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modulation, facial expression, verbal praise and appropri-
ate physical demonstrations of affection by all members of
the dental team. Non-social reinforcers include tokens and
toys.
Objective:
To reinforce desired behaviour.
Indications: May be useful for any patient.
Contraindications: None.
Distraction
Description: Distraction is the technique of diverting the
patients attention from what may be perceived as an
unpleasant procedure.
Objectives:
To decrease the perception of unpleasantness.
To avert negative or avoidance behaviour.
Indications: May be used with any patient.
Contraindications: None.
Parental presence/absence
Description: This technique involves using the presence or
absence of the parent to gain cooperation for treatment. A
wide diversity exists in practitioner philosophy and paren-
tal attitude regarding parents presence or absence during
paediatric dental treatment. Practitioners are united in the
fact that communication between dentist and child is para-
mount and that this communication demands focus on the
part of both parties. Childrens responses to their parents
presence or absence can range from very benecial to very
detrimental. It is the responsibility of practitioners to deter-
mine the communication methods that best optimize the
treatment setting; recognizing their own skills, the abilities
of the particular child and the desires of the specic parent
involved.
Objectives:
To gain the patients attention and compliance.
To avert negative or avoidance behaviours.
To establish appropriate adult-child roles.
To enhance the communication environment.
Indications: May be used with any patient.
Contraindications: None.
All these communication techniques integrate to enhance
the evolution of a compliant and relaxed patient. It is an
ongoing subjective process rather than a singular technique
and is often the extension of the personality of the dentist.
stories from his friends. His family are very supportive and
are regular attenders.
Liam responds well to communicative management but,
although he wants to have his treatment done he just cannot
override his fear of the unknown.
What additional help might you consider giving Liam?
Sedation there are two options for sedation, either oral or
inhalational sedation.
Oral sedation is now an increasingly viable option using
midazolam. A number of recent studies have shown that its
use in a dose of 0.30.5 mg/kg, depending on age, has been
therapeutically effective in producing effective sedation
that has allowed subsequent dental treatment. The objec-
tives, indications and contraindications for it are as follows
Objectives:
To reduce or eliminate anxiety.
To reduce untoward movement and reaction to dental
treatment.
To enhance communication and patient cooperation.
To increase tolerance for longer appointments.
To aid in treatment of the mentally, physically or medically
compromised patient.
To raise the patients pain threshold.
Indications:
Fearful, anxious patients in whom basic behaviour
management has not been successful.
Patients who cannot cooperate due to a lack of psychological
or emotional maturity and/or mental, physical or medical
disability.
Patients for whom the use of sedation may protect the
developing psyche and/or reduce medical risk.
Contraindications:
The cooperative patient with minimal dental needs.
Predisposing medical conditions that would make sedation
inadvisable.
Inhalational sedation has been known to be an effective
and safe method of reducing anxiety and enhancing effec-
tive communication for the past 30 years. Its onset of action
is rapid, the depth of sedation is easily titrated and revers-
ible, and recovery is rapid and complete. Additionally,
nitrous oxide mediates a variable degree of analgesia,
amnesia and gag reex reduction.
The need to diagnose and treat, as well as the safety of
the patient and practitioner, should be considered before
the use of nitrous oxide. The decision to use nitrous oxide
must take into consideration:
Alternative behaviour management modalities.
Dental needs of the patient.
The eect on the quality of dental care.
The patients emotional development.
The patients physical considerations.
Written informed consent must be obtained from a legal
guardian and documented in the patients record prior to
use of nitrous oxide.
The patients record should include:
Informed consent.
Indication for use.
Key point
The objectives of distraction are:
To decrease the perception of unpleasantness.
To avert negative or avoidance behaviour.
Examination
After spending some time talking to Liam and showing him
that you are genuine in wanting to help, he allows you to
look at his teeth. Both lower rst primary molars are carious.
All the other teeth are sound. Liam has been frightened by
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MI N D MA P 2 4
Pharmacological
inhalation
sedation
indications
indications
contraindications
general anaesthesia
fearful / anxious / etc.
first trimester of pregnancy
patients treated with bleomycin sulphate
lack of psychological or emotional maturity
protect developing psyche
and/or reduce medical risks
significant surgical procedures
extremely uncooperative, fearful,
anxious or uncommunicative
local anaesthesia ineffective
allergy
anatomical variations
acute infection
mental / physical or medical disability
unable to cooperate
sickle cell disease
drug-related dependencies
severe emotional disturbances
chronic obstructive pulmonary diseases
where profound local anaesthesia cannot be obtained
gag reflex interferes with dental care
certain mentally / physically / medically
compromised patients
contraindications
healthy, cooperative patient
with minimal dental need
medical condition where
general anaesthesia
inadvisable
immediate, comprehensive, oral / dental care required
contraindications
oral sedation
indications
fearful, anxious patient where unsuccessful
basic behaviour management
psychological / emotional immaturity
and / or mental physical / medical disability
cooperative with minimal dental needs
medical condition where sedation inadvisable
may protect developing psyche
and/or reduce medical risk
Communicative
any patient
indications
indications
indications
indications
indications
indications
none
contraindications
contraindications
contraindications
contraindications
any patient
none
none
none
none
distraction
tell-show-do
non-verbal
voice control
positive reinforcement
parental presence / absence
none
contraindications
contraindications
any patient
any patient
any patient
any patient
History
The Uncooperative Child
dental
medical
family / parental
peers
development delay / cognition