This script has 2 parts ; continues from the last lecture (bm 2) and bm 3

Never lie about needle. If the child asks do you have a needle? or If the child asked " will injection hurt?" dont directly say that it is hurt.. but answer him that he will feel a little pinch (when you are honest, the child will behave better.) If avoidance behavior by the child - like moving his face or pushing your hand... - use firm voice control, change your voice control so you can give authority. - dont delay the LA. Once mouth is open for access and LA in your hand, give the LA. Do not show needle to patient. dont show at all or your mark will be reduced. It is ok if child cries during LA. but you have to keep assuring and keep talking to the child. Restraint of arms and body required always. - When patient in supine position, operator on the right, and - Assistant is on the left side. , pass needle to the operator below the patient's chin and behind the patient. His left arm put across pt's arm just gently to restrain the arm of pt. and the right hand use to stabilize head of patient. - Operator retract tissue wuth one hand and the other hand giving the injection. - So, that's why you are working in pairs. This is how you are giving LA together. One thing i want to remind you about ID block. It's wrong to retract tissue using finger bcoz 3:24 The needle can suddenly strike your thumb during retracting the tissue. So it is better to use the mirror. It will be a bit difficult at the beginning because you use to have your thumb there. But you can fee the area with your thumb and focus on the spot of injection. Then, you can retract using the mirror.

5. THE DENTAL PROCEDURE. Also can be something critical or feared by the patient. Goo d patient accept treatment and may fall asleep. The restorative tx : poor beh may result from drilling especially from the sound or vibration eventhough a good LA is provided. Extraction : poor beh from torquing and force applied to tooth eventhough with good LA provided. Example of good behavior patient pic in slides page 14.

6. END OF APPOINTMENT. Some patients are good throughout procedure and keep emotions then explode at the end. Good child eager to leave but waits to be dismissed and praised Bad child cries runs off chair

1|Page

7. RETURN TO THE PARENT Some children want parents to feel guilty about making them go to the dentist behave as victims. Good patient returns with pride, pleased by self Bad patient cries and behave as a victim. Start blaming his parent.

CONSEQUENCES OF BM ETHICAL AND LEGAL ISSUES. The legal guardian shares with dentist decision about tx and BM. Before you start you should explain some of the technique to the parents. some BM techniques dont require legal consent because they are part of communication like voice control techniques but some of them need signature of the parent such as HOM technique The dentist informs legal guardian about BM technique used (nature risks, benefits and any alternative technique) All questions must be answered as this is the essence of informed consent : Informed consent means that the parent has given dentist permission to do a particular technique like HOM . the parent should know the following about technique: - why indicated? - what constitutes its practice - why do u use it ? - what are alternatives to it ? ( e.g. you want to use HOM , you tell the parent that my alternative is GA) - what are potential benefits of it? ( we talk about potential benefits because there are benefits but on the other hand it may have drawbacks ) - what are potential disadvantages or untoward event that may occur bc of technique. Different according to child beh, technique used some have good effect on child some have bad effect, parent attitude. Eg ; use of (1) HOM may lead to phobic pt, or develop +ve attitude. And parent may still seek your care. (2) +ve reinforcement (praise, rewards , modelling) decrease disruptive beh. Time out decrease pt disruptive beh according to period and frequency . (should be short & used 1-2 times)

2|Page

Behaviour management III

In general BM techniques are classified into: - pharmacologic - nonpharmacologic 1) pharmacologic : by giving certain drugs to make the patient behave. - LA, GA, sedation or combination. 2) Non-pharmacologic techniques: - communication - Tell-Show-Do (TSD) - Voice control (VC) - Distraction - Positive reinforcement - Modeling - Parental presence/ absence [1] COMMUNICATION : Is a sense of BM Something that happen by gesture as the pt enter the clinic. Before you start communicate with them asking information and history , establish a rapport with them first. 2 types : 1.1 : verbal communication talking or speech. Use with anybody either cooperative or non cooperative patient. Its the most fundamental form for BM Its the basis for establishing relation with child and it help develop positive attitude. Associate with all other types of techniques. Comprise elements of communication and appropriate for all patient.

1.2 : non verbal communication Gesture or facial expression smile, look into patients eyes, etc. It enhances the effectiveness of other communication techniques It gains or maintains patient attention and compliance It may be used with any patient and has NO contraindications smile in front of your patient , show him that you are happy for how good he is today and pat on his shoulder.

[2] TELL SHOW DO

3|Page

It involves informing, then demonstrating and finally the procedure for example . verbal explanation of procedure in phrases appropriate to the developmental level of patient ( tell part) , demonstrating for patient of visual, auditory ,olfactory &tactile aspect of procedure (Show) and then without deviating from explanation complete the procedure (DO). it is used with communication skills it is CONTAINDICATED in LA injection where you tell and do WITHOUT show.

E.g. Matt, I'm going to clean your teeth with this special dental toothbrush. You see this soft rubber cup? Well, when I step on this gas pedal this cup turns, and when it is full of toothpaste it can really make your teeth shine (TELL). Now, Matt, pinch the cup and you will see how soft it is. Now let me run it on your fingernail so you can feel how it works (SHOW) if you feel you gain his attention and he understands say: Okay, please open your mouth for me. And then praise, Thank you the objective : it teaches the patient about the procedure it shapes the response. You make him response in positive way. It may be used with any patient and there are no contraindications.

[Voice control] Controlled operative in the vocal tone. For example, if youre angry, and you decide that youre going to raise your voice so, that the child will behave. Then, your voice will turn to normal. So, it is controlled. it is controlled operation in vocal tone, volume, pace and intonation (serosity). Intonation means that you try to apply authority in your voice. so, this is to employ direct patient behaviour . considered acceptable by parents and reflecting the parents used at home. It requires the dentist to interject authority into the communication with the child.

Facial expressions are important. When you work in child authority, your facial expression has to be overwied. Your objectives are to gain the child attention and compliance and avert any negative or avoidance behaviours, and establish appropriate adult-child roles. Doesnt mean you have to be shouting and screaming,

4|Page

or youre angry, you just change the tone of your voice for a few seconds until you behave and go back to the procedure. [Distraction.] It means ignoring then diverting attention away from what may be perceived as unpleasant procedure to something considered less fearful and provoking.

For example, if youre in the middle of extraction, and you want to remove the tooth, suddenly the tooth fractures. The patient is panic. Then, you put a piece of gauze, press it for a few minutes and go back to the treatment procedure. So, it is some of distraction. You divert the patients attention away from what you work. The objectives : to decrease the perception of unpleasantness-it may be from tangible objects or task such as during administration of LA to avert any negative and avoidance behaviours.

[Positive reinforcement.] It is a technique to reward any desired behaviour and strengthens as it occurs . so, this is what we do at home. When the children do something good, we reward them with the money or gifts. Because we are happy and we dont mind it reoccur. Social reinforcers are very important because they include facial expressions smiling to the patient, praising him. So, verbal praises are important as well for all dental team. in the clinic, you and your nurses, the receptionist and everybody is working with you, even the mate, they should understand your work. so if you praise the patient, everybody should also praise him. It is just like some sort of agreement between the dental team.

The objectives to reinforce the desired behaviour and is indicated for any patient. It is an excellent technique for children

[Modelling]. It involves providing examples and demonstration about how to do something. It helps children accept certain task/procedure in which they are not familiar. For example, exampling older children in front of younger children. And sometimes it can be opposite. It involves acquisition and performance. So, when youre performing modelling in front of him, the other child will acquire and he will perform.

5|Page

Role models should be somebody that the child respects and normally they are imitated.

[Parental presence absence] Objectives: -gain patients attention and compliance - avert negative or avoidance behaviour - establish authority of the dentist - enhance communication environment

Advance technique
-hand over mouth - immobilization technique * both require written consent

[HOM] where the dentist places his hand over the mouth of a hysterically crying child. It is used to intercept tantrums or other fits of rage. This technique is not intended to scare the child and is intended to get the child attention. The child cools down and to hear what are youre going to say.

American Academy of Pediatric Dentistry (AAPD) recognizes HOM as legitimate technique with certain indications and contraindications. The hand is gently placed over the mouth. It is actually to show that child is in controlled. The idea of it is the management aspect, not to scare the child. Maintenance of the patients airway is mandatory. Upon the childs demonstration of self control and suitable behaviour, the hand is removed and the child is given positive reinforcement. Communication should be used.

The indications: The child should normal and healthy to understand what you say so, he understands the directions by the dentist and

6|Page

Co- cooperative but exhibits defiant behaviour.

The contraindications: To any disabled, immature and medicated children and preventing the child from breathing.

Legal aspect. You have to explain other behaviour modalities/ other alternatives technique. patients dental needs the effect on the quality of dental care patients emotional development patients physical consideration Regarding the written consent, you should have informed consent and indication why to use it.

The objectives Redirect the childs attention Eliminate avoidance behaviour Ensure childs safety Reduce need for sedation or GA

Critics suggested that it may be psychologically aggravating to the child. [Immobliization]. It involves mouth prop. It si used to keep the mouth open. It holds childs had head, arms or feet employed by dental assistant. it is called restraining device papoose board.

It is stabilization device and important especially to the child who need special need. Indications : It is used for very young children who need emergency treatment after trauma, disabled patients the safety of the patient would be at risk

Contrandications: .patient who cant be immobilized safely due to medical conditions

Other techniques:
1. Structuring : you tell the child the specific goals for the visit. Explanation should be given in short time.
7|Page

2. Systemic desensitization : gradually working through hierarchy of stimuli from least anxious to most anxious. For example, today you do fissure sealant and the next visit,probably you will do PRR. So you start with something simple and then to something more difficult. 3. Time out : means save time during dental procedure for the child to cope. When the child is crying, you ask the child to count from 1-10 during cavity preparation. Then, you stop, and you give break. So, it is called time-out. 4. Playful humor : means everybody have the humour even the way we dress, the way we behave and they way we explain him. Rubber dam in paediatric dentistry, it is consired behaviour a management technique because it allows dental access, it controls tongue and lips, controls moisture and excellent infection control. Dental office Is one of behaviour management tools,. It includes the decor, the paintings, the toys we provide, the waiting room, the design of the whole office. Dental teams good attitude also helps.

By: Nadhirah ahmad Nurul adila mat dait

8|Page

9|Page