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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

 BEHAVIOUR SHAPING:- is the
procedure which slowly develops
BEHAVIOUR by reinforcing a
successive approximation of the
desired behaviour until the
desired behaviour comes into
being.
 BEHAVIOUR MODIFICATION:-
is defined as the attempt to alter
human behaviour an emotion in
a beneficial way and in
accordance with laws of
learning.

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.

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

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.

LAMPSHIRE'SCLASSIFICATION(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:

CLASSIFICATIONBY 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

 UN-COOPERATIVE
a) UNCONTROLLED/HYSTERICAL:
usually seen in
 preschool children at their first dental visit
 temper tantrums i.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

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.

NONPHARMACOLOGICALMETHODS OF
 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

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

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.
 Airotor as whistle.

 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”

 TELL SHOWDO 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.

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

3.CONTIGENCY MANAGEMENT
 It is the management of modifying the
behaviour of 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
behaviours and thus strengthen the recurrence of
those behaviours.

 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

 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 gives
stimulation and the subject is taught to control the signals,
therefore useful in anxiety and stress related disorders.

 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 relief
in 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.

 COPING:
It is defined as the cognitive and behavioural efforts
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.

 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.

 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 behavioural and
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.

 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.

 TECHNIQUE:
After determining the child the child’s
BEHAVIOUR, the dentist firmly places his hand
over the child’s mouth and behavioural
expectations are calmly explained close to the
child’s ear.
When the child’s verbal outbrust is 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.

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:
Head positioner
Forearm body support
Velcro straps
Posey straps.
Towel and tapes
Pedi wrap
Papoose board
Sheets
Beanbag with strap
Towel and tapes

 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.

• 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..

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PHARMACOLOGICAL MEANS OF BEHAVIOUR
MANAGEMENT

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 .

 PHARMACOLOGICAL MEANS
CLASSIFICATION:-
 CONCIOUS SEDATION
 DEEP SEDATION
 GENERAL ANAESTHESIA

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

• CONSCIOUSSEDATION
OBJECTIVES
AcctoBennett:-
1.Thepatientsmoodshouldbealtered.
2.Pat.shouldbeconscious,respondtoverbalstimuli.
3.Pat.shouldbeco-operative.
4.Allprotectivereflexesintact.
5.Vitalsignsstable&normal.
6.Child’spainthresholdshouldbeincreased.
7.Amnesiashouldoccur.

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)

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

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.

 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.

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

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 –

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.

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

SEDATIVE DRUGS & DOSAGE
Chloral Hydrate: 30-80 mg/kg/dose PO, PR
Clonidine: 0.004 mg/kg PO (Max 0.1 mg)
Diphenhydramine: 0.2-2 mg/kg/dose IV q4-6h;
or 1.25 mg/kg/dose q6h (Max 400 mg/d)
Etomidate: 0.3 mg/kg IV
Haloperidol: 0.4-5 mg/dose
Ketamine: 1-2 mg/kg IV;
3-6 mg/kg PO;
6-10mg/kg PR;
3 mg/kg intranasal
Methohexital: 1-2 mg/kg/dose IV;
30-40 mg/kg PR
Midazolam: 0.05-0.3 mg/kg IV, IM;
Infusion: 0.4 mcg/kg/min
PO: 0.5-0.75 mg/kg
PR: 0.5-1 mg/kg
Intranasal: 0.2 mg/kg
Pentobarbital: 2 mg/kg IM, IV, PO
Propofol: 2-3 mg/kg IV;
Maintenance: 50-300 mcg/kg/min
Thiopental: 3-7 mg/kg IV
PR: 20-40 mg/kg

 GUIDELINES FOR USE D BEFORE 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.

 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.

 Do not drive an automobile. Bike or use
any machinery.
 Do not drink any alcohol or take any
medicine that is not prescribed by the
doctor.
 Do not take any complex or legal decision.
 Start with liquid and advance to other food.
 You feel groggy, dizzy and tired for 24
hours.

• Fear and anxitey 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..

HAPPY INDEPENDENCE DAY IN ADVANCE!!!!!!!

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