Behaviour management in a dental office refers to methods of obtaining a child’s approval for treatment on a dental chair based on communication, and patient/ parent education with empathy, coaching and listening. This article covers the factors and classification of behaviour management techniques.

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Objectives of behaviour management (Snowder, 1980)

1. To establish effective communication with the child and parent.
2. Gain child and parent confidence for dental treatment.
3. Teach children positive aspects of preventive dental care.
4. Provide a comfortable, relaxing environment for the child.

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Factors influencing child’s behaviour

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Classification of behaviour management techniques

A. Psychological approach

• Preappointment behaviour modification
• Communication
• Use of a second language
• Tell, show, do
• Tender love care
• Desensitisation
• Contingency management
• Visual imagery
• Modelling
• Behaviour shaping
• Assimilation and coping
• Hypnosis
• Retraining
• Distraction
• Externalisation
• Parental presence or absence
• Reframing
• Voice control

B. Physical approach

• Hand over mouth
• Physical restraints

C. Pharmacological

• Premedication
• Conscious sedation
• General anaesthesia

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Preappointment behaviour modification

A. Audiovisual modelling

1. The goal is to reproduce the behaviour exhibited by the model.
2. The child sees a video cassette before proceeding to the dental clinic, on the day of the appointment.
3. The type of model can be siblings, other children or parents.
4. It is best recommended to use the model of the same.

Advantages

• Stimulation of new behaviour
• Facilitation of behaviour in a more appropriate manner
• Elimination of inappropriate behaviour because of fear
• Extinction of fear

B. Preappointment mailing

1. Contact the child’s parents before the first dental visit.
2. Preparing the patient for the first dental visit increases the likelihood of success.
3. Parents can be contacted by telephone as a reminder the day before the dental appointment.

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Communication

There are 2 ways of establishing communication: Verbal & Nonverbal

Verbal communication (Use of Euphemisms)

Euphemisms should be used such as:

• Xray: photo
• Xray machine: camera
• Rubber dam: raincoat
• Air rotor: whistle
• 3way syringe: air water gun
• Suction: vacuum cleaner

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Tell-Show-Do(TSD)

1. By Addleston in 1959.
2. It is the most effective technique.
3. The child is told about the procedure in a language and words understandable to the child. Then child is shown instruments and materials and a way of performing the treatment(approximation). When the child becomes assured and relaxed, treatment is completed.

Various modifications of the concept of TSD have been introduced recently:

• Tell-Play-Do (TPD)
• Tell–Show-Play-Doh

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Ask-tell-ask

1. It involves inquiring about the patient’s visit and feelings toward or about any planned procedures (ask).
2. Explaining procedure through demonstrations and non-threatening language(tell).
3. And again inquiring if the patient understands and how the child feels about treatment (ask).

Objectives

• Examine any anxiety that can cause non-compliant conduct while receiving treatment
• Teach the patient about the procedures and their implementation
• Confirm the patient is comfortable with treatment before proceeding

Desensitisation

1. By James and popularised by Wolpe.
2. It means to take away one's sensitivity to a type of behaviour. This is used in children having pre-established fears and uncooperative behaviour.

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Modelling

1. Based on Bandura’s social learning theory, states that one’s learning or behaviour acquisition occurs through observation of a suitable model performing a specific behaviour.
2. It is used to eliminate or minimise the fear of dentistry in children by allowing children to observe an older sibling undergoing dental treatment.

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Contingency management

1. Based on BF Skinner’s operant conditioning.
2. Contingency management is the process of presenting positive reinforcers or removing negative reinforcers.

There are 3 Types of reinforcements:

• Social (praise, handshake, pat, hug)
• Material (gift, toys and not sweets)
• Activity (watching TV shows, cartoons)

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Externalisation

The process by which a child’s attention is focused away from sensation associated with dental treatment by involvement in verbal or dental activity.

Objectives

• To decrease the perception of unpleasantness
• To interest and involve children

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Distraction

1. A more recent approach to behaviour control lowers anxiety by diverting the patient's attention from the sounds and/or visuals of dental procedures.
2. Objective relax the patient and reduce anxiety during treatment.
3. Use stories and fairy tales.
4. Use slow instrumental music.
5. The sound of music will eliminate unpleasant dental sounds like the sound of a handpiece.

There are two types of distractions:

A. Active distraction

• Interactive toys
• Guided imagery
• Controlled breathing and relaxation
• Virtual reality

B. Passive distraction

• Audio: listening to music
• Audio-visual: watching television

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Memory restructuring

Behavioural approach in which memories associated with negative or difficult events (e.g., first dental visit, local anaesthesia, restorative procedure, extraction) are restructured into positive memories using information suggested after the event has taken place.

Restructuring involves four components:

1. Visual reminders (photo of a child smiling at first visit).
2. Positive reinforcement through verbalisation.
3. Concrete examples to encode sensory details.
4. Sense of accomplishment.

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Retraining

Designed to fabricate positive values and to replace negative behaviour

Approaches

• Avoidance (e.g. avoid extensive pulp therapy with pulp capping)
• De-emphasis and substitution (e.g. substitute high-speed handpiece with spoon excavator)
• Distraction (e.g. distract the child with stories/activities/audiovisual aids)

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Flooding technique

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Voice control

1. By Pinkham in 1985.
2. Sudden and firm commands are given to gain the child’s attention.

Objectives

• To gain patient attention and compliance
• To avoid negative behaviour
• To establish authority

Contraindications

 Children who due to age, disability, or mental or emotional immaturity are unable to understand.

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Reframing

It is defined as “taking a situation outside the frame up to that moment containing the individual in different conditions and visualise(reframe) it in an acceptable manner to the person involved and with this reframing, both the original threat and the threatened solution can be abandoned”

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Hypnosis

By Franz A Mesmer in 1773.

Uses

• To reduce nervousness and apprehension
• To eliminate defence mechanisms that patients use to postpone dental work
• To control functional or psychosomatic gapping
• To prevent thumb sucking and bruxism
• To induce anaesthesia

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Hand-over-mouth technique

By Dr Evangeline Jordan in 1920.

Objectives

• Gain the child’s attention by enabling communication with the dentist
• Eliminate inappropriate avoidance behaviour to dental treatment
• Increase child’s confidence
• Assure child safety

Variations of the techniques: Airway uninstructed, hand over both nose and mouth(HOMAR), towel held over mouth only, dry towel over nose and mouth, wet towel over nose and mouth.

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Protective stabilisation

Restriction of patient’s freedom of movement, with or without patient’s permission, to decrease risk of injury while allowing safe completion of treatment.

Equipments:

For limbs:

• Posey strap
• Posey vest

For body:

• Pedi wrap
• Papoose board

For mouth

• Mouth props
• Tongue blades

Objectives

1. To reduce or eliminate unwanted movement.
2. Protect patient, staff, dentist or parent from injury.
3. Facilitate delivery of quality dental treatment.

Indications: In the patient who requires immediate diagnosis, urgent care, and treatment.

Contraindications: Patients associated with medical, psychological, or physical conditions.

Precautions:

1. Patient’s medical history- reviewed carefully.
2. Tightness and duration of stabilisation must be monitored at regular intervals.
3. Stabilisation around extremities or the chest must not restrict respiration.

Disclaimer- The views and opinions expressed in this article are those of the author and do not necessarily reflect the official policy or position of M3 India.

About the author of this article: Dr Neha Kalantri is a practising dentist from Nashik.