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BEHAVIOUR MANAGEMENT

BEHAVIOUR MANAGEMENT. INTRODUCTION. behavioural dentistry is an interdisciplinary science which needs to be learned, practiced and reinforced.

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BEHAVIOUR MANAGEMENT

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  1. BEHAVIOUR MANAGEMENT

  2. 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.

  3. DEFINITION OF BEHAVIOUR • Behaviour is defined as any change in the functioning of an organism. • Behaviour refers to changes that we can see and count.

  4. BEHAVIOUR MANAGEMENT Definition: • 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

  5. BEHAVIOUR SHAPING:- is the procedure which slowly develops BEHAVIOUR by reinforcing a successive approximation of the desired behaviouruntil the desired behaviourcomes into being. • BEHAVIOUR MODIFICATION:- is defined as the attempt to alter human behaviouran emotion in a beneficial way and in accordance with laws of learning.

  6. 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.

  7. CLASSIFICATIONS OF CHILD’S BEHAVIOUR FRANKEL'S CLASSIFICATION(1962)(Frankel's BEHAVIOUR Rating Scale) Divided into four categories Rating 1: definitively negative {- -} Features: Refusal of treatment Crying forcefully Extreme negativism Rating 2: negative {–} :difficult to accept treatment Un co-operative

  8. Rating 3: positive {+} :Acceptness of treatment. Willingness to follow dentists instruction. May be hesistant too. 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.

  9. LAMPSHIRE'S CLASSIFICATION(1970) • COOPERATIVE: the child is physically and emotionally relaxed. is cooperative throughout the entire procedure. • TENSE COOPERATIVE: the child is tensed, and cooperative at the same time. • OUTWARDLY APPREHENSIVE: avoids treatment initially, usually hides behind the mother, avoid looking or talking to the dentist. eventually accepts the treatment • FEARFUL: requires considerable support so as to overcome the fears of dental treatment. • STUBBORN: passively resist treatment by using techniques that have been successful in other situations. • HYPER MOTIVE: the child is acutely agitated and resorts to screaming, kicking etc. • HANDICAPPED: physically/mentally, emotionally handicapped. • EMOTIONALLY IMMATURE:

  10. CLASSIFICATION BY WRIGHT(1975) • COOPERATIVE(POSITIVE BEHAVIOUR) • UN-COOPERATIVE(NEGATIVE BEHAVIOUR) • CO OPERATIVE : a) COOPERATIVE BEHAVIOUR:child is cooperative b) 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.

  11. UN-COOPERATIVE a) UNCONTROLLED/HYSTERICAL: usually seen in • preschool children at their first dental visit • temper tantrumsi.e physical lashing out of legs & arms, loud crying and refuses to cooperate with the dentist b) DEFIANT/OBSTINATE BEHAVIOUR: • can be seen in any age group • usually in stubborn children • these children can be made cooperative c) TENSE COOPERATIVE: • in the borderline between positive and negative BEHAVIOUR • does not resist the treatment but is tensed at mind

  12. d) TIMID BEHAVIOUR/TIMID: • seen in over protective child at first visit • is shy but cooperative e) WHINING TYPE: complaining type of BEHAVIOUR allows for treatment but complaints through out the procedure f) STOIC BEHAVIOUR: seen in physically abused children. they are cooperative & passively accept all treatment without any facial expressions.

  13. BEHAVIOUR MANAGEMENT

  14. NON PHARMACOLOGICAL METHODS OF BEHAVIOUR MANAGEMENT • CLASSIFICATION • COMMUNICATION. • BEHAVIOUR SHAPING a.) DESENSITIZATION b.) MODELLING c.) CONTINGENCY MANAGEMENT • 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

  15. 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 EUPHEMISMS • Euphemisms 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. • Airotoras whistle.

  17. 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”

  18. 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.

  19. 2.MODELLING: BY BANDURA(1969) Learning principle procedure involves a patient to observe one or more individuals who demonstrate a positive behaviourin a particular situation. • MODELLING CAN BE DONE BY: a.) Live models- siblings,parent of child etc. b.) Filmed models c.) Posters d.) Audiovisual aids.

  20. 3.CONTIGENCY MANAGEMENT • It is the management of modifying the behaviourof 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 behavioursand thus strengthen the recurrence of those behaviours.

  21. 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

  22. 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 givesstimulation 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 reliefin 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.

  24. COPING: It is defined as the cognitive and behaviouralefforts 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 situation • Cognitive: 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 patient • Contraindications: patients who are hearing impaired.

  26. 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 behaviouraland physiological changes. When used in dentistry it is known as hypnodontics or psychosomatic.Benefit: reduce anxiety and pain • IMPLOSION 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.

  27. 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. HOME • Introduced 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.

  28. TECHNIQUE: After determining the child the child’s BEHAVIOUR, the dentist firmly places his hand over the child’s mouth and behaviouralexpectations are calmly explained close to the child’s ear. When the child’s verbal outbrustis 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 20-30 seconds.

  29. PHYSICAL RESTRAINTS • Restraints 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 device TYPES OF RESTRAINT:

  30. MOUTH: 1.mouth block 2. banded tongue blade 3. mouth props – it is used at time of local anesthesia .  • It is used for: - physical/mental handicapped child. - young child who cannot keep the mouth open for long time. - child becoming fatigues because of long appointments and frequently close his mouth.

  31. Fear and anxiETy are hand to hand problem of more than 50% of pediatric patients, to over come that for the treatment you should be skilled an wise enough. Then the treatment success rate is remarkable..

  32. THANK YOU

  33. PHARMACOLOGICAL MEANS OF BEHAVIOUR MANAGEMENT

  34. 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 .

  35. PHARMACOLOGICAL MEANS CLASSIFICATION:- • CONCIOUS SEDATION • DEEP SEDATION • GENERAL ANAESTHESIA

  36. 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.

  37. 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)

  38. 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 constantly

  39. 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.

  40. GENERAL ANASTHESIA

  41. 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.

  42. PREANESTHETIC EVALUATION AND PROCEDURES-APD 1985 • Instruction to patients • Preoperative health assessment • Clinical examination • Doctors order • INSTRUCTION TO PARENTS The practitioner should provide verbal andwritten instruction to the parents. It should include explanation of potential/ anticipated postoperative behaviour and limitation of activities along with dietary precautions.

  43. 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.

  44. 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.

  45. DRUGS USED FOR PRE-MEDICATION ANTICHOLINERGICS Atropine Glycopyrrolate SEDATIVES Benzodiazepines Barbiturates ANTI-EMITICS Hydroxyzine Metaclopromide

  46. SEDATIVE DRUGS & DOSAGE

  47. GUIDELINES FOR USE DBEFORE 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.

  48. 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.

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