Behaviour management

Question 1

Up to what % of the child population have dental fear & anxiety and dental behaviour management problems?

Answer 1

10%

Question 2

What is dental fear?

Answer 2

a normal emotional reaction to one or more specific threatening stimuli in the dental setting

Question 3

What happens to fears with age?

Answer 3

They change

Question 4

How do fears change between a child 2-3 y/o vs. a child 7-8 y/o?

Answer 4

2-3 y/o: fear anything that differs from the norm

7-8 y/o: fewer fears in general but able to verbalise them

Question 5

What may you be scared at at the dentists?

Answer 5

Failure in front of strangers
Smell
Needles
Lack of control 
Self protection
= May be neurotic/disproportionate

Question 6

What is dental anxiety?

Answer 6

a state of apprehension that something dreadful is going to happen in relation to treatment
= multidimensional consisting of somatic, cognitive and emotional elements

Question 7

What is predictive of child onset dental anxiety?

Answer 7

A family history of dental anxiety

Question 8

What is adoloscent onset dental anxiety usually characterised by?

Answer 8

Trait anxiety

Question 9

What is adult onset anxiety?

Answer 9

= severe fears

Can indicate psychiatric problems

Question 10

What is exogenous dental anxiety?

Answer 10

Through conditioning, learning and experiences e.g. from parents or due to bad previous dental experience

Question 11

What is endogenous dental anxiety?

Answer 11

Due to constitutional vulnerability = due to internal stressors = typical of an anxiety disorder

Question 12

What can determine the consequences of traumatic dental experiences?

Answer 12

The context in which they occurred e.g. pain occurred during treatment

n.b. there are often problems with accurate recall = false memory syndrome

Question 13

What is dental phobia?

Answer 13

A severe type of dental anxiety = marked and persistent anxiety that is excessive and unreasonable

Question 14

What causes most patients to have a dental phobia?

Answer 14

Fear of injections

Question 15

What can dental phobias be in response to?

Answer 15

Either to specific situation or the dental situation in general

Question 16

Because the person can recognise that the anxiety is excessive and unreasonable why is it still an issue?

Answer 16

The person cannot physically help themselves get over it

Question 17

What are the behaviour management techniques?

Answer 17

Pharmacology (Sedation or GA)

Psychology

Question 18

What is the IOSN used for?

Answer 18

Estimating the need for sedation

Question 19

What is the IOSN based on?

Answer 19

1. anxiety score
2. medical history
3. treatment complexity

n.b. these are all sliding scales and can change on any day of the week

Question 20

What are the different sources of guidelines for behaviour management?

Answer 20

1. Non pharmacological behaviour management BSPD -2011
2. Use of GA in pages BSPD 2008
3. Sedation in children and young people NICE 2010)

Question 21

Name the different measurement techniques?

Answer 21

1. Behavioural rating scale (Frankyl scale)
2. Anxiety rating (dental anxiety scale)
3. Pain rating (FACES)

Question 22

What is the behavioural rating scale (Frankyl scale)?

Answer 22

Observation of childs behaviour during treatment
Bx1 = definitely negative (not looking at you, crying, unable to walk in)
Bx2 & Bx3 = more hesitant
Bx4 = definitely positive (lovely pt.)

Question 23

What is the anxiety rating (dental anxiety scale)?

Answer 23

Reports of anxiety by child/parent using psychometric scales in a questionnaire
= 5 x questions with a total summed score of 5- 25, score >19 indicates highly anxious pt.

Question 24

With an anxious patient, what determines what treatment you carry out and how?

Answer 24

Level of anxiety

Presence of urgent treatment needed

Question 25

If a patient is highly anxious and needs urgent treatment what do we do?

Answer 25

Relative analgesia, conscious sedation or general anaesthesia

Question 26

If a patient is highly anxious but does not need urgent treatment what do we do?

Answer 26

Cognitive behavioural therapy

Question 27

If a patient is moderately anxious whether or not they need urgent treatment what do we do?

Answer 27

The same as for low levels of anxiety + provision of preparatory information

Question 28

If a patient is a low level of anxiety whether or not they need urgent treatment what do we do?

Answer 28

``` Rapport building Voice control Distraction Modelling Memory reconstruction Environmental change ```

Question 29

Which interventions do we use for low levels of anxiety?

Answer 29

``` Distraction Voice control Positive reinforcement Modelling Show tell do Behaviour shaping Enhancing the sense of control Environmental change Rapport building ```

Question 30

What is voice control?

Answer 30

A controlled alteration of voice volume, tone or pace to influence behaviour = gains patient attention and compliance, alters negative or avoidance behaviour, establishes adult - child roles

Question 31

What is positive reinforcement?

Answer 31

Rewarding positive behaviour

Question 32

What is modelling?

Answer 32

One child observing a predictably reliable and well behaved patient having treatment (older siblings are often good = demonstrates the desired behaviour)

Question 33

What is tell-show-do?

Answer 33

= age appropriate verbal explanation of a procedure, demonstrating the procedure (auditory) and completion of procedure) n.b. too much information can tip the balance = helps familiarise the patient with the surroundings and shape the patient response

Question 34

Which interventions do we use for moderate anxiety?

Answer 34

Provide information about what will happen (procedural information), what the patient can do to cope, what sensations the individual will experience Restraint Parental acceptance

Question 35

How can restraint be used?

Answer 35

Parental, Papoose board (often sedated too to keep comfortable) = to mobilise and protect them from harming themselves

Question 36

What is parental acceptance?

Answer 36

What a parent will allow you to do! Tell show do, positive reinforcement, sedation, voice control, GA an physical restraint (increasingly unacceptable down this list)

Question 37

What is behaviour shaping?

Answer 37

A series of small steps towards ideal behaviour achieved with selective reinforcement

Question 38

What interventions do we use for high anxiety individuals?

Answer 38

Pharmacological Cognitive behavioural therapy Systemic desensitisation

Question 39

What are the different pharmacological interventions?

Answer 39

Nitrous oxide (inhale) Midazolam GA

Question 40

What is cognitive behavioural therapy?

Answer 40

Changes how you think about anxiety inducing things, and challenges your beliefs (more realistic and effects the thoughts) n.b. change is not necessarily permanent

Question 41

What are the 3 steps of systemic desensitisation?

Answer 41

1. Identification of an anxiety inducing stimuli 2. learning coping techniques 3. react towards and overcome situations in the heir achy n. b. goes through the heirachy of fear stimuli e.g. think about spider, look at picture of spider, look at it in a closed box, go into the closed box, touch it, let it crawl on your hand etc.

Question 42

What is the paediatric triangle?

Answer 42

The interactions between the child, dentist and parent (can be complex)

Question 43

What is important with the paediatric triangle?

Answer 43

Good communication is important to build trust and communication, parental presence can significantly affect the atmosphere and influence child behaviour (not necessarily in good way e.g. if parent anxious) also depends how confident you feel in sending the parent out

Question 44

What is an important indicator of behaviour?

Answer 44

Child parent interaction

Question 45

N.b. behaviour management problems are not a quality of the child... but...

Answer 45

the quality of the relationship between the dentist and child