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 PRECAUTIONS:
 Tightness & duration of the stabilization must
be monitored
 The stabilization must not restrict circulation
 Stabilization should be terminated as soon as
possible in a patient who is experiencing severe
stress
Physical restraint
BEHAVIOUR MANAGEMENT
AVERSIVE CONDITIONING

BEHAVIOUR MODIFICATION
DESENSITIZATION
 Indications:
i. Initial visit
ii. Subsequent visits for every new interaction of the child
iii. Apprehensive child due to previous information .
 Effective in children above 3 yrs of age
 Begins from initial entry till completion of the procedure
 The heirarchy of events may be decided by the dentist
for the individual patient

⦿“The patient needs to wear the functional
appliance for a brief time only during day-time
to influence the muscles in such a way that
the neuromuscular masticatory pattern is
improved” (Sander, 2001).
⦿Furthermore, “three hours of continuous
stimulation is enough to move the tooth in the
periodontium and to produce alveolar bone
remodeling” (Roberts, 1997).

• Exercising jaw muscles
• Encouraging correct chewing
• Training correct nasal breathing
• Correcting tongue position
• Good replacement of pacifier / dummy

⦿ Introduced in 1992 (most successful product of MRC)
⦿Tooth channels and labial bows guide the
erupting/developing dentition into correct alignment,
while the tongue tag and lip bumpers treat
myofunctional habits.
⦿Starting is a soft (Silicone) Phase 1 appliance

⦿THIS IS MUCH STIFFER FINISHING OR PHASE 2 IS HARDER
(POLYURETHANE).(SAME PRINCIPLE AS ORTHODONTIC
ARCHWIRE). AS THE TEETH COME INTO PLACE, MORE
FORCE CAN BE USED TO ENCOURAGE THEIR ALIGNMENT.
⦿ The myofunctional characteristics are the same as the T4K
Phase 1.
⦿ Use the finishing T4K Phase 2 for a further 6 to 12 months.
⦿ NOTE : Use beyond this period is recommended depending on the outcome
and the next phase of orthodontic treatment.

 It involves three techniques:
 DESENSITIZATION
 MODELLING
 CONTINGENCY MANAGEMENT

DESENSITIZATION
 The concept comes from “systemic
desensitization” used to reduce anxiety in
patients by behavior therapists.
 Patient learns to replace anxiety by relaxation

GFXTUXCHVHKF JB J,BGJ,ATION
DESENSITIZATION
 Joseph Wolpe has suggested that in place of
imaginery scenes, real life contacts can be effective
in a dental situation.
 The method employed is called TELL-SHOW-DO
 Introduced by Addelston
 Involves telling, showing of stimuli in increasing order
of fear, followed by doing the procedures.
 Language chosen should be simple
 The situation is presented to the child slowly and
repeatedly

MODELLING:
 The basic procedure involves allowing the
patient to observe one or more individuals who
demonstrate appropriate behaviors in a
particular situation
 The model may be real or symbolic(posters)
 Was introduced by BANDURA

MODELLING:
 Steps-
 Gain attention of the patient
 Desired behavior is modeled
 Physical guidance may be needed
 Reinforcement of guided behavior
 Reinforcements for appropriate behaviors without
modelling

MODELLING:
 It is effective when :
 Observer is aroused
 Model has higher status and prestige
 Associated with positive consequences

CONTINGENCY MANAGEMENT
 It is a method of modifying the behavior of
children by presentation or withdrawal of
reinforcers
 Reinforcers by definition increase the
frequency of a behavior
 Types of reinforcers:
 Positive: presentation of which increases
behavior
 Negative: withdrawal of which increases
behavior

CONTINGENCY MANAGEMENT
 Can also be classified as
 Social reinforcers-praise, facial expressions,
physical contact
 Material reinforcers- toys, games. Sweets
should not be given.
 Activity reinforcers- seeing a movie, watching
tv,outdoor games,etc

PREAPPOINTMENT PREPARATION
 It involves preparing the child as well as
the parents for the forthcoming dental
visit.
 This can be done by:
 Messages in the form of letters or emails
 by showing videotapes, audiovisual aids
and live models.

 Also called as WHITE NOISE
 Involves providing a sound stimulus of
such intensity that the patient finds it
difficult to attend to anything else.
AUDIOANALGESIA

 Also called as “suggestion therapy”
 Technique of producing altered state of
consciousness without the use of
pharmacological agents.
 Very rarely used in dentistry.
HYPNOSIS

 Children respond to stressful situations by coping.
 It includes an individual’s internal and emotional
processes and his external behavioral responses.
 The way the patient copes with his fears
determines the type of patient he is.
COPING

 Mechanisms:
 By thinking of something else- “Distraction”
 Verbalizing fears to others
 Preferring to be with others, say, mother- this is
called “employing affiliative behavior”
 “Mental rehearsal”- going over in one’s mind in
advance the sequence of anticipated events and
reappraising the threats involved.
COPING

 It involves a series of basic exercises which the
patient practices at home and may require
several weeks to months to learn.
 Therefore seldom used by clinicians.
RELAXATION

 Aversive conditioning
 Aversive conditioning is the extension of overall
behaviour guidance designed to facilitate the
goals of communication, cooperation & delivery
of quality oral health care in difficult children.
 It includes three practices:
1. Voice control
2. Hand-over-mouth exercise (HOME)
3. Physical restraint/Treatment immobilization

1. Voice control
 Voice control is a controlled alteration of voice,volume,
tone,or pace to influence & direct the patients behaviour .
 Parents unfamiliar with this technique may benefit from a
prior explanation to prevent misunderstanding
 OBJECTIVES:
I. To gain patient’s attention & compliance.
II. To avert negative or avoidance behaviour.
III. To establish authority
Voice control

2. Hand-over-mouth exercise (HOME)
 popularized by : EVANGELINE JORDAN
 OBJECTIVES:
 To redirect child's attention enabling communication
 To extinguish excessive avoidance behavior
 To reduce the need for sedation or G.A .
 INDICATIONS:
 For uncooperative child
 A healthy child who is able to understand verbal
commands & cooperate , but exhibits negative behaviour
AVERSIVE CONDITIONING Hand over mouth exercise

 CONTRAINDICATIONS:
 Child under 3 yrs of age
 Special child (physically, emotionally & mentally
compromised)
 Child with airway obstruction or mouth
breather.

 MODIFICATIONS:
HOM with airway unrestricted
HOM with airway restricted (HOMAR)
Towel held over nose & mouth
Dry towel held over nose & mouth
Wet towel held over nose & mouth

3. Physical restraint/Treatment immobilization
 It is the direct application of physical force to a
patient with or without the patient’s permission to
restrict his or her freedom of movement.
 It may be:
 Active: Performed with restraining
device
 Passive: Performed without
restraining device
AVERSIVE CONDITIONING Physical restraint

 OBJECTIVES:
 To eliminate unwanted movement.
 To protect patient, staff or dentist from injury
 To facilitate quality dental treatment.
 INDICATIONS:
 A patient who requires immediate diagnosis treatment
& can’t cooperate
 When the safety is at risk
 Child who is becoming tired from long appointments
 A sedated pt who requires limited stabilization
 Stubborn child
Physical restraint

 TYPES OF RESTRAINTS:
 FOR BODY:
 Pedi wrap
 Papoose board
 Sheets
 Beanbag with straps
 Towel & tapes
 FOR EXTREMITIES:
 Velcro straps
 Posey straps
 Towel & tapes
Physical restraint

 FOR HEAD:
 Head positioner
 Forearm body support
 Extra assistant
 FOR MOUTH:
 Mouth blocks
 Banded tongue blades
 Mouth props
 Finger guard or interocclusal thimble
Physical restraint

 Implosion Therapy
 Child patient is flooded with so many stimuli that
he has no other option than to face it, until the
negative behavior disappears.
 It may include HOME, voice control, physical
restraints.
Implosion Therapy

 Retraining
 employed in case of children presenting negative
behavior, with bad experience in previous dental visits,
or improper peer or parental orientation.
 The child presents such behavior due to STIMULUS
GENERALISATION, where similarities in stimuli
generate similar responses.
 In retraining, we make the child DISCRIMINATE
between old and new stimuli,
 The older response gradually diminishes - this is known
as RESPONSE EXTINCTION.
Retraining

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