavioural expectations are calmly explained to the child
close to his ear
When the childs verbal outburst is completely stopped and
the child indicates his willingness to cooperate, the dentist
removes his hand.

 Indications
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

 Contraindications
Children under 3 years of age
Handicapped/immature child, frightened child.

 Several variants HOME

HOM & nose, airway restricted
Using dry towel over nose & mouth
Using a wet towel over nose & mouth
Towel held over mouth only

 HOMAR(airway restricted)
Advantage is that the child will be quiet so as to breathe and
the screaming will decrease so that the doctor can proceed.
Together with hand and over mouth, nostrils are punched for
15 sec.
Airway restriction is a critical element and it should be
avoided (Belanger, 1993)

 The legality of using Hand-Over-Mouth and other form of

restraints within the legal system of USA and Europe is
questionable (Bowers, 1982; Klein, 1987).
In the UN Convention on the Right of the Child, since 1989;
children have rights to be respected and also to be protected
against health hazards and any unfair treatment.
HOME, although very effective when used correctly, is no longer
endorsed by the American Academy of Pediatric Dentistry.
(AAPD Guidelines 2008)

 In a recent survey of AAPD members who responded, 50%

believed HOME was still an acceptable technique (Oueis et al.,
2010).
Advanced behavior guidance techniques, such as
sedation,protective immobilization, and general anesthesia,
will be utitilized more by pdiatric dentists as alternatives

Alternatives for Hand Over Mouth Exercise

PEDIATRIC DENTISTRY V 32 NO 3 MAY : JUN 10

Physical restraints
Usually needed for the children who are hypermotive,
stubborn and defiant (Kelly 1976).
Involves restriction of the movement of the child s hand, feets
or body.
Passive
Active

 Protective stabilization is defined as 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.
Informed consent must be obtained and documented in the
patients record prior to performing protective stabilization

AAPD Guidelines on Protective Stabilization for Pediatric Dental Patients

V 36 I NO 6 ; 2013

 Indications
A patient requires immediate diagnosis and/or urgent limited
treatment and cannot cooperate due to emotional and
cognitive developmental levels or lack of maturity or medical
and physical conditions.
Emergent 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
patients safety and help to expedite completion of treatment.

 A sedated patient may become uncooperative during

treatment.
A patient with special health care needs may experience
uncontrolled movements that would be harmful or
significantly interfere with the quality of care.

 Benefits
Reduction or elimination of untoward movements.
Protection of the patient, staff dentist, or parent from injury.
Facilitation of quality dental treatment.

 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 restraint (unless no other alternatives are available).
Patients with non-emergent treatment needs in order to
accomplish full mouth or multiple quadrant dental
rehabilitation.

FOR MOUTH
Tongue blade / Open wide mouth prop
Can be used directly to open mouth
Has a durable foam core on outside of tongue depressor
Easy to use
Available in two sizes

 Moult Mouth Prop

Helpful in the management of a difficult patient for a
prolonged period
Both sizes adult & child
Allows accessibility to the opposite side of mouth

 Disadvantages
Possibility of lip and palatal laceration
Luxation of teeth if not used correctly
Precaution
To prevent injury to patient
Prop should not be allowed to rest on teeth
Patients mouth not be forced beyond its natural limit

 Rubber bite blocks

Various sizes available to fit the occlusal surfaces of teeth
Stabilizes the mouth in an open position
Attachment of Floss for easy retrieval

FOR BODY
Papoose board
Originally a wood & leather device used by many American
tribes to swaddle their infants & children
It is a device with flat board & wide fabric straps that can be
fastened with velcro
Available in areas to hold both large and small children

 The child is made to lie on board & the straps are wrapped
around the upper body , middle body & sometimes legs
Various sizes available
Has head & arm immobilizers

Advantages
Can be applied quickly
Reusable
Prevents drills & needles from slipping & causing injury

 Triangular sheet
Described by Mink
Triangular sheet to control an extremely resistant child
Allows the patient to upright during radiographic examinations

 Disadvantages
Frequent need for straps to maintain the patients position in
the chair
Difficulty in using on small patients
Possibility of airway impingement
Hyperthermia
Constant supervision

 Pedi wrap
Various sizes available
Allows some movement while confining the patient
Mesh fabric prevents Hyperthermia
Requires straps to maintain body position in the dental chair

Constant supervision to prevent patient rolling out of chair

 Bean bag with strap

Developed to help comfortably accommodate Hypnotic and
Severely spastic persons, who need more support and less
immobilization
Reusable and washable
One size fits most people
Patients with physical disability Relax more in such settings

For extremities
Allow limited movement of extremities
Prevents overreaction by combative patients

Conclusion
A wide variety of behavioural management techniques are
available to paediatric dentists
Must be used as appropriate taking into account cultural,
philosophical and legal requirements in the country of dental
practice of every dentists concerned with dental care of
children, solely for the benefit of the child

References
Dentistry for the child & adolescent , Mc Donalds
Management of Children in Dental Office- Louis Ripa
Child Behaviour in dental Office Wright
Textbook of pedodontics Shobha Tandon

 Illustrated paediatric dentistry, PR Chokalingam

Manual of paediatric dentistry, Sridhar Premkumar
Child and Adolescent Development - WILLIAM DAMON
Guideline on behavior guidance for the pediatric dental
patient ; American academy of pediatric dentistry
Alternatives for hand over mouth exercise ; Pediatric dentistry
v 32 no 3 may : jun 10

 AAPD Guidelines on Protective Stabilization for Pediatric

Dental Patients ; V 36 I NO 6 ; 2013
Review: Behaviour Management Techniques in Paediatric
Dentistry; European Archives of Paediatric Dentistry 11
(Issue 4). 2010
Hypnosis for children undergoing dental treatment (Review),
The Cochrane Library2010, Issue 8
Parental acceptance of pediatric behavior management
techniques ;Journal of Indian Society of Pedodontics and
Preventive Dentistry, Vol. 30, No. 3, July-September, 2012

QUESTIONS
Discuss step by step management of a 7 year old child with a
previous painful dental experience.(RGUHS, Oct 2008)
Importance of first dental visit ( RGUHS, 2003)
Audio analgesia in the management of fear ( RGUHS 2003)