ISSN: 2456-8090 (online)

DOI: 10.26440/IHRJ/0712.03617

Behaviour Management of Children in a Dental Clinic

JASLEEN KAUR¹, NAVJOT KAUR*², HEENA WALIA³, GAURI GILL⁴, NICHOLAS CHINEMEZE AZUH⁵, RHYTHM SHARMA⁶

Cite this article as: Kaur J, Kaur N, Walia H, Gill G, Azuh NC, Sharma R. Behaviour Management of Child in a Dental Clinic. Int Healthc Res J. 2023;7(12):RV1-RV6. https://doi.org/10.26440/IHRJ/0712.03617

Author Affiliations:

1. MDS (Prosthodontics and Crown & Bridge), Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar, India
2. BDS, MPH (Advanced Research), Torrens University, Australia
3. MDS (Orthodontics and Dentofacial Orthopedics), Swami Devi Dyal Hospital and Dental College Panchkula, India
4. Dental Officer, University of Port Harcourt Teaching Hospital, Nigeria
5. BDS, Arogya Hospital, Amritsar, Punjab, India

Contact Corresponding Author at: navjotkaur569[at]yahoo[dot]com

ABSTRACT

The dental healthcare team treats a child in a pediatric clinic using a child management approach that is both effective and efficient. Managing children in a pediatric clinic requires a delicate balancing act between the child, the parent, and the dentist. It takes effective communication abilities to give dental treatment to youngsters. In addition to the well-known personality trait of anxiety, additional factors have also been discovered to contribute to the persistence of behavioral issues during dental procedures. It is often acknowledged that behavior management plays a crucial role in providing dental care for kids. It is undoubtedly difficult to deny a child the necessary dental care if their behavior in the office or dental clinic cannot be controlled. 

KEYWORDS: Behaviour Management, Children, Dental Clinic 

INTRODUCTION

The dental health care team treats a child in a paediatric clinic using a child management behavior that is both effective and efficient.¹ Establishing a positive dental attitude is the goal since it is crucial to all behavior management strategies.² It involves more than just the actions required to finish a certain procedure; it also fosters a sustained interest in the patient's mindset for continued prevention. In order for adequate treatment to be administered, the dentist and the child's parent(s) must develop a relationship built on trust; this is known as the treatment alliance.³ Dental emergencies may result from treatment refusal in children with dental phobia. Every member of the dental team who treats children should become proficient in behavioral management since it is a crucial skill. The personnel in dental offices should be laid back, hospitable, and kind. Give the child all the attention they deserve and smile. Stay away from using jargon and speak in an age-appropriate manner. Since the youngster might only be able to listen to one person at a time, decide who will speak to him or her and when. Steer clear of non-dental chats with coworkers when having procedures done.⁴ 

MANAGEMENT IN CHILDREN

In a pediatric clinic, managing children requires a delicate balancing act between the child, the parent, and the dentist. It takes effective communication abilities  to   give    dental   treatment to youngsters. A significant portion of kids resist in the dentist chair, which makes it difficult to provide high-quality dental care. This leads to the development of behavior management strategies or substitutes for communication management. A fundamental aspect of pediatric dentistry practice is the management of a child's behavior. In order to help the dentist treat and manage the child, parents and careers may also be crucial in lowering the child's fear.⁵ 

FACTOR INFLUENCING CHILD BEHAVIOUR

In addition to the well-known personality trait of anxiety, additional factors have also been discovered to contribute to the persistence of behavioral issues during dental procedures.

 a). Medical history

Youngsters who have had a bad experience with medical care may be more nervous about dental operations. Fear from unsatisfactory past dental visits may also contribute to unruly behavior at future appointments. When gathering the child's medical history, the dentist should inquire about prior medical treatments as well as the child's reaction to them.^6,7 

b). Parental influence

The anxiety of parents greatly affected the behavior of their children, especially if the parents had experienced unpleasant dental experiences in the past. A fearful or nervous parent may have a negative impact on a child's behavior. It's crucial to inform the parent before the child's first dentist appointment. Certain office practices, such as making an early call, following up with information from the office, and enticing parents to visit the website or even do a "pre-visit," can help ease the worry of parents.

Recent years have seen a shift in parenting approaches. The growing number of kids who frequently lack the abilities and self-control needed to handle new situations in the dental office presents difficulties for dentists. Parental expectations regarding their child's behavior, such as not crying, are typically unrealistic. Some parents may even try to control the course of treatment, even though they don't fully understand it. Additionally, parents will be able to precisely forecast the associated behavior of their children. Practitioners agree that trust and confidence are developed through effective communication between the parent, dentist, and parent. 

Practitioners also guarantee that there is meaningful communication between the child and the dentist, which is dominating and necessitates mutual comprehension. When a parent is with them during treatment, most children respond favorably. Parents' presence almost never has a detrimental effect on their child's communication with the dentist. It is the duty of each clinician to design the means of communication and support that best suit the treatment environment, taking into account the parent's intentions, the child's capabilities, and their own abilities.^8,9 

TYPES OF CHILD BEHAVIOUR MANAGEMENT TECHNIQUES

1. Tell show do
2. Positive reinforcement
3. Voice control
4. Distraction
5. Live modelling
6. Nonverbal communication
7. Systematic desensitization
8. Euphemism

 a). Tell Show Do

This approach is widely used to acquaint the patient with a novel procedure10. This involves verbally explaining procedures in a way that a young child could understand (tell); carefully presenting the procedure's visual, auditory, olfactory, and tactile components in a way that is non-threatening (show); and finally, performing the procedure (do) without deviating from the explanation and demonstration. The tell-show-do method is applied along with positive reinforcement and verbal and nonverbal communication abilities. Depending on whether the child has disorders or communication issues, more actions will be required. The kid patient's pre-existing anxiousness has been effectively reduced by this strategy11. Depending on the patients' ages, the dentist explains the process to them throughout the tell phase. The method is demonstrated during the display phase, for instance by using a slow handpiece on a finger. 

b). Positive Reinforcement and Behavioural Shaping

When used effectively, positive reinforcement reinforces desired behaviors and makes them more likely to occur again. Social cues including acceptable physical displays of affection, pleasant voice modulation, positive facial expressions, and verbal appreciation are all used by the dental team members. Toys and tokens are a couple of the non-social reinforcers. Patients must be informed and educated about the majority of dental procedures because they involve very complicated behaviors and actions. This should be explained to kids in simple, step-by-step instructions. We refer to this as the shaping process. It comprises of a clearly laid out series of actions leading to flawless and comprehensive behavior.¹⁴  The easiest way to accomplish this is by selective reinforcement. Reinforcements are behaviors that improve the likelihood of being expressed again in the future when they are strengthened.¹⁵ Positive reinforcers can be anything enjoyable for the youngster; for example, stickers and amusing labels can be used to show that the appointment went well. An emotive, child-centered response that offers particular compliments like "Good girl" or "I like the way you have kept your mouth open" However, it is demonstrated that the latter is more successful than the first generic observation16. This method works only with those who are able to communicate. 

c). Voice Control

The loudness, tone, and speed of one's voice can all affect a child's behavior. Children with significant hearing difficulties cannot benefit from this treatment. Young children frequently react more to a person's tone of voice than to the words themselves. All of these methods seek to increase compliance and attention spans while also exerting some degree of control over the child. Dentists utilize it extensively, however not all doctors or parents may find it appropriate12. The approach works well with talkative but inattentive kids, but it is inappropriate for young kids or kids who have emotional problems. It has been demonstrated that this method reduces disorderly behavior without having an adverse long-term impact.¹³ 

d). Distraction

This method takes the child's focus away from what they could see as an uncomfortable process. This can be accomplished by having a conversation, encouraging the parent to play with the child, letting the youngster watch cartoons or a DVD, or using headphones to play music.¹⁷ This method seeks to divert the patient's focus from the possibly uncomfortable dental operation to another circumstance. When combined with reinforcement—letting kids know that their behavior will result in the cartoon being turned off—cartoons have been demonstrated to help kids behave better18. It's been discovered that audio recordings could be much more successful at diverting attention than other strategies19. While applying topical paste and giving the local anesthetic, the dentist uses words to divert the patient's attention. As a topical anesthetic, short-term distractions like pulling one's lip can be highly helpful. All patients with verbal communication skills can benefit from this therapy. There aren't any limitations. 

e). Live Modelling Technique

Using this method, the physician has the youngster watch one or more people who behave well in a specific circumstance. For this modeling, role models such as parents or siblings might be used. Posters or filmed models, such as movies^20,21 can also be utilized to demonstrate if a live model is not available. The method is founded on the psychological idea that people pick up knowledge about their surroundings by the behavior of others. In this case, the model is someone who acts appropriately in a dental setting. This could reduce anxiety by showcasing a procedure's successful conclusion and serving as an example of appropriate behavior from a third party. Models should be the same age as the target child and should behave appropriately for the best results. They ought to be seen going into and coming out of the surgery.²² 

f). Nonverbal Communication

A person's posture, facial expression, and appropriate eye contact are utilized to support and direct their behavior. Children with hearing difficulties can use this strategy. Make contact in an attempt to soothe the child, but be aware that some kids have tactile defensiveness startle reflexes. 

Types

-body language

-smiling

-eye contact

-expression of feeling without speaking

-by touching the child

-giving him a pat

-showing concern

-giving him a hug 

g). Systematic Desensitization

This method focuses on helping people who have certain phobias or fears get over them through frequent interactions. Starting with the stimulus that poses the least threat, a hierarchy of stimuli that cause anxiety is created and the patient is exposed to them in order. In the context of dentistry, the application of local anesthetic is typically associated with a feared procedure. After being instructed to calm down, the patient is exposed to each stimulus in the hierarchy one at a time, moving on to the next as soon as they feel ready. For real phobias, a series of relaxation sessions with a psychologist or dentist trained in relaxation or hypnosis techniques may be necessary.² It is necessary to attend nine-hour therapy sessions.²³ On the other hand, kids who have already encountered something unpleasant can benefit from a similar strategy.24 For a child who can vocally convey and accurately name what they fear, this strategy can be helpful. 

h). Euphemism

The patient's emotional state is influenced by the words that the dentist and staff choose to employ. As a result, it's crucial to employ euphemisms or reframing while speaking with patients. 

1. Anaesthetic solution - water to put the teeth to sleep
2. Caries - a tooth bug
3. Rubber dam - rain coat
4. Radiograph - tooth picture

FOR HYPERACTIVE CHILDREN 

The majority of youngsters can be adequately controlled with the help of the above-listed approaches. Nevertheless, youngsters will require more sophisticated treatments when they occasionally exhibit behavioural abnormalities, such as hyperactivity. These kids frequently lack emotional or psychological development, as well as mental, physical, or medical disabilities, which prevent them from cooperating. Some of the advanced behavior guiding approaches taught in advanced pediatric dentistry programs include protective stabilization, sedation, and general anesthesia. 

a). Nitrous Oxide Oxygen Inhalation

It is a practical, safe, and efficient behavior management strategy.²⁵  When patients provide written informed consent and are nervous, use Nitrous Oxide Oxygen sedation as a supplement to local anesthesia in patients whose gag reflexes make dental care difficult. 

b). Physical Restraint

In order to prevent harm to the patient during dental treatment, it involves immobilization, either partial or total, with the help of a dentist, parent, or other technologies. The patient's informed permission must be obtained before to the procedure.

Various types of restraints

For the body

-Pedi wrap

-Papoose board

-Sheets

-Beanbag with straps

-Towels and tapes

For the Head

-Head positioner

-Mouth blocks

-Banded tongue blades

-Beanbag with straps

-Mouth props 

b). Hand Over Mouth Technique

It's another contentious behavior management strategy that can offend some parents. The child is instructed to cover his mouth with his hand, and the expectations for his behavior are discussed. Depending on the child's behavior, the hand is taken away. With the exception of senior clinicians and pediatric dentistry consultants, the use of this method is prohibited due to the increased legal obligations associated with it. Parental agreement is particularly crucial, and children who are too young to comprehend or who have mental or emotional disabilities should never be subjected to these procedures.^26,27 

c). Conscious Sedation

Using sedation to control a child's behavior during dental work is a crucial strategy. The medications being utilized aid in boosting cooperation and lowering any anxiety or pain related to dental operations. Most kids who take sedatives feel calmer and more sleepy. Sedation is not meant to render a patient asleep or unresponsive, in contrast to general anesthesia. Conscious sedation is indicated for patients who are healthy at the time of the appointment, patients who cannot cooperate due to disability or immaturity, and patients who need care is consistently with the risks of sedation and whose care can be completed in one or two appointments. 

d). General Anaesthesia

This method can be applied with toddlers who frequently exhibit severe dental anxiety. The sounds produced by the dental drill and the pressure they experience can send them into a hysteric state even if they are not in pain. Additionally, some kids will require extensive dental work to be done on a number of teeth. Therefore, it is usually ideal to put the child to sleep for the entire process and complete all of the treatment in a single, stress-free session. To treat young children with extensive dental decay in the safest and most painless manner possible, dentists employ an anesthesiologist to visit the office on a regular basis.  The youngster will next get the appropriate dosage of medication from the anesthesiologist to induce a deep sleep. The anesthesiologist will monitor the child's breathing and vital signs once they are fully asleep, and the pediatric dentist will handle any necessary treatment

In patients who would not otherwise receive dental care, such as those with very recalcitrant children or physical and mental impairments, general anesthesia should be used.  The use of GA must be supported by appropriate paperwork that covers its foundation, informed authority, parent instructions, dietary restrictions, and pre-operative health evaluation.²⁸ 

CONCLUSION

It is often acknowledged that behavior management plays a crucial role in providing dental care for kids. It is undoubtedly difficult to deny a child the necessary dental care if their behavior in the office or dental clinic cannot be controlled. Paediatric dentists have access to a wide range of behavioral management techniques that they must use when appropriate, keeping in mind the cultural, philosophical, and legal requirements in the nation where they practice dentistry. These techniques should be used exclusively for the benefit of the child receiving dental care. This is also connected to a crucial concept known as a therapeutic alliance: if a kid or parents feel comfortable receiving care from a clinician, they will continue to see that doctor. 

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