behavior guidance

Behavior Guidance

Dental patient &

pediatric dental patient

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DentistAdult pt

CHILDPT

DENTIST

PARENT

Communication is a two-way process .

Communication skills are a key aspect of a good dentist-pt

relationship .

Communication involves information giving & building rapport.

Good dentist-pt communication has a significant impact upon both the pt’s health and the dentist’s job satisfaction.

Communication

NON –VERBAL

GENERAL

VERBAL

SPECIFIC

VERBAL

General verbalcommunication skills

Give advice and instruction as early as possible in the interview .

Give specific detailed information rather

than general comment .

Use short words & sentences , avoid jargon .

Repeat essential information regarding the diagnosis and treatment .

Avoid asking questions which require

lengthy answers whilst you are working in the pt mouth .

Try to adopt a friendly , warm manner . .

Specific verbal communication

-Responses to dental treatment vary. -Some pts prefer to be given a step-by-step description of what is occurring ,but others like to distance themselves from the treatment process as much as possible. -Give positive information before the negative(non-threatening language) . -Clarify any

misunderstandings .

Non-verbal communication skillsUse appropriate eye contact .

Use active listening skills .Have a relaxed body posture .

Physical proximity .Use written information .

Principles of Behavior Change

PAVOLOV a Russian physiologist

identify the rln animal B &

environmental stimuli

Operant conditio

ning

Classical conditio

ning

Classical conditioninge.g the sound of a dental drill would be not noticed . However , if it has been paired with pain (unconditioned stimulus) during previous dental procedures, the sound of the drill becomes a conditioned response :fear ; anxiety. e.g white coat , eugenol odour ,protective glasses , even sitting in the waiting room.

Operant conditioning

Law of effect Any behavior that is followed by satisfying consequences will tend to be repeated or increase in frequency ,whereas behavior that is followed by unpleasant consequences will occur less frequently.

ReinforcerPunisherExtinction.

Dentist’s interpersonal skills.Interest in the pt’s well-being.Enthusiasm for the work the dentist is doing.

Encouragement of the pt’s efforts in what domain is relevant(OH ,overcoming fear , dietary change).

A Painful experience = significant punishing consequences

Adherence to treatment The extent to which a person’s behavior coincides with medical or health advice like taking medication , follow dental regimes , or executing lifestyle changes. Collaborative relationship.Pt is not a passive participant.

Carefully consider the pt’s perspective(beliefs , social

circumstances , level of support , language skills)

Adherence To Treatment

PROBLEMS With ADHERENCE

Information

Memory

Clinician pt

rln

Pt belief

s &cognitive level

Improving Adherence

Giving informatio

n

Motivation

Behavior GuidanceA continuum of interaction involving the dentist and dental team , the pt and the parent directed toward communication and education.

Assess accurately the child’s developmental level , dental attitude , temperament and to predict the child’s rxn to treatment.

-clinical art form.-Requires skills in communication ,

empathy , coaching , tolerance , flexibility , active listening

-cooperative , relaxed , self confident.g.

Goals of BG-Establish communication , alleviate fear and anxiety.

-Effective/efficient delivery of care.-Instills positive dental attitude.

-Builds foundation of respect and trust.-Teaches good coping skills.

Fear Types1.Innate fears : child

intellectually unable to arrest fears bc of chronologic age

-slow development(mental retardation)

-emotionally ill child(overreacting bc of emotional upsets in life)

2-Acquired fears :peers, siblings , parents.

3-Learned fears : due to previous painful experience.

Fears & Age -Fear of

strangers 7-12 month -Fear of separation

from parents start from 6 mths , peaks 13-18

mths , then declines……fades at 36-40 mths

-3 -yrs=sep anxiety + visual fear

-4- yrs=Auditory fear-5-yrs=sep anxiety

disappears + fear of harm to body

Pain management-critical for successful B.G

-Prevention of pain ; nurture the rxn btn dentist and pt , build trust , allay fear and anxiety , enhance positive dental attitude for further visit. BUT subjective nature of pain perception , varying pt responses to painful stimuli and lack of use of accurate pain assessment scales may hinder the dentist’s attempts to diagnose and intervene. during procedures

Faces Pain Scale-Revised

Dental team behavior

•The staff must be trained carefully to support the dentist’s efforts and welcome the patient and parent into a child-friendly environment that will facilitate B.G and positive dental visit.

Barriers-Reasons for noncompliance in the healthy ,

communicating child are more subtle and difficult to diagnose.

Dentist’s behavior : rushing through appt , not taking time to explain , barring parents from

exam. room& generally being impatient .Medical history : Developmental delay , physical/mental disability and chronic or acute disease.

-Fears transmitted from parents , a previous unpleasant and/or painful dental or medical experience , inadequate preparation for the first encounter in the dental environment , or dysfunctional parenting practices.

Parental influence-parents exert a significant

influence on their child’s behavior especially if they had previous negative dental experience . Educating the parent before the child’s first dental visit is important.

Child’s beh. dependant on type of interaction they have w their

parents .

Parental AttitudeOver

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Overi

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Attit

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Under-af

fecti

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MaladaptiveChild

Overprotective Attitude

Overindulgent Attitude

Over-authoritative

attitude

Under-affectionate/Rejecting

Misbehaving Child

Emotionally Compromise

d Child

Shy Introverted

Child

FrightenedChild

Child who isAversive toAuthority

Practitioners are faced with challenges from an increasing number of children lack the coping skills and self-discipline necessary to deal with new experiences in the dental office.

Patient Assessment-The response of a child pt to the

demands of dental treatment is complex and determined by many factors;

Child age/cognitive level, temperament /personality characteristic , anxiety and fear , rxn to strangers , previous dental experiences and maternal dental anxiety influences a child’s rxn to dental setting.

Dentists should record the pt’s behavior as a diagnostic aid for future visits.

Frankl Behavioral Rating Scale

Definitely Negative

_ _

Negative_

Definitely Positive

+ +

Positive+

Wright’s clinical classification

Cooperative

Lacking in cooperative ability

Potentially cooperative

Deferred treatment-Dental disease is not life-

threatening and the type and time of dental treatment can be deferred in certain circumstances .

-Risks and benefits , informed consent.

-Rapidly advancing disease , trauma , pain , infection usually dictates urgency of treatment.

-Deferring treatment and replaced with ITR,FL varnish , AB.

-Hysterical or uncontrollable child.

Informed consent

All decisions regarding use of behavior techniques must be based upon a benefit vs risk evaluation.

-Other than communication guidance.-Informing the parent about nature , risk benefits

of technique may be used and any professionally recognized techniques is essential to obtaining informed consent.

-All questions must be answered to the parent’s understanding.

BASIC BEHAVIOR GUIDANCE

ADVANCE BEHAVIOR GUIDANCE

Basic Behavior Guidance

COMMUNICATION

VERBAL & NONVERBAL

TSD

Advance Behavior Guidance

Protective Stabilization

Sedation

General Anesthesia

Communication-imparting or interchange of thoughts ,

opinions , or information.-affected primarily through dialogue , tone of

voice , facial expression and body language.-the 4 essential ingredients:

Sender , message , setting in which the message is sent and receiver.

Verbal Communication-Used w coop & uncoop

children(all pt)-Basis for establishing relation

w child.-Ass w all techniques.

A child’s cognitive development will dictate level &amount of information change.

No specific consent needed prior to use.

Verbal Communication

-Begin of dental apt the 2-way interchange of information gives way to 1-way guidance of behavior through commands.

-This type of interaction called requests and promises.

-Request elicit promises from the pt that , in turn, establish a commitment to cooperate.

-Assure the child is comfortable & no pain.

-Rerequest can be used

Nonverbal communication

The reinforcement & guidance of behavior through appropriate contact , posture , facial expression , and body language.

Obj.1-enhance the effectiveness of other communicative techniques

2-gain or maintain pt’s attention & compliance .

Ind. may be used w any ptContra. none

Tell-Show-Do-Tell=verbal explanation of procedures in phrases appropriate to the

developmental level of pt . Use fun labels or terms(word substitute)

-Show=demonstration for the pt of the visual , auditory , olfactory , and tactile aspects of the procedure in a carefully defined ,nonthreatening setting.

-Do=w/o deviation from the explanation and demonstration ,completion of procedure

TSDObjectives:

•1-Teach the pt important aspects of the dental visit& familiarize him w dental setting.

2-shape the pt’s response to procedures through desensitization and well-described expectation.Ind: may be used w any pt.

Contra. : LA injection or any procedures that defy explanation e.g pulp extirpation.

-Can be used w comm. +VC.

Voice ControlVC=A controlled alteration of voice volume , tone , or pace to influence and direct the pt’s behavior.

-Explain to parent to prevent misunderstanding.Obj:

1-Gain pt’s attention & compliance.2-Avert –ve or avoidance behavior.3-Establish appropriate adult-child

roles.Indication=may be used w any pt.

Contraindication=pt’s w hearing .impairment

Reinforcement Positive

-Technique to reward desired behavior & strengthen its recurrence(gift not bribe).

-Social reinforcers include facial expression, +ve voice modulation ,verbal praise & appropriate physical demonstrations of affection by all members of dental team.

-Nonsocial reinforcers include tokens &toys.Obj. To reinforce desired behavior.Ind. May be useful w any pt.

Contra. None

Distraction- Diverting the pt’s attention from

what may be perceived Visual d. posters))as an unpleasant procedure.

Obj.1-Decrease the perception of unpleasantness;

2-Avert –ve or avoidance behavior.Ind. May be used w any pt.Contra. None.

Parental Presence/absence-A wide diversity exists in practitioner philosophy &

parental attitude regarding parent’s presence or absence during pediatric dental treatment.Obj. for parents to :

1-Participate in infant exam/ treatment; 2-Offer very young children

physical & psychological support;3-Observe the reality of their

child’s treatment.

Protective Stabilization -The restriction of pt’s freedom of movement , w or w/o pt’s permission,

to decrease risk of injury while allowing safe completion of treatment.-Involves another human(s), a pt’s stabilization device, or a combination.

-Serious consequences such as physical or psychological harm , loss of dignity ,& violation of pt’s rights.

-Careful continuous monitoring of pt is mandatory(respiration + circulation restriction).

Ind:1-pt require immediate treatment or diagnosis or limited treatment & cannot cooperate due to lack of maturity or mental or physical disability;

2-safety of pt ,staff , dentist , or parent would be at risk w/o use of PS;3-sedated pt require limited stabilization to help reduce untoward

movement.

Contrind:1-cooperative non-sedated pt;2-pts who cannot be immobilized safely due to associated

medical or physical conditions;3-pts experienced previous physical or psychological trauma

from PS;4-non-sedated pt w non-emergent treatment requiring

lengthy appointments.Pt’s record must include IC , indication , type , duration , beh.evaluation.

ModelingObservation of a competent others being exposed to the feared stimulus and being seen to overcome their anxiety.

SystemicDesensitizationInvolves progressively exposing the pt to the feared stimulus using a graded steps of increasingly arousing stimulus

Time - out-Involving taking time away

from task or procedure to allow the child to cope.

-e.g counting from 1-10 during cavity prep & stopping at 10 for a rest.

-Indicated when child’s beh becomes uncoop for planned procedure.

-Sometimes unsuccessful as it reinforces the negative beh.

References 1-American Academy of Pediatric Dentistry 2011,Revised.

2-Pediatric Dentistry , Jimmy Pinkham , Fourth edition3-Dentistry for the child and adolescent , Ralph E. McDonald , eighth edition.

4-Clinical Pedodontics ,Sidney B. Finn,4th edition.5-Handbook of Pediatric Dentistry , Angus Cameron , Second edition. 6-

Oxford Handbook of Dental Applied Dental Science , Crispan Scully.

Done by : Dr. Razan Salaymeh