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Behavior
Guidance
Dental patient
&
pediatric dental
patient
Any interaction btn 2
or more people can
be considered as a rln
ACIVITY-PASSIVITY
GUIDENCECOOPERATION
Dentist
Adult pt
Communication is a two-way
process.
Communication skills are a key
aspect of a good dentist-pt
relationship.
Communication involves
information giving & building
rapport.
Good dentist-pt communication
has a significant impact upon
both the pt’s health and the
dentist’s job satisfaction.
Communication
SPECIFIC
VERBAL
GENERAL
VERBAL
NON –VERBAL
General verbal
communication skills
Give advice and instruction as early
as possible in the
interview.
Give specific detailed information
rather than general
comment.
Use short words & sentences , avoid
jargon.
Repeat essential information regarding
the diagnosis and
treatment.
Avoid asking questions which require
lengthy answers whilst you are
working in the pt
Specific verbal
communication
-Responses to dental
treatment vary.
-Some pts prefer to be
given a step-by-step
description of what is
occurring ,but others
like to
distance
themselves from the
treatment process as
much as possible.
-Give positive
information before the
negative(nonthreatening language)
-Clarify .
Non-verbal communication skills
Use appropriate eye contact.
Use active listening skills.
Have a relaxed body posture.
Physical proximity.
Use written information.
Principles of Behavior Change
Classical
conditioning
Operant
conditioning
PAVOLOV a Russian
physiologist identify
the rln animal B &
environmental
stimuli
Classical conditioning
e.g the sound of a dental drill would be not noticed .
However , if it has been paired with pain (unconditioned
stimulus) during previous dental procedures, the sound of
the drill becomes a conditioned response :fear ; anxiety.
e.g white coat , eugenol odour
,protective glasses , even sitting in the waiting room.
Operant conditioning
Law of effect
Any behavior that is followed by
satisfying consequences will
tend to be repeated or
increase in frequency
,whereas behavior that is
followed by unpleasant
consequences will occur less
frequently.
Reinforcer
Punisher
Extinction.
Dentist’s interpersonal skills.
Interest in the pt’s well-being.
Enthusiasm for the work the dentist is doing.
Encouragement of the pt’s efforts in what domain is
relevant(OH ,overcoming fear , dietary change).
A Painful experience = significant punishing
consequences
Adherence to treatment
The extent to which a person’s
behavior coincides with medical or
health advice like taking medication
, follow dental regimes , or
executing lifestyle changes.
Collaborative relationship.
Pt is not a passive participant.
Carefully consider the pt’s
perspective(beliefs , social
circumstances ,
level of support , language skills)
Adherence To Treatment
PROBLEMS With ADHERENCE
Information
Memory
Clinician pt
rln
Pt beliefs
&cognitive level
Improving Adherence
Giving
information
Motivation
Behavior Guidance
A continuum of interaction involving the
dentist and dental team , the pt and
the parent directed toward
communication and education.
Assess accurately the child’s
developmental level , dental attitude ,
temperament and to predict the
child’s rxn to treatment.
-clinical art form.
-Requires skills in communication ,
empathy , coaching , tolerance ,
flexibility , active listening
-cooperative , relaxed , self confident.
Goals of BG
-Establish communication , alleviate fear and anxiety.
-Effective/efficient delivery of care.
-Instills positive dental attitude.
-Builds foundation of respect and trust.
-Teaches good coping skills.
Fear Types
1.Innate fears : child
intellectually unable to
arrest fears bc of
chronologic age
-slow development(mental
retardation)
-emotionally ill
child(overreacting bc of
emotional upsets in life)
2-Acquired fears :peers,
siblings , parents.
3-Learned fears : due to
previous painful
experience.
Fears & Age
-Fear of
strangers 7-12 month
-Fear
of separation
from parents start
from 6 mths , peaks
13-18 mths , then
declines……fades at
36-40 mths
-3- yrs=sep anxiety +
visual fear
-4 -yrs=Auditory fear
-5-yrs=sep anxiety
disappears + fear of
harm to body
Pain management
-critical for successful B.G
-Prevention of pain ; nurture
the rxn btn dentist and pt ,
build trust , allay fear and
anxiety , enhance positive
dental attitude for further
visit. BUT subjective nature
of pain perception , varying
pt responses to painful
stimuli and lack of use of
accurate pain assessment
scales may hinder the
dentist’s attempts to
diagnose and intervene.
during procedures
Faces Pain Scale-Revised
Dental team behavior
The staff must be trained carefully to •
support the dentist’s efforts and
welcome the patient and parent into a
child-friendly environment that will
facilitate B.G and positive dental visit.
Barriers
-Reasons for noncompliance in the healthy ,
communicating child are more subtle and
difficult to diagnose.
Dentist’s behavior : rushing through appt , not
taking time to explain , barring parents from
exam. room& generally being impatient.
Medical history : Developmental delay ,
physical/mental disability and chronic or
acute disease.
-Fears transmitted from parents , a previous
unpleasant and/or painful dental or medical
experience , inadequate preparation for the
first encounter in the dental environment ,
or dysfunctional parenting practices.
Parental influence
-parents exert a significant
influence on their child’s
behavior especially if they had
negative dental previous
experience .
Educating the parent before
the child’s first
dental visit is important.
Child’s beh. dependant on type of
interaction they have w their
parents.
Parental Attitude
Overprotective
Over-Authoritative
Attitude
Attitude
Maladaptive
Child
Overindulgent
Under-affectionate
Attitude
Rejecting Attitude
Overindulgent Attitude
Overauthoritative
attitude
Misbehaving Child
Emotionally
Compromised
Child
Shy
Introverted
Child
Frightened
Child
Child who is
Aversive to
Authority
Practitioners are
faced with
challenges from an
increasing number
of children lack the
coping skills and
self-discipline
necessary to deal
with new
experiences in the
dental office.
Patient Assessment
-The response of a child pt to the
demands of dental treatment
is complex and determined by
many factors;
Child age/cognitive level,
temperament /personality
characteristic , anxiety and fear
, rxn to strangers , previous
dental experiences and
maternal dental anxiety
influences a child’s rxn to
dental setting.
Dentists should record the pt’s
behavior as a diagnostic aid for
future visits.
Frankl Behavioral Rating Scale
Definitely
Negative
__
Definitely
Positive
++
Negative
_
Positive
+
Cooperative
Lacking in
cooperative ability
Potentially
cooperative
Deferred treatment
-Dental disease is not lifethreatening and the type and
time of dental treatment can be
deferred in certain
circumstances.
-Risks and benefits , informed
consent.
-Rapidly advancing disease ,
trauma , pain , infection usually
dictates urgency of treatment.
-Deferring treatment and replaced
with ITR,FL varnish , AB.
-Hysterical or uncontrollable
child.
Informed consent
All decisions regarding use of behavior techniques
must be based upon a benefit vs risk evaluation.
-Other than communication guidance.
-Informing the parent about nature , risk benefits
of technique may be used and any professionally
recognized techniques is essential to obtaining
informed consent.
-All questions must be answered to the parent’s
understanding.
BASIC
BEHAVIOR
GUIDANCE
ADVANCE
BEHAVIOR
GUIDANCE
Basic Behavior Guidance
COMMUNICATION
VERBAL & NONVERBAL
TSD
Advance Behavior Guidance
Protective
Stabilization
Sedation
General
Anesthesia
Communication
-imparting or interchange of thoughts , opinions
, or information.
-affected primarily through dialogue , tone of
voice , facial expression and body language.
-the 4 essential ingredients :
Sender , message , setting in which the message
is sent and receiver.
Verbal Communication
-Used w coop & uncoop
children(all pt)
-Basis for establishing relation w
child.
-Ass w all techniques.
A child’s cognitive development
will dictate level &amount of
information change.
No specific consent needed
prior to use.
Verbal
Communication
-Begin of dental apt the 2-way
interchange of information
gives way to 1-way guidance
of behavior through
commands.
-This type of interaction called
requests and promises.
-Request elicit promises from
the pt that , in turn, establish a
commitment to cooperate.
-Assure the child is comfortable
& no pain.
-Rerequest can be used
Nonverbal
communication
The reinforcement & guidance
of behavior through
appropriate contact ,
posture , facial expression ,
and body language.
Obj.1-enhance the
effectiveness of other
communicative techniques
2-gain or maintain pt’s
attention & compliance.
Ind. may be used w any pt
Contra. none
Tell-Show-Do
-Tell=verbal explanation of procedures in phrases appropriate to the
developmental level of pt . Use fun labels or terms(word substitute)
-Show=demonstration for the pt of the visual , auditory , olfactory , and
tactile aspects of the procedure in a carefully defined ,nonthreatening
setting.
-Do=w/o deviation from the explanation and demonstration ,completion of
procedure
TSD
Objectives:
1-Teach the pt important aspects of the dental •
visit& familiarize him w dental setting.
2-shape the pt’s response to procedures through desensitization
and well-described expectation.
Ind: may be used w any pt.
Contra. : LA injection or any procedures that defy explanation
e.g pulp extirpation.
-Can be used w comm. +VC.
Voice Control
VC=A controlled alteration of
voice volume , tone , or pace to
influence and direct the pt’s
behavior.
-Explain to parent to prevent
misunderstanding.
Obj:
1-Gain pt’s attention &
compliance.
2-Avert –ve or avoidance
behavior.
3-Establish appropriate adultchild roles.
Indication=may be used w any pt.
Contraindication=pt’s w hearing
impairment.
Positive Reinforcement
-Technique to reward desired
behavior & strengthen its
recurrence(gift not bribe).
-Social reinforcers include facial
expression, +ve voice
modulation ,verbal praise &
appropriate physical
of affection by demonstrations
all members of dental team.
-Nonsocial reinforcers include
tokens &toys.
Obj. To reinforce desired behavior.
Ind. May be useful w any pt.
Contra. None
Distraction
-Diverting the pt’s attention from
what may be perceived
as an unpleasant procedure.)Visual d. posters)
Obj.1-Decrease the
perception of unpleasantness;
2-Avert –ve or avoidance behavior.
Ind. May be used w any pt.
Contra. None.
Parental Presence/absence
-A wide diversity exists in practitioner philosophy &
parental attitude regarding parent’s presence or
absence during pediatric dental treatment.
Obj. for parents to:
1-Participate in infant exam/ treatment ;
2-Offer very young children
physical & psychological support;
3-Observe the reality of their
child’s treatment .
Protective Stabilization
-The restriction of pt’s freedom of movement , w or w/o pt’s
permission, to decrease risk of injury while allowing safe completion
of treatment.
-Involves another human(s), a pt’s stabilization device, or a combination.
-Serious consequences such as physical or psychological harm , loss of
dignity ,& violation of pt’s rights.
-Careful continuous monitoring of pt is mandatory(respiration +
circulation restriction).
Ind:1-pt require immediate treatment or diagnosis or limited treatment
& cannot cooperate due to lack of maturity or mental or physical
disability;
2-safety of pt ,staff , dentist , or parent would be at risk w/o use of PS;
3-sedated pt require limited stabilization to help reduce untoward
movement.
Contrind:1-cooperative non-sedated pt;
2-pts who cannot be immobilized safely due to associated
medical or physical conditions;
3-pts experienced previous physical or psychological trauma
from PS;
4-non-sedated pt w non-emergent treatment requiring
lengthy appointments.
Pt’s record must include IC , indication , type , duration ,
beh.evaluation.
Modeling
Systemic
Desensitization
Involves
progressively
exposing the pt
to the feared
stimulus using a
graded steps of
increasingly
arousing stimulus
Observation of
a competent
others being
exposed to
the feared
stimulus and
being seen
to overcome
their anxiety.
Time - out
-Involving taking time away
from task or procedure to
allow the child to cope.
-e.g counting from 1-10
during cavity prep &
stopping at 10 for a rest.
-Indicated when child’s beh
becomes uncoop for
planned procedure.
-Sometimes unsuccessful as
it reinforces the
negative beh.
References
1-American Academy of Pediatric Dentistry 2011,Revised.
2-Pediatric Dentistry , Jimmy Pinkham , Fourth edition
3-Dentistry for the child and adolescent , Ralph E. McDonald , eighth edition.
4-Clinical Pedodontics ,Sidney B. Finn,4th edition.
5-Handbook of Pediatric Dentistry , Angus Cameron , Second edition. 6Oxford Handbook of Dental Applied Dental Science , Crispan Scully.
Done by : Dr. Razan Salaymeh