Pediatric Dentistry I Forth Year

1. Psychological growth
• Every child has a rhythm & style of growth
and no two children, even in same family,
develop in exactly the same pattern
• The psychological & physiologic age of the
child must be considered in the diagnosis of
behavior problems& treatment planning
 Infancy period (Birth to 1 year)
 Toddler hood period (1 to 3 years)
 Preschool period (3 to 6 years)
 School period (6 to 12 years)
 Adolescent years (12 to 19 years)

2. Infancy period (Birth to 1 year)
• Infancy represents the first critical period for
personality growth & the development of a
sense of trust. Then develop feelings of security
that last throughout life.
• At the age of 6 months (teething ,bite on
anything)
• Prenatal teeth
• Child clinical exam can be done by:
1) Seating on his mother's legs on the dental
chair, Or
2) The child is placed in-between the mother
&the dentist on other chair.

3. Toddler hood period (1 to 3 years)
• The child moves from the sensori-motor
stage (in infancy) to pre operational stage.
Objects are now grasped and put in order.
• In the dental clinic, the child takes orders
from his mother through her facial
expressions, also tone of voice.
• (tell-show-do technique).
• Without exception the child should be
accompanied by a parent to the treatment
room.

4. Preschool period (3 to 6 years)
• At the stage the child now grips with the
development of a sense of initiative and
imagination so the child explores the world
of people & things also imagines himself in
a variety of roles & activities.
• The 3-year old child (desire to talk ,enjoy
telling stories to the dentist & assistants)
• The child is closely attached to his parents
• During the late preschool period the child
now able to be easily separated from his
parents
• Waiting room (full of toys )

5. School period (6 to 12 years)
• At this age the child achieve enough
trust also initiative to become involved
in the private world of children.
• Becomes a part of peer group.
• He takes orders from dentist as he
takes orders from his teachers in
school

6. Adolescent years (12 to 19 years)
• Hormonal activity usually associated with
rapid physical growth, genital maturity
and changing environmental expectation
so adolescence is a period of uneven
biologic, psychological and social
development
• The dentist should deal with them through
firmness and authority.

7. BEHAVIOUR
Definition :
The term behavior is broadly used
to include the entire complex of
observable and potentially measurable
activities including cognitive and
physiological classes of response.

8. I. WRIGHT’S CLASSIFICATION
A) Co-operative (Positive behavior)
1. Co-operative behavior
Child is cooperative, relaxed with minimal
apprehension.
2. Lacking in Cooperative Ability
• Includes very young children with whom communication
cannot be established.
• Another group of children who lack in cooperative ability
is of those with specific debilitating or disabling
conditions.
• Physical and mental handicap children are also included
under this.

9. 3. Potentially Cooperative
• Has the potential to cooperate, but because of
the inherent fears (subjective/ objective) the
child does not cooperate.
B). UN- COOPERATIVE BEHAVIOUR
1. Uncontrolled /Hysterical/ Incorrigible
 Usually seen in the preschool children
at their first dental visit.
 Temper tantrums i.e. the physical
lashing out of legs and arms , loud
crying and refuses to cooperate with
the dentist.

10. 2. Definite/Obstinate behavior
• Can be seen in any age group.
• Usually in spoilt or stubborn children.
• These children can be made
cooperative.
3. Tense cooperative
• These children are the border line between the
positive and negative behavior.
• Does not resist treatment but the child is
tensed at mind.

11. 4. Timid Behavior/Shy
• Usually seen in a overprotective child at the first
visit.
• Is shy but cooperative.
5. Whining type
• Complaining type of behavior allow for treatment
but complains throughout the procedure.
6. Stoic type
• Seen in physically abused children .
• They are cooperative and passively accept all the
treatment without any facial expression.

12. 1. COOPERATIVE
• The child is physically and emotionally
relaxed .
• Is cooperative throughout the procedure.
2. Tense cooperative
• The child is tensed and cooperative at the same time.
Lampshier classification (1970)
3. Outwardly apprehensive
• Avoids treatment initially, usually hides behind the mother,
avoids looking or talking to the dentist.
• Eventually accepts dental treatment.

13. 4. Fearful:
 Requires considerable support so as to
overcome the fears of dental treatment.
5. Stubborn/Defiant
 Passively resists treatment by using
techniques that have been successful in other
situations.
6. Hypermotive
 The child is acutely agitated and resorts
to screaming kicking etc.
7. Handicapped
 Physically/mentally, emotionally handicapped.

14. III.FRANKEL’S CLASSIFICATION
(1962)
(Frankel’s behavior rating scale)
Rating Behavior
1. Definitely Refuses treatment, crises
negative (- -) forcefully extremely
negative behavior
associated with fear.
2. Negative (-) Reluctant to accept
treatment and displays
evidence of slight
negativism.

15. Rating Behavior
3. Positive (+) Accepts treatment,
but if the child has a bad
experience during treatment,
may become uncooperative.
4. Definitely Unique behavior, looks
positive (++) forward to and
understands the
importance of good
preventive care.

16. a). Normal or bold
 The child is brave enough to face new situations, is
co-operative, and friendly with the dentist.
B). Tasteful or timid
 The child is shy, but does not interfere with the
dental procedures.
IV. WILSON’S CLASSIFICATION
(1933)
c). Hysterical or rebellious
 Child is influenced by home environment – throws temper-
tantrums and is rebellious.
d). Nervous or fearful
 The child is tense and anxious, fears dentistry.

17. Reactions of the child to the dental
experience
• There are at least 5 negative reactions
to the dental experience:
1) Fear
2) Anxiety
3) Resistance
4) Timidity
5) Crying

18. Fear:
• Dentistry should never be employed by the parents as a
threat. Also, taking the child to the dentist should never
be implying punishment.
*** Types of fear ***
A- Native fear: it is an instinct present in every
human being
B- Objective fear: It originates from a frightening or
painful experience in the child's past that faced
the child himself
C- Subjective fear: it is based on feelings and
attitudes suggested to the child by others around
him without the child having had the experience
himself.
Subjective fear may be acquired by imitation and
may be transmitted from parents

19. Anxiety
• Anxious children are essentially
fearful of new experiences and their
reaction may be violently aggressive
such as temper tantrums in dental
office.
• Child is truly fearful the dentist may
be sympathetic and starting working
slowly but if the child demonstrating a
temper tantrum the dentist may
demonstrate authority & mastery of
situation.

20. • The child may display temper tantrums or head
beating or may develop vomiting habits or may make
no attempt to talk plainly.
• Withdrawal is another manifestation of anxiety
• This is observed in the case of the first time
patient. This is the child who tries to hide
behind his mother; he looks to the floor or
another direction.
• The timid child needs to gain self confidence
and confidence in dentist
Timidity

21. A- Obstinate crying:
Siren-like noises, temper tantrum, kicking, biting, usually no
lacrimation.
B-Frightened crying:
Profusion of tears, constant wailing sound, convulsive and
rasping, cry tends to hysteria rather than temper tantrum
C-Hurt crying:
lack of or very low volume tears may be the only manifestation
moaning, respiration may be affected if child hold his breath
D-compensatory crying:
Wailing or whining sound as the dentist makes sounds of
similar volume, not loud but consistent, no tears or sobs

22. • Behavior management problems are what the dentist
observe while the dental fear and anxiety is what the
patient feel.
• Some children present behavior management
problem without having fear and anxiety.
• Some Children having dental fear and anxiety but
able to cope up with situation.
• Some children experience dental anxiety and fear
and present behavior management problems

23. • Age
• Dentist
• Maternal anxiety
• Past medical history
• Time & length of app
• Patient awareness of the problem
• parents

24. 1. Personal Factors
A. Age B. General fear and anxiety.
C. Temperament. D. Other problems e.g.DAMP
2. External Factor
A. Parental Dental fear & anxiety.
B. Social Situation of the family.
C. Ethnic background of family.
D. Child rearing and child’s
role in society.
3. Dental Factor
A. Pain B. The Dental Problems
Factor affecting child Behavior in dental
clinic

25. Factor affecting child Behavior in dental
clinic
Factor involving Child
Growth and development of child
 Personality & tempermant of child.
a) Type 1 Positive of mood.
b) Type 2 Difficult children.
c) Type 3 Slow to warm up
 Formal learning experience
 Social and adaptive skill.
 I.Q. of child.
 Past Dental & Medical Experience.
 Awareness of dental problem.
1. Appearance of Dental Office.
2. Personality of Dentist
3. Dental’s skill & Speed
4. Dentist’s conversation
5. Attention to the Pts.
6. Use of praise and reward.
7. Dentist’s self control.
Factor involving Dentist

26. 1. Socioeconomic Status
2. Culture
3. Maternal Anxiety
4. Familial Disorders
5. Parental-Child relationship
6. Sibling influence

27. • Over Protective and dominant
prevent the natural development of the child toward
independence; for example, the parent insists on remaining
with the child,
• Over Indulgent (manipulative)
excessively demanding (appointment time; course of
diagnosis or treatment)
• Under affectionate
• Rejecting (neglectful)
• Authoritarian
• Hostile Parents :-
{A} poor personal experiences in the dental office,
{B} a general negativism toward health professionals,
{C} feelings of insecurity in a foreign environment, or

28. The functional inquiry
–During the inquiry, two primary goals:
(1) To learn about patient and parent
concerns and
(2) To gather information enabling a
reliable estimate of the cooperative ability of
the child
–Functional inquiries are conducted in
two ways:
(1) By a paper and pencil questionnaire
completed by the parent
(2) By direct interview with child and parent

29. Parent education
(instruction to parents)
• Not to voice their own personal fears in
front of their child toward dentistry.
• Not use dentistry as a threat of
punishment.
• Familiarize their children with dentistry by
taking the child to the dentist to become
accustomed to the dental office.
• Not bribing their child to go to the dentist.
• Parents shouldn't challenge the dentist's
authority or contact the operator filed

30. • It should be warm and stimulate homely
environment.
• Appointment should be short.
• Children should not kept waiting not more
than 30 minutes.
EFFECT OF DENTIST’S ACTIVITY:
• Data gathering and observation :- Should be
collect by child steps in dental clinic during
history taking and dental procedure being carried
out.

31. Child's first dental visit
• The ideal time of the first visit is at one year of age
• To safeguard against problems such as baby
bottle tooth decay, teething irritations, gum
disease, and prolonged thumb-sucking
• Preparation for the visit (Talk to child about what
to expect)
• What will happen on the first visit (examination,
prophy; OHI; fluoride application)

32. Fundamentals of behavior
management
• is means that the dental health team effectively and
efficiently performs treatment for a child and, at the
same time, instills a positive dental attitude.
{1} The team attitude (warmth and interest , pleasant
smile, using nick names )
{2} Organization (dental office staff , well organized,
written treatment plan )
{3} Tolerance ( dentist ability to tolerate any
misbehaviors from the child)
{4} Flexibility (Since children are children, lacking in
maturity, the dental team has to be prepared to

33. BEHAVIOUR MANAGEMENT
1 PRE APPOINTMENT BEHAVIOUR MODIFICATION.
A.Audiovisual modeling
B. Introductory appointment
C. Patient modeling
D.Pre-appointment mailing.
2. COMMUNICATION :
It can be verbal or non verbal
3. BEHAVIOUR MODIFICATION
A. Behavior shaping.
B. Tell, show & Do.
C. Desensitization
D. Modeling
E. Contingency Management
F. Retraining

34. 4. BEHAVIOUR MANAGEMENT
A. Distraction/ Externalization
B. Parental Presence or absence.
C. Audio analgesia
5. AVERSIVE CONDITIONS
A. Voice Control
B. Home (Hand Over mouth exercise
C. Hypnosis
D. Coping
E. Confusion
F. Implosion Therapy

35. • The Objectives are establish the good rapport with patient & to
develop the positive behavior.
Done by
A. Audiovisual modeling
B. Patient modeling
1. Sibling 2. Other Children
C. Reappointment e-Mailing Any greeting, cartoon, comic (
conveying the procedure
COMMUNICATION :- To establish good relationship with child.
1. Verbal (Steps
A. Establishment of
Communication
B. Establishment of
Communicator
C. Message Clarity
Use of the Euphuism :- Using Other words other
then original
D. Problem Ownership : take all blame on yourself.
E. Active listening of child.
F. Appropriate response.
2. Non Verbal : It is the reinforcement & guiding of behavior
through contact, posture & facial expression.

36. Instead of… We prefer to say…
Radiographs or x-rays Tooth pictures
Poke with explorer or sharp
instrument
Tooth counter
Suction Mr. Thirsty or Thirsty Straw
Cavities Sugar Bugs
Fluoride treatment Tooth vitamins
Laughing gas/Nitrous Oxide Happy Air
Give a shot or use a needle Spray sleepy juice
Mouth prop Tooth chair or pillow
Use a rubber dam
Keep the tooth dry with a
raincoat
Clamp Tooth hugger or ring
Drill the tooth Polish the tooth
Fillings Paint or polish

37. A. State General task/ Goal to child at the outset
B. Explain necessity for the procedure.
C. Divide Explanation for the procedure.
D. Make all explanation at the child’s level of understanding.
E. The successive approximation (T.S.A.)
1. Behavior Shaping: It is that procedure which very slowly
develops behavior by reinforcing successive approximation of
desired behavior until the desired behavior comes to be.
2. Tell show, and do : The dentist should demonstrate the various
instruments step by step before there application telling, showing
and doing.
3. Desensitization :- Patient is taught to relax while procedure is
going on with least anxiety evoking stimulus.
Sequence: 1. Introduction 2. Orientation
3. Clinical Examination 4. Oral Prophylaxis
5. Restoration 6. Extraction.
PROCEDURE

38. 4. Modeling A. Audiovisual Modeling B. Live
Modeling
5. Contingency Management :- It is a presentation or
withdrawal of reinforcement. It can be positive or negative.
Objective: To reinforce desired behavior It can be
3 Type: 1. Material reinforcement
2. Social Reinforcement 3. Activity Reinforcement
6. Retraining:- Designated to fabricate positive values
in place of negative behavior that has develop.
BEHAVIOUR MANAGEMETN TECHNIQUE
A. Distraction: Process by which the attention of child is focus away from
the sensation associated with dental treatment.
B. Parental Presence or absence
C. Audio analgesia – like pleasant music.
D. Visual fantasy – like Hypnosis & Day dreaming.

39. Distraction
• Five senses
• a CD-player
• watching a movie
• pleasant smell ,(smell of oil of cloves or
eugenol ), aromatherapy heaters
• Use of Choice-Based Distraction
• Taste (drinks from the refreshing (water,
fresh juice )
Contingent Escape
Allowing the child to stop treatment gives him a sense of control.
e.g.: raising hand when he wants to stop
- Tell the child that you will need him to let you work on his teeth for
a count of 10 & then stop & allow him to rest for a while

40. • Hypnotic language patterns are an effective instrument for supporting fear-
and pain-free treatment. Hypnosis has nothing to do with witchcraft or
submission but makes use of the child's natural state of relaxation and
imagination. It enables your child to focus more on pleasant things whilst
unpleasant things fade into the background and your child leaves our practice
feeling good.
• What do we do?
• Use positive concepts
• Explain in a language suitable for children
• Reinforce positive feelings with praise
• Tell stories
• Constant physical contact gives a feeling of safety and security
Your child's state:
• Reduced pain perception
• Altered perception of time
• Concentrated on inner self (introspection)
• Thus less distracted by external stimuli
• Positive memory of the treatment

41. 1. Voice Control : Should be controlled alteration
of voice volume.
2.(HOME:- Hand over mouth exercise): Use in
very uncooperative child. A hand is placed
over the child’s mouth and behavioral
expectation are calmly explained close to the
child’s ear.
When desired behavior comes than removal of
hand
In this procedure airway is not restricted
Modification of HOME is HOMAR (Hand over
mouth Airway restricted): Generally avoided
because restriction of airway.

42. (A) Hand -Over- mouth
• An extreme measure in dealing with an
uncooperative child.
• Involves holding the child in the dental
chair; the dentist should gently but firmly
places his hand over the child's mouth.
Then the dentist speaks quietly but clearly
into his ear to reassure him and explains
the procedures about to be done in an
attempt to establish confidence.
• Isn't a punishment measure

43. (B) Physical restraints
• Range from holding a child's hands during
injection procedure to full body restraint
• for patients who are not capable of understanding
the dental procedure ,some physically or mentally
handicapped patients.
(1) To control body movements:
* pedi-wrap: it is reinforced nylon mesh sheet with
Velcro fasteners and is supplied in small, medium
or large sizes. The child's arms are placed by his
side and the wrap is then fastened over his chest.
* Papoose board
*Triangular sheet
* Beanbag dental chair sheet
* Safety belt
* Extra assistant

44. (4) To control the oral cavity:
•intraoral mouth prop: like wraped
tongue blades, intraoral bite block (
is a medium hard rubber wedge that is
inserted between the occlusal surfaces
on the side of the mouth where the
treatment is not performed).
* extraoral mouth prop: like Molt
mouth prop which is constructed of
metal and covered with rubber tubing.

45. Practical considerations
Scheduling:-
• Time of the appointment may
influence child's behavior especially
young child, early morning hours. The
suggestion was based on the facts
that the child is alert and the dental
team is fresher in the morning.
• Appointment length should be short
not more than 30 minutes especially
for young and fearful child.

46. Local anesthesia
Relative analgesia
Oral or rectal sedation
Intravenous sedation
General anesthesia
Pharmacological behavior management: -