Behavior Management: What Makes Paediatric Dentistry Special?
Behavior management is a crucial factor in providing dental care for children. These behavior management techniques are rooted in empathy and a concern for the well-being of the child.
Behavior management can be pharmacological (different levels of sedation and general anesthesia) and Non-pharmacological (where different behavior modification techniques based on psychology and different behavioural science theories are used). Here, I would like to focus on non-pharmacological behavior management.
Non-pharmacological behavior modification aims to build and maintain a relationship with the child, allowing the highest quality of dental care to be delivered to the child. Our priority is to communicate to the child through words, body language, and most importantly, gaining their trust and convincing them that hat dentistry is non- threatening. It starts with a friendly front desk, a colorful play area to welcome them, where their favorite cartoon is playing. Even with our PPE, Welcoming the child and having a friendly chat before starting the procedure also plays a role.
At times, it could be challenging if the child already has a developed fear for dentists due to one of these reasons:
- Previous visits for vaccinations
- Direct or indirect fear of dentistry expressed by parents
- Previous dental visits with an unpleasant experience
- If removal of teeth /visit to the dentist is used as a threat at home
- Inherent age-dependant fear of the unknown seen in younger children.
Communication is the key for children above three years old; clear communication between a child and the dentist helps them trust, understand, and help them carry out the procedure. The parents’ passive presence in the initial appointments is encouraged as constant communication between parents and children may make it difficult for them to bond with the doctors. The parent’s company can be useful for younger children, but it may not work in our favor if a child can communicate and understand. That said, things are different for each child, and we, as pediatric dentists, understand child psychology and try to work on a technique that works best given the situation. In some instances, it’s hard to communicate with a child who is continuously crying; having the parent wait out for a while until the communication barrier is broken and then bringing in the parent as a reward once the child calms down can help a great deal.
Younger children (three years and below) usually don’t do well in their parent’s absence. It’s better to have the parents in the operatory or even make them sit on their lap. We keep reinventing ourselves based on the situation and the child we are dealing with. It is best to keep observing the child and decide the best way forward.
It is always a triangle with the child at the apex and parent and pediatric dentist at the ends, continuously working in sync for the well-being of the child’s dental health and favorable behavior modification.
The various behavior management techniques we frequently use are:
- Desensitization: Typically used in children with previous anxieties. The child’s anxiety is dealt with by exposing the child to pleasant dental experiences. Simple procedures like check-ups, x rays, sealants are done in the first few appointments to reduce the child’s anxiety. This also helps in increasing a child’s confidence in handling dental procedures. Such procedures have worked very well as the child also develops a sense of achievement, and we also compliment and gift the child for helping us with a successful check-up. We also combine it by introducing the child to drill by showing them how it works (Tell-Show-Do), preparing the child for subsequent appointments.
- Tell – Show – Do: The procedure involves describing in words and phrases to the child’s understanding. We believe in using many euphemisms here (e.g., water spray instead of a drill, vanilla paste instead of restorative material). The procedure is then demonstrated in a way that involves appropriate senses and finally performed without any delay. We then take it one step further and let the child feel the jet of water in the mouth first before actually using them on the teeth.
- Modelling: Typically, children tend to learn and gain confidence from other children of similar age, gender, or someone they look up to – here, the kid learns by imitation alone, without any specific verbal direction. Modelling has limited usage in clinical practice.
- Reinforcement: When a behavior that follows a stimulus is reinforced, it is strengthened and is more likely to recur in similar circumstances. There is positive reinforcement when the desired action is rewarded with compliments. We award every child who completes the treatment with stickers and balloons, and over the years, we have realized what a positive impact it has had on children and how they remember it for years.
There is also negative reinforcement – For example, I request the parents to wait outside and call them in once the child calms down and agrees to listen. Sometimes voice modulation works best with kids, where a firm, loud voice is used to gain their attention, and once a desirable behavior is achieved, the child is complimented.
- Voice control: Usage of the right words, tone, and even facial expressions is critical when undertaking dental procedures with children. “Open your mouth and stop crying” in a loud and sharp voice can surprise the child, help the dentist gain the child’s attention, and proceed with the procedure. Voice control has helped me manage many children who were referred from other clinical set up due to un-cooperation. We have had instances of children who were advised treatment under general anesthesia as their behavior was considered unaccommodating for chair-side treatment. But we have managed to avoid general anesthesia with these techniques, thereby putting the child at ease.
- Restraints: Restraint in a dental setting physically limits the child’s body movements to facilitate a dental procedure and decrease the possibility of injuries to the child. For younger children, we encourage using lap to lap position, facing the parent, which restrains and comforting the child. As the child’s age increases, the child can sit on the parent’s lap, and the parents can hug the child from behind, which would provide restraint and comfort to the child. Our dental team also plays a role in gently holding the child’s hand or head to avoid injuries.
Conclusion: A wide variety of behavior management techniques are taught to us as pediatric dentists, but it is only with experience and patience that we start understanding the child’s thinking process, their anxieties, their fears, discomforts, etc.
As a practicing pediatric dentist, I find it most satisfying to help reduce children’s anxiety, gain the desired behavior, and complete dental treatments.