Principles of Behavior Management Technique

Pedodontics / 5th Stage ‫مظفر فاضل‬.
‫د‬
Lec. 5
Principles of behavior management technique

Non-pharmacological behavior management
The prevention of pain and discomfort combined with the establishment
of a good psychological relationship with the child and his/her parents on
are the major issues of behavior management. Behavior management is a
complex problem that requires a team effort involving the parent, the
dental staff and sometimes even the teacher.
Principles of behavior management technique are as following:

1. Anticipation: Explaining the child regarding the procedure and
answering the question regarding dentistry and procedures. This can be
done through Tell-show-do approach, Good communication etc.
2. Diversion: Diverting the child’s attention away from fear producing
situation may calm the child and allow the dentist to perform the
treatment without disturbance. This can be done through Audioanalgesia,
Hypnodontics etc.
3. Substitution: It involves substituting unwanted behavior by an accepted
behavior. This can be done by Contingency management, Modeling etc.
4. Restriction: Restricting a child from exhibiting unwanted behavior.
This can be achieved through Physical restrains.
Behavior management can be achieved via two methods

1. Nonpharmacological methods.
2. Pharmacological methods.
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1. Non-pharmacological methods
A. Pre-appointment behavior B. Communication

modification
C. Behavioral shaping D. Behavioral management

- Tell-show-do technique techniques
- Desensitization - Audioanalgesia
- Modeling - Hypnodontics
- Contingency - Relaxation
- Aversive conditioning
A. Pre-appointment behavior modification

It is aimed to prepare the child for a dental visit. Various methods used
for pre appointment behavior modification includes audiovisual aids,
letters, films and videotapes. Children are explained the importance of
maintaining the teeth in health. Video clipping may include other children
undergoing dental treatment so that the child will feel the similarity and
reproduce the behavior exhibited by the model. Preappointment behavior
modification can also be performed with live patient as models such as
siblings, other children or parents. Mails can be sent addressed to the
child that provides brief information regarding the procedure. It is called
as pre appointment mailing. Parents can also be given advice for
preparing the child for their first dental visit.
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B. Communication
The hallmark of a successful dentist in managing child dental patient is
his ability to communicate with them and win their confidence. The fears
and the natural innate oddity of a child predict that explanations must be
given for new or different techniques and procedures.
Types of Communication:
A. Verbal.
B. Non-verbal.
Non-verbal communication may be in the form of patting, smile,
acknowledging good behavior and by showing concern.
C. Behavioral shaping
It is based on the stimulus-response theory and principles of social
learning. The child is taught how to behave. Different techniques used for
behavior shaping are:-
a) Tell-show-do technique
b) Desensitization
c) Modeling
d) Contingency
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a) Tell-show-do technique
In this technique, the child is told first about the treatment, showed the
instruments and then the treatment is actually performed. Thus a child
who requires a restoration is told that his teeth are to be brushed or
cleaned. He is shown the hand piece and how it revolves and is
introduced to the child as a special brush that cleans his teeth with water.
The child should be assured that it won’t hurt him but only goes near the
cheek.
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While taking radiographs, the x-ray machine is introduced as a camera
that takes the photo of the teeth. This technique should be practiced every
time a new instrument or object is brought near the child.
‘Praise’ should be added to the TSD sequence to reinforce good behavior.
Tell-show-do technique needs to be modified while treating a child who
is visually impaired. When the tell-touch-do, or tell-smell-do techniques
are to be used, the child is allowed to touch, feel and smell the materials
and instruments (except the sharp ones).
b) Desensitization
It is also called as reciprocal inhibition. It is a training procedure or steps
taken to reduce the sensitivity of the patient to a particular anxiety
producing situation or object. Each situation or object is then introduced
progressively starting from least fear producing to more threatening
stimuli.
c) Modeling
This procedure involves, allowing a patient to observe one or more
individuals (model) who demonstrate appropriate behavior in a particular
situation. Models can be – live (other children present in the operatory) -
filmed (symbolic or vicarious).
Modeling includes the following steps

1. Obtaining the patients attention.
2. Modeling the desired behavior.
3. Physical guidance of the desired behavior.
4. Reinforcement of the required behavior.
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d) Contingency management
The presentation or withdrawal of reinforcers to modify a child’s
behavior is termed contingency management. Reinforcers by definition
always increase the frequency of a behavior.
They can be of two types-

1. Positive reinforcers–is one whose contingent presentation increases the
frequency of a behavior.
2. Negative reinforcers–is one whose contingent withdrawal increases the
frequency of a behavior. Reinforcers can be material, social or activity.
D. Behavior Managing Techniques

 Audioanalgesia: It is also called as ‘white noise’. It is the relief of
pain using white noise or music without using pharmacological
agents while doing painful medical procedures such as dental
treatments. It was first introduced in 1959. This consists of
providing a sound stimulus of such intensity that the patient finds it
difficult to attend to anything else. The effect is due to distraction,
displacement of attention and a positive feeling on the part of the
dentist that it can help.
 Hypnodontics: Use of hypnosis in dentistry is known as
hypnodontics. Hypnosis is defined as a particular state of mind
which is usually induced in one person by another – a state of mind
in which suggestions are not only more readily accepted than in the
waking state, but are also acted upon more powerfully than would
be possible under normal conditions. The practice of this method
requires prior training.
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 Relaxation: Relaxation usually involves a series of basic exercise
that may take several months to learn and which require the
patients to practice at home for at least fifteen minutes each day.
This technique apparently works by reducing tension, well-known
potentiator of pain.
 Aversive conditioning: There are 3 modes of aversive

conditioning.
1. Hand over mouth technique.

2. Physical restraining.
3. Voice control.
Aversive conditioning is used as a last resort for a very young, the

immature, physically handicapped or those who are mentally or
emotionally afflicted. Some dentists consider this method as punishment
and some parents might disapprove them and there have been legal
considerations also.
1) Hand over mouth technique

It is also called hand over mouth exercise (HOME).
 Indications of HOME:
 For normal children who are momentarily hysterical, belligerent or
defiant.
 Used for children with sufficient maturity to understand simple
verbal commands.
 Contraindication of HOME:
Immature, frightened child or the child with a serious physical, mental
or emotional handicap.
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 Technique of HOME
The dentist gently but firmly places his hand over the child’s mouth. With
the verbal outburst completely stopped, the child is told that when he
cooperates the hand will be removed. When the patient indicates his
willingness to cooperate, usually by a nod of the head and cessation of
attempts to scream, the hand is removed and the patient is reevaluated. If
the disruptive behavior continues, the dentist again places his hand over
the child’s mouth and tells him that he must cooperate. Once the child
cooperates he must be complimented.
2) Physical restraining
Consent of the parent’s should be taken prior to the use of physical
restraints. They are useful and effective in facilitating the delivery of
dental care for patients who need help controlling their extremities and
for managing extremely resistant patients who need dental care but are
not candidates for general anesthesia. Some of the commonly used
physical restraints.
For the body: For the extremities:

• Papoose board • Posey straps
• Triangular sheet • Velcro straps.
• Pedi wrap • Towel and tape
• Beanbag dental chair insert • Forearm body support
• Safety belt • Extra assistance
• Bed sheet
For the teeth:

For the head: • Padded and wrapped tongue
• Head positioner
blades
• Extra assistance
• Mouth props or bite block
• Finger guard or interocclusal
thimble
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Papoose board Triangular sheet
Beanbag Mouth props
3) Voice control
Sudden and firm commands that are used to get the child's attention and
stop the child from his current activity. Soft, monotonous soothing
conversation can also be used as it is supposed to function like music to
set the mood. In both cases what is heard is more important because the
dentist is attempting to influence behavior directly and not through
understanding. The tone of voice and the facial expression of the dentist
are also important as they function like a mirror.
Voice control is most effective when used in conjunction with other
communications. A sudden command of “Stop crying and pay attention!”
may be a necessary preliminary measure for future communication. Voice
control is an effective behavior guidance tool when it is used properly in
a correct situation. However, because parents may find voice control to
be an aversive technique, discussing this technique with parents prior to
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its use may decrease the risk for misunderstanding. (It may not be
acceptable to all parents or clinicians, some parents might feel offended if
you raise your voice on their child.)
Objectives
 To gain the patient attention and compliance.
 To avoid negative or avoidance behavior.
 To establish authority.
Indications
Uncooperative and inattentive patients.
Contraindications
Children who due to age, disability, mental or emotional immaturity are
unable to understand.

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Pedodontics / 5th Stage ‫مظفر فاضل‬.

Principles of behavior management technique

Principles of behavior management technique are as following:

Behavior management can be achieved via two methods

A. Pre-appointment behavior B. Communication

C. Behavioral shaping D. Behavioral management

A. Pre-appointment behavior modification

Modeling includes the following steps

They can be of two types-

D. Behavior Managing Techniques

 Aversive conditioning: There are 3 modes of aversive

1. Hand over mouth technique.

Aversive conditioning is used as a last resort for a very young, the

1) Hand over mouth technique

For the body: For the extremities:

For the teeth:

Beanbag Mouth props

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