Overview on nonpharmacological managent of behaviour in children Presented by : Mayuri Karad SDDCH Parbhani Guided by : Dr. Rehan Khan Dept, of Pediatric and preventive dentistry

1. PRESENTED BY –
MAYURI KARAD

3.  DEFINITION
-BEHAVIOR
-BEHAVIOR MANAGEMENT
-BEHAVIOR SHAPING
-BEHAVIOR MODIFICATION
 CLASSIFICATION
 NON-PHARMACOLOGICAL BEHAVIOR
MANAGEMENT
-COMMUNICATION
-USE OF SECOND LANGUAGE(EUPHEMISMS)
-TELL-SHOW-DO

4. -DESENSETIZATION
-MODELING
-BEHAVIOR SHAPING
-CONTINGENCY MANAGEMENT
-EXTERNALIZATION
-DISTRACTION
-ASSIMILATION AND COPING
-PARENTAL PRESENCE OR ABSENCE
-RETRAINING
-VISUAL IMAGERY
-FLOODING TECHNIQUE
-VOICE CONTROL
-USE OF POETRY AND DRAWINGS
-HYPNOSIS
-HAND OVER MOUTH TECHNIQUE
-PROTECTIVE STABILISATION

5.  BEHAVIOR-
Behavior is any activity that can be observed , recorded
and measured.
 BEHAVIOR MANAGEMENT-
Behavior management is the means by which dental health
team effectively and efficiently performs treatment for a child and at
the same time instills a positive dental attitude.(WRIGHT,1975)
 BEHAVIOR SHAPING-
It is the procedure , which slowly develops behavior by
reinforcing a successive approximation of desired behavior until
desired behavior comes into being.

6. BEHAVIOR MODIFICATION
It is defined as the attempt to alter human behavior
and emotion in a beneficial manner according to laws of
modern learning theory.(EYSENCK,1964)

7.  NON-PHARMACOLOGICAL(PSYCHOLOGICAL
APPROACH)
-COMMUNICATION
-USE OF SECOND LANGUAGE
-TELL-SHOW-DO
- DESENSITIZATION
-MODELING
-BEHAVIOR SHAPING
-CONTINGENCY MANAGEMENT
-EXTERNALIZATION
-DISTRACTION
-ASSIMILATION AND COPING
-PARENTAL PRESENCE OR ABSENCE
-RETRANING
-VISUAL IMAGERY

8. -FLOODING TECHNIQUE
-VOICE CONTROL
-USE OF POETRY AND DRAWINGS
-HYPNOSIS
-HAND OVER MOUTH TECHNIQUE
-PROTECTIVE STABILISATION
PHARMACOLOGICAL MANAGEMENT
-PRE-MEDICATION
-CONSCIOUS SEDATION
-GENERAL ANESTHESIA

9. COMMUNICATION
-Communicative management is universally used in pediatric
dentistry with both the cooperative and uncooperative child
(chambers,1976)
-By involving in conversation, the dentist not only learns about
the patient but may also relax the patient
-Types of communication :
1. Verbal communication by speech
2. Nonverbal communication -Expressions without
words like hand shaking , eye contact , smiling
3. Both verbal and non verbal

10. -communication should be comfortable and relaxed.
- Communication with children aged 3 to7 years should be
based on Piagetian concept which involves life like name to
dental instruments like handpiece called whistling Charlie.
-The most important aspect of communication is getting the
child to respond to dentist’s command.
-The three most important facets of communication are source,
medium and receiver . In reference to dentistry , dentist is the
source , dental clinic is the medium and child is the receiver .
- If the dentist is good , sympathetic , confident and honest ;
dental is neat ,quiet , familiar to children ,full of toys; the
automatically child is communicating and is well managed.

12. USE OF SECOND LANGUAGE
(EUPHEMISM)
- Euphemisms are substitute words, which can be used in the
presence of child .
-The dental staff as well as dentist should oriented to the use of
second language .
DENTAL TERMINOLOGY WORD SUSTITUTE
Air - Wind
Anesthetic - Sleepy medicine or sleepy water
Bur - Brush or pencil
Impression material - Pudding or mashed potatoes
Caries - Brown spot : sugar bugs
Matrix - Fence for filling
Rubber dam - raincoat
stainless steel crown – Hat for tooth
X – ray - Camera
Radiograph - picture
Handpiece - Whistling train

13.  TELL – SHOW- DO
-Tell- show –do(TSD) , the cornerstone of behavior
management was given by Addleston in 1959.
- Specifically , the dentist tells the child what is going to be
done in words the child can understand .Second , the dentist
demonstrates to child exactly how the procedure will be
conducted . Finally ,practitioner performs the procedure
exactly as it was described and demonstrated .
- Objectives :
- To teach the patient aspect of dental visit and to
familiarize him with the dental settings.
- to shape the patients response to various procedures.
-TELL:
Tell the child before you do it, while you are doing it
and after you have done it . You voice should be soft , yet firm
, confident , and continuous .You should be truthful with the
child and if the procedure is going to be painful or
uncomfortable , say so.

14. Show :
- Demonstration of the visual , auditory, olfactory and tactile
aspect of the procedure in a carefully defined, nonthreatening
setting
- The dentist can either demonstrate on himself or an
inanimate object.
-The noise of running handpiece shows the child through
the hearing medium . A pinch on the arm before anesthesia
administration demonstrate to the child how the pinch of the
injection in the mouth might feel.
- Bring equipment from behind the child or the visual level
is preferred.

15. DO :
-With0ut deviating from explanation and demonstration dentist
perform the previewed operation .
-In doing, do what you said you would do.
- Do not do until the child has clear awareness of what it is you
are going to do.

16. - This technique was demonstrated by James and popularize by
Wolpe.
- It means take away ones sensitivity to a type of behavior.
- This is used in children having pre-established fears and
uncooperative behavior .
- Desensitization accomplished by teaching the child a
competing response such as relaxation and then introducing
progressively more threatening stimuli.
- Is an effective method for reducing maladaptive behavior .

17. -Introduced by Bandura ( 1969).
- It is based on one’s learning or behavior acquisition occurs
through observation of suitable model performing specific
behavior.
- Synonyms : imitation , observational learning , identification,
internalization , coping .
- Modeling seems to improve of the apprehensive child who
have had no previous dental experience .
- Types of modeling:
1. Audiovisual
2. Live modeling by parents , sibling etc.

18. OBJECTIVES OF MODELING:
 Stimulates acquisition of new behavior .
 facilitating the behavior already in the patients in more
appropriate manner.
 Elimination of avoidance behavior .
 Extinction of fear.
ADVANTAGES OF MODELING:
 Patient’s attention is obtained.
 Designed behavior is modeled.
 Physical guidance of the desired behavior.
 Reinforcement of the desired behavior

20. - It is defined as a process which slowly develops a behavior
by reinforcing successive approximation of the desired
behavior until the desired behavior is expressed ( Lenchner
and wright ,1975)
- It is based on stimulus- response theory.
- when shaping the behavior the dentist is teaching to a child
to behave .

22. - The presentation of positive reinforcers or withdrawal of
negative reinforcers is termed contingency management.
- It include :
- Positive reinforcement
- Negative reinforcement
- Omisssion or time out
- Punishment
a) Positive reinforcement – is one whose contingent
presentation increases the frequency of behavior ( Henry
W Fields ,1984)
b) Negative reinforcement – is one whose contingent
withdrawal increases the frequency of behavior ( Stokes
and Kenndy ,1980).

23. -Types of reinforcers =
 Social – e.g. , praise , positive facial expression , physical
contact by shaking hand , hug ,pat on shoulder
 Material - may be given in the form of games ,toys.
 Activity reinforcers – Involving child in some activity like
watching TV shows , visit to park.

24. - It Is the process by which child’s attention is focus away
from the sensation associated with dental treatment by
involving in verbal or dental activity.
Objectives:
- To decrease perception of unpleasantness
- to interest and involve children .

25. - The patient is distracted from the sound and/or sight of dental
treatment thus reducing anxiety.
- Objective is to relax the patient and to reduce anxiety during
treatment.
- Use stories and fairy tales.
- Use slow instrumental music .
- Types of distraction:
a. Audio distraction
b. Audiovisual distraction .

26. DISTRACTION

27. - Stress can act to increase pain perception while coping
decrease it by process called assimilation .
- Coping is defines as the cognitive and behavioral efforts made
by an individual to master, tolerate or reduce stressful
situations (Lazaue ,1980) .
- Coping effect may be of two types :
1. Behavioral – are physical and verbal activity in which the
child engages to overcome a stressful situation .
2. cognitive - Efforts which involves manipulation of
emotions .

28. OBJECTIVES -To avert avoidance behavior
-To establish authority
-To gain patient’s attention and compliance
-- Advantages of parental absence
a) Overcoming parental conditioning
b) Avoiding communication interference
c) Avoiding parental interference
-- Advantages of parental presence
a) Supporting and communicating with the child
b) Very young patients.

29. - Given by Pinkham in 1985
- Sudden and firm commands that are used to get the child
attention and stop the child from his current activity
Objective
1.attention and compliance
2. To avoid negative or avoidance behavior
3. To establish authority
 Indications
1. uncooperative and inattentive patients
 Contraindications
1. Children who due to age, disability, mental or emotional
immaturity are unable to understand .

30. - Use of poetry is employed in children above 7yrs of age .
- The poem is written as collective effort, the dentist contributing one
line and child next.
- Use of drawing is useful for children of 3-5 yrs of age .
- Child is given a paper and pencil or crayon and ask to draw some
picture.
 Advantages
-It allows repetition without monotony .
- The rhyme and rhythm can be used to guide the child towards the
information to be implied .
- It gives the child sense of achievement and increases self esteem.

31. - It was first suggested by Franz A Mesmer in 1773
-It is defined as state of mental relaxation and restricted awareness in
which subjects are engrossed in their inner experiences such as
imaginary are less analytical and logical in their thinking and have
enhance capacity to respond to suggestions in an automatic and
dissociated manner
 Uses
1. To reduce nervousness and apprehension
2. To eliminate defense mechanism that patients used to postpone
dental work
3.To control functional or psychosomatic gaping
4.To prevent thumb sucking and bruxism
5.To induce anesthesia

32. - This technique was first described in 1920 by Dr. Evangeline Jordan
Other terminologies :
- Aversive conditioning by Lenchner and Wright in 1975
- Emotional surprises therapy by Lampshire
- Hand over mouth airway restricted (HOMAR) by Levitas in 1947
- Aversion by Crammer in 1973
 Objectives
- To gain child attention enabling communication with dentist so that
appropriate behavioral expectation can be explained.
- To eliminate inappropriate avoidance behavior to dental treatment
and to establish appropriate learned responses.
- To assure child safety in delivery of quality dental care

33. Indication :
A healthy child who is able to understand and cooperate who
exhibit defiant , obstreperous or hysterical behavior to
dental treatment.
Contraindication :
1. Immature child
2. When it prevents child from breathing
3. When the dentist is emotionally involved with child

35. Indication :
 A patient who requires diagnosis or treatment and cannot cooperate
because of lack of maturity.
 A patient who requires diagnosis or treatment and cannot cooperate
because of mental or physical disabilities .
 When the safety of the patient or practitioner would be at risk
without the protective use of stabilization .
Contraindication:
 A cooperative patient
 As punishment
 A patient who cannot be safely immobilized because of underlying
medical or systemic conditions
 It should not be used solely for the convenience of the staff.

36.  Restraints are usually needed for children who are hyperactive ,
stubborn or defiant.
 Types of restraints-
a) For body- pedi wrap
papoose board
sheets
Beanbags with straps
Towels and tapes
b) For extremities- velcro straps
posey straps

37. c)For mouth- mouth blocks
mouth props
- molt mouth prop
- rubber bite block
- finger guards
d) Others – straps are attached to dental unit to restrain a child
waist and legs.
- sheets used to restrain patients movement. Eg;
papoose board/ pedi wrap.

38. Papoose board
Mouth props

39.  Proper assessment of children behavior of dentist to plan
appointments and render effective and efficient dental
treatment. Appropriate use of management techniques can
improve the child behavior in subsequent visits.
 A wide variety of behavior management techniques are
available to pediatric dentists which must be used as
appropriate for the benefit of each child patient, and
which, importantly, must take into account all cultural,
philosophical and legal requirements in the country of
dental practices of every dentist concerned with dental care
of children.

40. 1) TEXTBOOK OF PEDODONTICS- 2ND EDITION-
SHOBHA TANDON
2) TEXTBOOK OF PEDIATRIC DENTISTRY-3RD EDITION
–NIKHIL MARWAH
3)INTERNET SOURCES