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It has been said that the major difference between adult and pediatric dental patients is that the latter did not request the treatment and frequently they do not even understand why they are at the dentist's office! Essentially, from many childrens' perspective, a dentist has little to offer to them except short-term pain and long-term gain, the latter being a difficult concept for many a young mind to grasp. Consequently children frequently display behaviors that make traditional dental care delivery a challenge. It becomes the job of the dental practitioner, therefore, to understand the unique issues at stake and to make these patients, and often their parents too, feel at ease.
The goals of behavior management in dentistry are to establish effective communication, to alleviate patient fear and anxiety and build a trusting relationship with the child that will ultimately allow the dentist to deliver quality dental care and promote in the child a positive attitude towards dental care and oral health.
For us to fully understand the problem it is necessary to clearly define the nature of this diverse patient group. It has traditionally been considered to consist of infants, children and adolescents under age 21 years. For the purposes of specialized behavioral/dental needs this group should be extended to include those patients who present behavioral challenges due to mental, physical or medical disabilities and patients with prior negative dental or medical experiences resulting in poor behavior.
Management of these patients has been traditionally considered to comprise three elements; medical management, managing their behavior and meeting their dental needs.
The first element can be best addressed by taking a thorough medical history in consultation with the specialists providing care for the patient. Following a careful dental examination a comprehensive dental treatment plan can be developed. A behavior assessment is made which should include a history of previous dental and medical experiences, and an assessment of general behavior and communication skills. All patient responses should be evaluated in relation to those that would be considered age appropriate.
There is no question that parenting styles have evolved tremendously in the United States in the last decade. Unfortunately, these have not always been for the better, resulting in many young children arriving at the dental office with poorly developed coping skills and little or no sense of self-restraint. In addition, many parents have unrealistic expectations for the course of the dental visit, and may be unwilling to permit the dentist to practice effective traditional behavior management techniques.
Often the first potential source of conflict to be encountered is whether to allow the parents to accompany a child into the dental operatory. There is currently no real consensus regarding parental presence in the operatory, however it is agreed that it may sometimes be effective in gaining cooperation for treatment. There is little disagreement however that effective communication between the dentist and the child requiring close attention from both parties is of prime importance. The presence of a parent must not circumvent this communication. Well meaning parents in the operatory can be a major source of distraction even if they are echoing the instructions from the dentist. Children vary in their response to their parents' presence or absence ranging from very positive to highly detrimental. It is the responsibility of the practitioner to determine the communication and support methods that will optimize the child's response in the dental operatory and also, as far as possible without compromising the desired outcome, to meet the requests of the parents involved. The role of the parent must be clearly defined as supportive if the parent is to be permitted in the operatory during the visit, and parental questions regarding treatment should not be directed at the dentist or assistant during the delivery of dental care. Clearly some patients will benefit more than others, particularly those for whom there are language problems, very young patients, or those with a developmental disability.
Commonly stated fears reported by children regarding the dental experience can be either real - such as those based on a previous negative experience; acquired fears such as needle (pain); potential fear responses include those that may be induced by the emotional state of dentist or assistant, or protective fears - such as fear of the unknown, fear of bodily harm, of a stranger or of separation from the parent. Any child displaying these types of responses should be evaluated in the context of the patient's cognitive age. As although they may indeed indicate a potential for a management problem, conversely they may be entirely appropriate responses for a child of that age (e.g. fear of separation is a normal developmental stage in very young children but associated with behavior management problems if displayed in a school-age child).
Avoiding the use of evocative language and "threatening" words, such as "pain, hurt, drill, or extract" is second nature to most dental professionals. However, with a young patient, it is particularly important to use non-threatening terms such as "whistle" (not drill), "make your tooth sleepy" (not give a needle, shot, or injection) or "clean the soft part of the tooth away" (not "drill the tooth"). The use of such words and phrases, coupled with a positive environment, can result in a decrease in the negative associations and experiences, which will benefit the patient during future dental visits.
Effective communication with children poses challenges for the dentist and the dental team. A child's cognitive development will dictate how much information can be absorbed and processed. In addition, children have no appreciation of concepts and situations that they themselves have never experienced. It is important for the dentist to understand cognitive development of children so that they can communicate ideas through the use of appropriate vocabulary, consistent with the child's intellectual development. In the dental office, communication is accomplished primarily through speech, tone of voice, facial expression, and body language. Body language is particularly important in the close communication that takes place during dental treatment even with very young children. A dentist whose body language displays disinterest or distraction will not be effective in communicating clinical confidence. Common examples of distractions to effective communication include hearing another child cry, or parent interruption during dental treatment.
Communication based techniques are most effective in managing the cooperative preschool child. In such a situation, the two-way interchange that marks the start of a dental appointment is replaced with one-way manipulation of behavior by way of a promise "contract," with the activity to follow request. In other words, the aim is for the dentist to frame an effective request and reframe if the desired patient response does not follow. Reframing a previously given request in an assertive voice with appropriate facial expression and body language is the basis for the technique of voice control. Simple instructions are given to the child such as "open your mouth", "quit wiggling" or "bite on this".
Effective communication should follow an assessment of the cognitive ability of the patient and of parental expectations and will comprises a host of different techniques that, when integrated, enhance the evolution of a cooperative patient. Finally, the most effective communication always reflects the personality of the dental professionals themselves.
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