Saturday, July 9, 2011

Behavior Management for the Pediatric Dental Patient

Behavior Shaping
 Non-pharmacological methods
1.       Tell-Show-Do
2.       Modeling
3.       Using parents as leverage
4.       Restraints
5.       Aversive techniques – HOM
 Pharmacological methods
1.       Nitrous Oxide-Oxygen
2.       Sedation's : Oral, IV
3.       GA
·         Developed by Addelston in 1959.
·         Tell it !
·         Show it !
·         Do it !
·         Always be honest !
·         Never sneak things up on kids !
Parental LeverageParental Leverage
·         Sometimes, need to use parents as leverage to obtain appropriate behavior.
·         Get informed/implied consent from parents.
·         Explain procedure to the parents first.
·         Parents sent out immediately when child cries.
·         Bring parent back when child stops crying.
·         Use an older sibling or child to model for an apprehensive patient.
·         Best to use someone they look up to.
·         Very effective in families that have 2 or more kids.

·         Can be used for anesthesia administration.
·         Informed consent prior to use.
·         Human - parents, assistant.
·         Sensitive about the use of the word.
·         Can be called a “positioner”.
     e.g. : Papoose Board, Pedi-Wrap, Molt
              mouth props etc.
      Aversive Techniques
·         Hand over Mouth and Airway - not used anymore.
·         Hand over Mouth Exercise (HOME) only.
·         Informed consent must be obtained prior to use.
·         Never use on a frightened child.
·         Rarely used. Legal Issues.
Hand Over Mouth Technique
·         Used for an extremely uncooperative-defiant-hysterical child.
·         Hand placed over the mouth to muffle screaming.
·         Talk very softly close to the ears.
·         Place hand back if child starts screaming again. Keep repeating until cooperative.
·         Always be in control of your emotions.
Pharmacological Methods
1.       Nitrous Oxide-Oxygen
2.       Premedication
3.       Conscious Sedation
4.       General Anesthesia
Nitrous Oxide-OxygenNitrous Oxide-Oxygen
·         “Laughing gas”.
·         One of the safest pharmacologic methods of behavior management.
·         Very few adverse effects, easily removed from the lungs in <4 minutes.
·         Special equipment required.
·         Will not work for a defiant child.
·         Cannot replace local anesthesia.
Indications :
·         reduce fear in an anxious or apprehensive patient.
·         to raise the pain threshold.
·         w/ conscious sedations.
Contra-indications :
·         defiant child.
·         to replace poor behavior management local anesthesia.
·         upper respiratory infections.
·         psychiatric  disorders.
·         h/o motion sickness  and vomiting.
·         Can give mild sedative night before or the morning of the appointment.
·         Rarely done for very young children.
·         Can be used to teenage children.
·         Common Drugs: Valium
Conscious SedationsConscious Sedations
·         Sedative drug (Oral/Nasal/IV/IM/ Rectal) + Nitrous.
·         Special training required in several states.
·         Patient is able to maintain their own airway. Can cry during procedure.
·         Advantages : retrograde amnesiac properties of the drugs commonly used.
General Anesthesia
·         Completely under, (Oral/Nasal) endotracheal tube to maintain respiration.
·         Usually done in a Hospital.
·         Anesthesiologist or anesthetic nurse required.
·         Special training and hospital privileges required.
Indications :
·         extremely young child with rampant caries.
·         handicapped children
·         extremely fearful children
·         any systematically complication condition e.g. congenital heart condition etc.
Written consent
                         Medical clearance - Pediatrician, Anesthesia.

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