PEDODONTICS

Behaviour Management

BEHAVIOUR MANAGEMENT

It is defined as the means by which the dental

30

Desensitization (COMEDK-09)

Introduced by Joseph Wolpe (1975)

A competing response is taught and then

health team effectively and efficiently performs

progressively more threatening stimuli are

dental treatment and thereby instills a positive

introduced

dental attitude.

Behavior management

Tell Show Do (TSD) Technique

Non pharmacological

Pharmacological

05, KCET-07)

Communication

Verbal

Non verbal

Introduced by Addleston (1959) (COMEDKTell & show every step and instrument,
explain what is going to be done

Modeling

Behavior shaping

Desensitization

Modeling

Contingency management

Introduced by Bandura (1969)

Model - live models - siblings, parents;

audiovisual aids; posters

Involves allowing the child to observe models

who demonstrate a positive behavior in a
particular situation so that he can imitate the

Behavior management

models behavior when placed in a similar

Audio analgesia

Bio feed back

Voice control

Hypnosis

Implosion therapy

Aversive conditioning

situation
Retraining

Stimulus must be altered to elicit a change in

response

3 types Substitution / deemphasizing /

distraction

VERBAL COMMUNICATION

Voice should be gentle & constant

Tone of voice should express empathy &

Contingency management

firmness

Positive reinforcer is one whose presentation

increases the frequency of behavior.

Address the patient by his name

Euphemisms are substitute words that can be

withdrawal

used for communication

behavior.

NON VERBAL COMMUNICATION

Speaking at the eye level (eye contact)

Giving the child a pat or hug

Smiling

Negative

reinforcer
increases

is
the

one

whose

frequency

of

Types of reinforcement social, material,

activity reinforcer

Aversive Conditioning (PGI-02)

It is effective method of managing extremely

negative behavior.

BEHAVIOURAL SHAPING

Procedure which slowly develops behavior by

Parental consent needed

2 common methods: Home Hand Over

reinforcing a successive approximation of

Mouth (by Evangeline Jordan) (AIPG-05) &

desired behavior until the desired behavior

Hand Over Mouth with Airway Restricted

comes into being

(HOMAR)

Based on Stimulus response theory

BRIHASPATHI ACADEMY SUBSCRIBERS COPY NOT FOR SALE

PEDODONTICS
Behaviour Management

Indications

31

Coping is defined as the cognitive and

3-6 years old (COMEDK-04)

behavioral efforts made by an individual to

Child who can understand simple verbal

master, tolerate or reduce stressful situations.

commands

Voice control is the modification of intensity

and pitch of ones own voice in an attempt to

Contraindications

dominate the interaction between the dentist

Child < 3 years

Physical, mental & emotional handicap

and child

Hypnosis is an altered state of consciousness

characterized by a heightened suggestibility to

TYPES OF RESTRAINTS

produce

Active performed by dentist/staff or parent

without the use of restraining device

Passive with the aid of restraining device

For body

Pedi wrap

Papoose board

Triangular sheet

Bean bag with strap

Towel & tapes

desirable

behavioral

and

physiological changes.
Implosion therapy mainly comprises of
HOME, voice control and physical restraints.

PHARMACOLOGICAL MEANS OF
PATIENT MANAGEMENT

Conscious sedation A minimum depressed level

For extremities

of consciousness, protective reflexes are intact,

Velcro strap

responds

Posey strap

command

Towel & tapes

For head

Head positioner

Forearm body support

to

physical

stimulation

&

verbal

Deep sedation partial loss of protective reflexes

General

Anaesthesia

controlled

state

of

unconsciousness

For mouth

American

Mouth blocks

Classification

Banded tongue blades

Mouth props

Academy

of

Anesthesiologists

(ASA)

Class I

Normal

patient

with

localized

pathology
Indications

Emotionally immature child

Hyper motive, stubborn

Handicapped child

Class II

Audio analgesia or white noise is the auditory

stimulus such as pleasant music used to

Biofeedback
instruments

like

electromyography

use

of

certain

sphygmomanometer,
etc.

to

detect

Severe life threatening condition

Class V

involves

Severe systemic disturbance

Class IV

reduce stress.

Mild to moderate systemic problem

Class III

Some Important Notes

No systemic problem

Moribund patient

Class VI

Brain dead

certain

physiological processes associated with fear.

Humor helps to elevate the mood of the

child, which helps the child to relax.
BRIHASPATHI ACADEMY SUBSCRIBERS COPY NOT FOR SALE

PEDODONTICS
Behaviour Management
Conscious Sedation
Indications

Only patients who are categorized into ASA

class I are routinely acceptable as candidate
for it.

Lack of psychological or emotional maturity

Fearful and anxious patients

Contraindications (MAHE-98)

Chronic

obstructive

(COPD),

myasthenia,

pulmonary
epilepsy,

disease
bleeding

disorders

Uncooperative patients

BRIHASPATHI ACADEMY SUBSCRIBERS COPY NOT FOR SALE

32

PEDODONTICS
Behaviour Management

33

Sedation Routes and Agents (KCET-99)

Routes of
Administration

Drug

Indications and Advantages

Most

frequently

used

sedative

Limitations

agent

Inhalation

Nitrous oxide
(PGI-03)

Nausea and vomiting

are most

common side effects

Produces

non

specific

CNS

depression

Rapid onset and elimination

Duration of action can be easily

Has weak potency

Cannot be used in severe, behavioral

problems & emotional illness

controlled

other

contraindications

are

claustrophobia (phobia for closed

spaces), nasal obstructions, COPD
(MAHE-98)

Oral route

Hydroxyzine

Antihistaminic effect

Clinical effect seen in 15-30

Extreme drowsiness, dry mouth and

hypersensitivity

minutes

Phenothiazines with sedative &

antihistaminic properties
Promethazine

Well absorbed orally

Potentiates

other

Dry

mouth,

blurred

vision,

thickening of bronchial secretions.

CNS

Should be used with caution in

children with asthma

depressants

Long working time

Premedication of choice for a

Chloral

depression

child below 2 years of age

Prolonged drowsiness & respiratory

hydrate

Large doses depress myocardium so

should be avoided in patients with
cardiac disease

Diazepam

Meperidine

Strong anticonvulsant effect

Ataxia & prolonged CNS effects

Safe agent

Synthetic opiate agonist

Poor oral absorption

Best used in combination for

Should be used with caution in

brief

procedures

with

children

Promethazine or Hydroxyzine

Intramuscular

with

hepatic

or

renal

disease or history of seizures

dissociative

Safety of oral use not yet established

Potent analgesic

High water solubility, so can be

Higher

Ketamine

Produces
anaesthesia

given intravenously (risk of

Midazolam

doses

may

produce

respiratory depression

thrombophlebites is very less)

Greater potency as compared to

diazepam

Intravenous

Midazolam

This route has most rapid onset

Requires excessive armamentarium

of action, permits titration and

is easily reversible

BRIHASPATHI ACADEMY SUBSCRIBERS COPY NOT FOR SALE