BEHAVIORAL MANAGEMENT

Dr Sadia Tabassum
Asst Prof
Operative Dent
Anxious and uncooperative children

One of the major sources of stress for general dental practitioners is ‘coping with difficult
patients’

Dentists do not want to be considered as people who inflict unnecessary anxiety on the
general public.

However, anxiety and dental care seem to be locked in the general folklore of many
countries.
 Anxiety

Anxiety is ‘a vague unpleasant feeling accompanied by a

premonition that something undesirable is going to happen’

In other words it relates to how people feel—a subjective definition.

Another point of view is that anxiety manifests itself in behaviour.

For example, if a person is anxious, he/she will act in a particular manner. A person will
avoid visiting the dentist.
Anxiety

In a US study (Agras et al. 1969) it was found that visiting the dentist ranked fourth behind
snakes, heights, and storms in terms of anxiety

Children remember pain and stress suffered at the dentist and carry the emotional scars
into adult life

Some people may develop such a fear of dentistry that they are termed phobics. A
phobia is an intense fear which is out of all proportion to the actual threat.
Anxiety

Extent of anxiety that a person experiences does not relate directly to dental knowledge,
but is an amalgamation of personal experiences, family concerns, disease levels, and
general personality traits.

Such a complex situation means that it is no easy task to measure dental anxiety and
pinpoint etiological agents
Anxiety

The most widely used dental anxiety measure is the Dental Anxiety Scale, which takes the
form of a questionnaire.

Patients are asked to choose an answer which best sums up their feelings. The answers
are scored from 1 to 5 so that a total score can be computed.

A high score should alert the dental team that a particular patient is very anxious.
 Helping anxious patients to cope with
dental care

A dentist who can alleviate anxiety or prevent it happening in the first place will always be
popular with patients

It is important to establish a trusting relationship, listening to a child’s specific worries and

concerns.

Every effort must be made to ensure that any treatment is pain free.

With the use of a topical anesthetic paste and slow release of the anesthetic solution most
‘injections’ should be painless.
Helping anxious patients to cope with dental care

1. Reducing uncertainty
2. Modelling
3. Cognitive approaches
4. Relaxation
5. Systematic desensitization
Reducing Uncertainty

The majority of young children have very little idea of what dental treatment involves and
this will raise anxiety levels.

Most children will cope if given friendly reassurance from the dentist, but some patients will
need a more structured program
Reducing Uncertainty: Tell, show, do

1. Tell: explanation of
procedures at the right
age/educational level

2. Show: demonstrate the

procedure.

3. Do: following on to
undertake the task. Praise is
an essential part of the
exercise
Reducing Uncertainty: Tell, show, do

Another technique for reducing anxiety in very worried children is to send a letter home
explaining all the details of the proposed first visit so that uncertainty will be reduced.

The evidence for this approach is not clear cut as parental anxiety, rather than the child’s
anxiety, is changed by pre-information.

Acclimatization programs which gradually introduce the child to dental care over a
number of visits have been shown to be of value.
Modelling

Modelling makes use of the fact that individuals

learn much about their environment from observing
the consequences of other people’s behaviour.

You or I might repeat an action if we see others being rewarded, or if someone is

punished, we might well decide not to follow that behaviour.

If a child could be shown that it is possible to visit the dentist, have treatment, and then
leave in a happy frame of mind, this could reduce anxiety due to ‘fear of the unknown’.
Modelling

It is not necessary to use a live model; videos of cooperative patients are of value.

Ensure that the model is close in age to the nervous child or children involved.

The model should be shown entering and leaving the surgery to prove that treatment has
no lasting effect.

The dentist should be shown to be a caring person who praises the patient.
Cognitive Approaches

Most common cognitive modification techniques

asking patients to identify and make a record of their negative thoughts;
helping patients to recognize their negative thoughts and suggesting more positive
alternatives—‘reality based’;
working with a therapist to identify and change the more deep- seated negative beliefs.
Cognitive Approaches

Another approach that could be considered a cognitive approach is distraction.

This technique attempts to shift attention from the dental setting towards some other kind
of situation.

Distracters such as videotaped cartoons and stories have been used to help children
cope with dental treatment.

The results have been somewhat equivocal, and the threat to switch off the video was
needed to maintain cooperation.
Relaxation

Relaxation training is of value where patients report high levels of tension and consists of
bringing about deep muscular relaxation.

It has also been used in conjunction with biofeedback training.

As the techniques require the presence of a trained therapist, the potential value in
general pediatric dentistry has still to be assessed.
Systematic desensitization

The basic principle of this treatment consists of allowing the patient to come to terms
gradually with a particular fear or set of fears by working through various levels of the
feared situation, from the ‘mildest’ to the ‘most anxiety’ program

This technique relies on the use of a trained therapist and in most instances a simple
dentally based acclimatization program should be tried first.
Hand over mouth Exercise

The physical restraint of children in order to undertake clinical dental care has prompted
much debate.

Hosey (2002) and Manley (2004) note that in the UK the use of such physical restraint is
currently unacceptable
To perform this technique, a doctor or parent gently places their hand over the child's mouth and nose,
allowing the child to feel their breath and focus on the sensation of breathing.
The child is instructed to take deep breaths in and out, which can help them slow down their breathing and
regulate their emotions.
The child is informed that the hand would be removed only after required behavior begins.
As the child responds, the hand is removed.
If after removal of hand, negative behavior is shown, the process is repeated.
Nowadays HOMAR is not done by dentist