Download BEHAVIOR MANAGEMENT TECHNIQUES:A BAG OF TRICKS

ESTABLISHMENT OF A DENTAL HOME
FOR PEDIATRIC DENTAL PATIENTS
Dr. Lisa Jacob
Chief of Pediatric Dental Medicine
Dell Children’s Medical Center
Austin, TX
Early Detection
__ Infants be evaluated by a dentist within 6 months
of
eruption of their first tooth and no later than 12 months
__ Allows a dentist to assess a child’s risk of developing
caries
__ Counsel parents and caregivers about what they can
do to reduce risk
© Lisa S Jacob, DDS, MS 2009
Goal

Establish an ongoing relationship
between dentist and the patient, inclusive
of all aspects of oral health care, delivered
in a comprehensive continuously
accessible, coordinated and family
centered way
© Lisa S Jacob, DDS, MS 2009
Dental Home
D0145- Oral evaluation for a patient under
three years of age and counseling with
primary caregiver
Goal: To prevent dental problems
© Lisa S Jacob, DDS, MS 2009
First Dental Home Visit
1.
Review of Dental and Medical history
2.
Comprehensive oral examination
3.
Caries risk assessment
4.
Application of topical fluoride varnish
5.
Dental prophylaxis
6.
Oral hygiene instructions with primary caregiver
7.
Dental anticipatory guidance
8.
Establishment of recall schedule
© Lisa S Jacob, DDS, MS 2009
Why complete a caries risk
assessment?
Determine potential for development of Severe Early
Childhood Caries by identifying:
√
Oral Health Status
√
Potential transmission sources
Direct dental anticipatory guidance content
Determine an appropriate recall periodicity schedule for the
child
© Lisa S Jacob, DDS, MS 2009
Caries Risk Assessment Tool
(CAT)
2002- American Academy of Pediatric Dentistry (AAPD)
adopted CAT for infants, children, and adolescents
2006 AAPD revised the CAT
AAPD encouraged both dental and non-dental health care
providers to use the CAT
Clinicians had to perform an adequate visual examination
of the child’s teeth and mouth
© Lisa S Jacob, DDS, MS 2009
© Lisa S Jacob, DDS, MS 2009
Risk factors to consider
History
Determined by interviewing the parent/primary
caregiver
Clinical evaluation
Determined by examining the child’s mouth
Supplemental Professional Assessment
Optional
© Lisa S Jacob, DDS, MS 2009
High caries risk patient
Each child’s overall assessed risk for
developing decay is based on the highest
level of risk indicator
Single risk in any area of the “high risk”
category classifies a child as being “high
risk”
© Lisa S Jacob, DDS, MS 2009
Child’s use of dental home
Frequency of dental
visits
Never :High risk
Irregular: Moderate risk
Regular: Low risk
http://www.ardentoys.co.uk/images/uploads/bay-tree-house2.jpg
© Lisa S Jacob, DDS, MS 2009
Child has decay
Yes: High risk
No: Low risk
www1.istockphoto.com/file_thumbview_approve/1609464/2/istockphoto_1609464_uh_oh_a_cavity_vector.jpg
© Lisa S Jacob, DDS, MS 2009
Patients with special needs
Especially those that impact motor coordination or
cooperation
Ectodermal dysplasia
Dental enamel is not well mineralized

Newbrun E. Current treatment modalities of oral problems of patients with Sjogren’s syndrome: caries
prevention. Adv Dent Res. 1996: 10; 20-34.
© Lisa S Jacob, DDS, MS 2009
Parent’s socioeconomic status
Low SES: High risk
Midlevel SES: Moderate
risk
High SES: Low risk
© Lisa S Jacob, DDS, MS 2009
http://library.thinkquest.org/J003358F/money_tree5.jpg
Impaired saliva composition/flow

Long-term doses of medications can
increase caries risk
Impaired salivation
High mineral loss

Bardow A, Nyvad B, Nauntofte B. Relationships between medication intake and
complaints of dry mouth, salivary flow rate and composition, and the rate of tooth
demineralization in situ. Arch Oral Biol. 2001: 46; 412-23.
© Lisa S Jacob, DDS, MS 2009
Time lapsed since child’s last
cavity
<12 months: High risk
12-24 months: Moderate risk
>24 months: Low risk
http://www.ntlf.com/images/calendar.jpg
© Lisa S Jacob, DDS, MS 2009
Child wears braces or
orthodontic/oral appliances
Yes: High risk
No: Low risk
© Lisa S Jacob, DDS, MS 2009
Child’s immediate family has decay
Yes: High risk 
No: Low risk 
The earlier the child is infected…
the higher the risk of caries
Vertical transmission ↓ Mother to child
Horizontal transmission ↔ Sibling to sibling
© Lisa S Jacob, DDS, MS 2009
Daily intakes Between-Meals and cavity
producing foods
Mealtimes: Low risk
1-2 snacks: Moderate risk
>3 snacks: High risk
Consumption of juice, carbonated beverages or sports drinks
Use of bottle/sippy cup containing liquid other than water
Use of sweetened medications
© Lisa S Jacob, DDS, MS 2009
Child’s exposure to fluoride
High Risk



Does not use fluoridated toothpaste
Drinking water is not fluoridated
Does not take fluoride supplements
Moderate Risk



Uses fluoridated toothpaste
Usually does not drink fluoridated water
Does not take fluoride supplements
Low Risk



Uses fluoridated toothpaste
Drinks fluoridated water
Takes fluoride supplements
© Lisa S Jacob, DDS, MS 2009
Times per day that the child’s
teeth/gums are brushed



<1: High risk
1: Moderate risk
2-3: Low risk
http://www.eslkidstuff.com/images/toothbrush.
gif
© Lisa S Jacob, DDS, MS 2009
Clinical Evaluation
© Lisa S Jacob, DDS, MS 2009
Visible Plaque
Present: High risk
Absent: Low risk

http://www.scharfphoto.com/fine_art_prints/archives/199901-024-Dental-Plaque.jpg
© Lisa S Jacob, DDS, MS 2009
Gingivitis
Present: High risk
Absent: Low risk
© Lisa S Jacob, DDS, MS 2009
Areas of enamel demineralization
>1: High risk
1: Moderate risk
None: Low risk

http://www.uiowa.edu/~c090247/images/varnish/demineralized.jpg
© Lisa S Jacob, DDS, MS 2009
Enamel Defects
Deep pits/fissures
Present: High risk
Absent: Low risk

http://www.ojrd.com/content/figures/1750-1172-217-1.jpg
© Lisa S Jacob, DDS, MS 2009
Tooth anatomy and hypoplastic
defects
Developmental pits
and deep pits have
been shown to
predispose a child to
develop dental caries
© Lisa S Jacob, DDS, MS 2009
Radiographic Enamel Caries
Present: High risk
Absent: Low risk

http://www.ndeb.ca/en/accredited/images/SNAG-0202.jpg
© Lisa S Jacob, DDS, MS 2009
Levels of mutans streptococci or
Lactobacilli
High: High risk
Moderate: Moderate
risk
Low: Low risk
© Lisa S Jacob, DDS, MS 2009
Dental Record
Document Caries Risk
▲ High
► Moderate
▼ Low
© Lisa S Jacob, DDS, MS 2009
© Lisa S Jacob, DDS, MS 2009
Topical Fluoride Varnish
D1206
* Therapeutic application for
moderate to high caries
risk patients
* Goal is to eliminate or
control a disease
* Prevent and re-mineralize
early caries
© Lisa S Jacob, DDS, MS 2009
Fluoride Varnish
Advantages
High dose with minimal volume
Minimal swallowing
Contact on teeth for hours
Reduced caries
Low plasma fluoride levels
Tolerated by children
Unit dose
Fast
© Lisa S Jacob, DDS, MS 2009
Fluoride Varnish 5% NAF
Disadvantages
Fuzzy, sticky and uneven
Appearance on tooth
4-6 hours you can’t brush
Soft food for one day
© Lisa S Jacob, DDS, MS 2009
Topical Fluoride
 Inhibits demineralization
 Enhances re-mineralization
 Inhibits plaque bacteria
© Lisa S Jacob, DDS, MS 2009
Topical application of fluoride
D1203 (Child)
Foams
Gels

Most effective if placed in
mouth for four minutes
© Lisa S Jacob, DDS, MS 2009
Fluoride testing
Fluori-check
(Omnii Oral)
© Lisa S Jacob, DDS, MS 2009
© Lisa S Jacob, DDS, MS 2009
Fluoride Products
© Lisa S Jacob, DDS, MS 2009
Oral Hygiene Instructions
D1330
Toothbrushing
Flossing
© Lisa S Jacob, DDS, MS 2009
Toothbrushes
Electric toothbrush
Spin Brush
© Lisa S Jacob, DDS, MS 2009
Surround Toothbrush
_ 3 rows of bristles
_ Compact head
_ Helps protect the oral
environment if the person
moves unexpectedly
during brushing
© Lisa S Jacob, DDS, MS 2009
Flossers
© Lisa S Jacob, DDS, MS 2009
Nutritional counseling for control of
dental disease
D1310
* Frequency of intake is more important than overall
quantity
* “Grazing” between meals should be discouraged
* Avoid frequent consumption of sodas
* Sweet intake should be limited-mealtime
© Lisa S Jacob, DDS, MS 2009
Bacterial Cultures
Identify the presence of
cariogenic bacterial infections
© Lisa S Jacob, DDS, MS 2009
Caries Susceptibility Test
D0425
If mother has had active dental decay in the past 12
months, dentist may perform a bacterial culture on the
mother
If primary caregiver’s bacteria count is significant, the
dentist will develop prevention strategy
Minimizes the risk of mom transmitting the infection to
the child
© Lisa S Jacob, DDS, MS 2009
Recommendations for caregiver
√ Antibacterial rinse
√ Chew xylitol gum or
mints each day
Studies show that chewing xylitol gum 4 times a day helps
reduce the transmission of cariogenic bacteria from caregivers to
infants
© Lisa S Jacob, DDS, MS 2009
Dental anticipatory Guidance
* Age appropriate information/education for parents
* Multi-topic overview of oral health environmental
influences
* Directed at increasing the parents understanding
of the importance of good health
© Lisa S Jacob, DDS, MS 2009
Dental anticipatory Guidance
* Discuss oral health and home care
* Development of Mouth and Teeth
* Oral Habits
* Diet, Nutrition and Food Choices
* Fluoride Needs
* Injury Prevention
* Antimicrobials
© Lisa S Jacob, DDS, MS 2009
Birth -1 year old
√ Clean baby’s mouth/brush teeth
√ Parents need to maintain their own oral health
√ Do not share utensils and cups
√ Discuss primary tooth eruption patterns
√ Discuss teething and ways to sooth sore gums
© Lisa S Jacob, DDS, MS 2009
Birth-1 year old
√ Review pacifier use
√ Do not put baby to bed with bottle
√ Encourage use of cup by year one
√ Fluoride needs
√ Child proof the home
√ Car seat usage
√ Discuss use of medications with sweeteners
© Lisa S Jacob, DDS, MS 2009
1-3 years old
☺ Offer healthy food, snacks, drinks
☺ Clean baby’s teeth
☺ Use fluoridated toothpaste (smear)
☺ Continue regular dental visits
☺ Discuss importance of baby teeth with parents
☺ Begin weaning of non-nutritive sucking habits by age 2
© Lisa S Jacob, DDS, MS 2009
1-3 years old
☺
Continue
Healthy nutritional choices
☺ Frequency of exposures

Do not use sippy cup like a bottle

No running with objects in mouth

Helmet use with toddlers riding bikes
© Lisa S Jacob, DDS, MS 2009
3-5 years old
* Pea-sized amount of fluoridated toothpaste
* Discuss permanent tooth eruption patterns
* Importance of teeth
* Discuss consequences of digit sucking or prolonged non
nutritive sucking
* Should be using a regular cup
© Lisa S Jacob, DDS, MS 2009
Behavior Guidance
* “a clinical art form and skill built on a
foundation of science”
* Continuum of interaction involving the
dentist, dental team, the parent, and the
patient
© Lisa S Jacob, DDS, MS 2009
Goals
√
√
√
√
Establish communication
√
Promote child’s positive attitude toward
dental health
Alleviate fear and anxiety
Deliver quality dental care
Build a trusting relationship between dentist
and child
© Lisa S Jacob, DDS, MS 2009
Dental Office
Website
__ Introduce parents to the practice
Location
__ FQHC dental within medical clinic
Design
__ Kid friendly
© Lisa S Jacob, DDS, MS 2009
DENTAL TEAM BEHAVIOR
Receptionist
__ First contact with parent via phone
__ Sets expectations
__ First staff member the child meets
Dental Assistant
__ Language
Dental Hygienist
__ Establish rapport
Dentist
__ “White Coat Syndrome”
© Lisa S Jacob, DDS, MS 2009
Recommend behavior guidance
based on:
* Health history
* Consequences of no
treatment
* Special health needs
* Dental Needs
* Type of treatment
required
* Emotional and intellectual
development of patient
* Parental preferences
© Lisa S Jacob, DDS, MS 2009
BASIC BEHAVIOR GUIDANCE

© Lisa S Jacob, DDS, MS 2009
VOICE CONTROL
Gain the patient’ attention
Establish adult-child roles
Controlled alteration of :
Voice Volume
Pace
Tone
© Lisa S Jacob, DDS, MS 2009
Non-verbal Communication
Reinforcement and guidance of behavior
through:
Appropriate contact
Posture
Body Language
Facial Expression
Gain or maintain the patient’s attention
© Lisa S Jacob, DDS, MS 2009
TELL-SHOW-DO
Tailored verbal explanation of procedures
Educate – importance of dental visit
Familiarize patient with dental setting
Demonstrate:
It’s OK to
Visual, Auditory,Touch,Taste, Smell
© Lisa S Jacob, DDS, MS 2009
POSITIVE REINFORCEMENT
Rewarding desired behavior
☺ Verbal praise
☺ Prizes
☺ Facial expression
Gives appropriate feedback
Strengthens recurrence of those behaviors
© Lisa S Jacob, DDS, MS 2009
DISTRACTION
Diverting the patient’s attention from what
may be perceived as an unpleasant
procedure
≈ Find out interests
≈ Give patient a short break
© Lisa S Jacob, DDS, MS 2009
PARENTAL PRESENCE/ABSENCE
__ Gain patient’s attention
__ Improve compliance
__ Depends on if the parent can help reduce the
patient’s anxiety
__ Parental attitudes have changed
__ Legal reasons
__ Do not use with parents who are unwilling or
unable to extend effective support
© Lisa S Jacob, DDS, MS 2009
MODELING
Have a patient observe the positive
behavior of another patient
© Lisa S Jacob, DDS, MS 2009
HYPNOSIS
Guided self-imagery that focuses
in relaxation and analgesia
* Helps decrease gagging
* Helps overcome dental phobia
© Lisa S Jacob, DDS, MS 2009
ADVANCE BEHAVIOR GUIDANCE
→ Protective Stabilization
→ Nitrous oxide
→ Conscious Sedation
→ General anesthesia
© Lisa S Jacob, DDS, MS 2009
PROTECTIVE STABILIZATION
* Any form of restriction of movement by a patient
in the dental environment
* Reduce or eliminate untoward patient movement
* Protect patient, staff, dentist or parent from
injury
* Facilitate delivery of quality dental care
© Lisa S Jacob, DDS, MS 2009
INDICATIONS
Patient requires immediate diagnosis or
limited treatment
Use with sedated patient that need to help
reduce untoward movement
© Lisa S Jacob, DDS, MS 2009
PHYSICAL RESTRAINS
Head holds
Hand guarding
Used by dental assistant
Therapeutic holds
Third person
© Lisa S Jacob, DDS, MS 2009
Dental Record for any use of
Stabilization
Informed consent
Indication
Type
Duration of application
Frequency of stabilization evaluation and safety
adjustments
Behavior evaluation/rating during stabilization
© Lisa S Jacob, DDS, MS 2009
Precautions
with protective stabilization
√ Tightness and duration must be
monitored
√ Do not restrict breathing and
circulation
√ Must not use if patient experiences
severe stress or hysteria
© Lisa S Jacob, DDS, MS 2009
MOUTH PROPS
McKesson Bite Block
Molt
© Lisa S Jacob, DDS, MS 2009
Mouth Rest
Open Wide Mouth RestDisposable
Reusable
Can hold a saliva
ejector in place
© Lisa S Jacob, DDS, MS 2009
Positioning Devices
☺ Wheelchair head
supports
☺ Bean Bags
☺ Rainbow Airway
Positioner
© Lisa S Jacob, DDS, MS 2009
Stay N Place Booster Chair
© Lisa S Jacob, DDS, MS 2009
Rainbow Elbow and Knee
Stabilizers
Easy to apply and
remove
“Incremental
Relaxation” teaching
tool for patients to
learn safe behavior
© Lisa S Jacob, DDS, MS 2009
Pedi-Wrap
© Lisa S Jacob, DDS, MS 2009
NITROUS OXIDE
Safe and effective technique to
Reduce anxiety
Enhance effective communication
Rapid onset of action
Easily titrated and reversible
Rapid recovery
Helps with: analgesia, amnesia and gag reflex
reduction
© Lisa S Jacob, DDS, MS 2009
CONSCIOUS SEDATION
√ Control anxiety
√ Minimize psychological
trauma
√ Maximize potential of
amnesia
√ Control behavior
movement
© Lisa S Jacob, DDS, MS 2009
DENTAL RECORD
* Informed consent
* Instructions and information
* Medical evaluation
* Time based record monitoring patient
HR, BP, RR, Oxygen saturation
* Adverse events
* Time and condition of patient at discharge
© Lisa S Jacob, DDS, MS 2009
General Anesthesia
* Controlled state of unconsciousness accompanied with a
loss of protective reflexes
* Provide safe, efficient and effective dental care
* Eliminate anxiety
* Reduce untoward movement
* Aid in treatment of mentally, physically or medically
compromised patient
© Lisa S Jacob, DDS, MS 2009
Minimal Intervention
* Modern medical approach to the
management of oral disease
* Early Diagnosis
* Change environment
* Repair
© Lisa S Jacob, DDS, MS 2009
Early Detection
Identify
Assess any potential caries risk factors
Recognition
White spot lesions
Gingivitis
© Lisa S Jacob, DDS, MS 2009
Change Environment
Prevent
Minimize risk factors to prevent caries
Rebalance oral environment
Remineralize
© Lisa S Jacob, DDS, MS 2009
RESTORE
Restore tooth with
bioactive materials
Preserve tooth
structure
Repair
http://www.wpclipart.com/tools/hammer/hammer_1.png
© Lisa S Jacob, DDS, MS 2009
Dental Restorative Material

Glass Ionomer

Composite

Amalgam

Resin Crown

Stainless steel crown
© Lisa S Jacob, DDS, MS 2009
Glass Ionomer Restorations





Fluoride release
Primary and permanent teeth
Cement stainless steel crowns
Orthodontic appliances
Transitional restorations for caries control



Tooth isolation
High caries risk
Base
© Lisa S Jacob, DDS, MS 2009
Resin-based composite
Excellent restoration in primary and permanent
dentition in low caries risk patient
 May not be ideal for patient at high risk for dental
decay

Donly KJ, Garcia-Godoy F. The use of resin-based composite in children. Pediatric Dentistry. 2002: 24; 480-8.
© Lisa S Jacob, DDS, MS 2009
Frequency of Radiographs
Depends on caries risk of patient
ADA/FDA Guidelines
© Lisa S Jacob, DDS, MS 2009
Low Caries Risk
Primary and Mixed Dentition
Bitewings every 12-24 months
Adolescent with permanent dentition
Bitewings every 18-36 months
Adult Dentate or partially edentulous
Bitewings every 24-36 months
© Lisa S Jacob, DDS, MS 2009
High Caries Risk
Child and adolescent with permanent dentitions
Bitewings should be taken every 6-12 months
Adult dentate or Partially Edentulous
Bitewings every 6-18 months
© Lisa S Jacob, DDS, MS 2009
Frequency of Recall Exam and
Prophys
Low Risk: Every year
Moderate Risk: Every 6
months
High risk: Every 3
months
© Lisa S Jacob, DDS, MS 2009
Frequency of Prophylaxis
Depends on caries risk of patient
at discretion of practitioner
.
© Lisa S Jacob, DDS, MS 2009
Low Caries Risk
Goal is to MAINTAIN
Recall exam every year
Radiographs
Every 12-18 months in primary teeth
Every 2 years in permanent teeth
Continue good diet and oral hygiene
Daily use of fluoridated toothpaste
© Lisa S Jacob, DDS, MS 2009
Moderate Caries Risk
_ Goal is to REPAIR
_ Recall every six months
_ Radiographs every 18-24 months
_ Fluoride varnish every 6 months
_ Daily use of xylitol or fluoride rinse
_ Change Behavior by decreasing snacking
© Lisa S Jacob, DDS, MS 2009
High Caries risk
Goal is to REPAIR and RESTORE
Recall every three months
Radiographs every 6-12 months
Glass ionomer as an interim material
Fluoride varnish every 3 months
Chew 5 pieces of xylitol gum every day
© Lisa S Jacob, DDS, MS 2009
High Caries Risk
* Counsel on diet
* Review oral hygiene instructions
© Lisa S Jacob, DDS, MS 2009
Take Home Messages for Parents
Cavities are preventable
Caries is an infectious disease
Transmitted from parents/caregivers
© Lisa S Jacob, DDS, MS 2009
Suggestions for Practitioners
√ Be flexible
√ Be consistent
√ Be Compassionate
√ PRAISE, PRAISE, PRAISE
© Lisa S Jacob, DDS, MS 2009
Q&A Session
© Lisa S Jacob, DDS, MS 2009