Sedation + Behavior Guidance + Abuse/Neglect + Pain Management

Question 1

Goals of procedural sedation

Answer 1

• Promote patient welfare + safety
• Facilitate provision of quality care
• Minimize extremes of disruptive behavior
• Promote positive psychological response to tx

Question 2

Child has ~__ alveoli at birth which grows to ~__ by adulthood

Answer 2

Child has ~20 million alveoli at birth which grows to ~300 million by adulthood

Respiratory system is the last to develop

Young children have less surface area for gas exchange

Question 3

Hypercarbia + children

Answer 3

Children tolerate greater incidences of hypercarbia, unlike adults, where hypercarbia drives immediate increased respiratory response.

Hypercarbia may be associated w/ onset of cardiac arrhythmias

Question 4

Pediatric diaphragms

Answer 4

Pediatric diaphragm is less capable of displacing large volumes in vertical dimensions.

Children have relatively small functional reserve capacity.

Likewise, children have relatively larger post-expiration volume.

Question 5

Pediatric vs. adult airways

Answer 5

• ⇡airway resistance
• Glottis (vocal cords) are positioned more anteriorly + cephalad
• Narrowest portion of the upper airway is at level of cricoid cartilage (below vocal cords)
• A relatively larger tongue + epiglottis
• A larger head to body size ratio
• Mandible is less developed
• Potential for significant lymphoid tissue obstructing:
  
  • Nasopharynx
  • Oropharynx
  • Larygopharynx

Question 6

What affects medication regimen selection in sedation?

Answer 6

• Extent of tx
• Child temperament
• Age/parental expectations

Question 7

Patient selection for sedation

Answer 7

• Traditional techniques have been unsuccessful in managing behavior
• Patient ASA I or ha a medical condition that is well-controlled ASA II
• Patient is pre- or uncooperative
• Extent of tx: ultimately determined by amount of LA allowed by weight
• Needle phobic; excessively fearful older child
• Older child w/ poor experiences or coping abilities
• Distance traveled even for patients w/o behavioral problems

Question 8

Prematurity + sedation

Answer 8

• Reduced surfactant; alveoli less patent
  
  • Less surface area for qualitative gas exchange
• Poor qualitative + quantitative gas exchange
• ⇡incidence of early life intubation
• Altered neural reflex pathways; ⇡gag reflex
• Potentially at greater risk for laryngospasm
• Hospitalization; ventilator use

Question 9

Atopic triad

Answer 9

• Asthma
• Eczema
• Food allergy

May suggest IgE hyper-responder caution

Question 10

C-spine precautions w/ sedation

Answer 10

Down syndrome

Arnold-Chiari malformation

Question 11

ASA pre-procedure fasting guidelines for sedation

Answer 11

• No solid foods, non-human milk, and infant formula up to 8hr
• Clear liquids = 2hr minimum fasting period
  
  • For children +6mo
  • Clear liquids include anything w/o pulp/particulate
• Breast milk = 4hr minimum fasting period
• Infant formula = 6hr minimum fasting period
• Non-human milk = 6hr minimum fasting period
• Light meal = 6hr minimum fasting period

Question 12

ADD/ADHD medications + sedation

Answer 12

• Should be taken following NPO guidelines
• Bladder empty prior to giving meds
• Baseline vital signs

Question 13

LA toxicity

Answer 13

Initial signs of mild LA toxicity may mimic effects of N2O/O2 or may be misinterpreted as painful response/maladaptive behavior

• Lidocaine: CNS + CV effects
  
  • 4.4mg/kg w/ or w/o epi
• Septocaine: CNS + CV + immune effects
  
  • 4-5mg/kg (7mg/kg listed by manufacturer but also noted that should not be used on children <4yo; 5mg/kg noted for children)

Question 14

Causes + effects of LA toxicity

Answer 14

• Causes of OD
  
  • Intravascular injection
  • Excess dosage delivered to patient
• Effects
  
  • CNS excitement followed by depression, seizures, disorientation, loss of consciousness
  • CV system depressed
• ⇣myocardial contractility
• ⇣cardiac output
• CV collapse

Question 15

Minimal level of sedation: Cognitive Function, Physiological Function, Monitor, Personnel

Answer 15

• Cognitive Function: May be impaired
• Physiological Function: Not affected
• Monitor: Observation only; intermittent
• Personnel: Not specified

Question 16

Moderate level of sedation: Cognitive Function, Physiological Function, Monitor, Personnel

Answer 16

• Cognitive Function:
  
  • Depression
  • Responds to light tactile stimulation
• Physiological Function:
  
  • Patent, self-correcting airway
  • Ventilation + CV function is adequate
• Monitor:
  
  • O2 sat
  • HR
  • Intermittent BP + RR (no designated period of recording)
  • Capnography recommended if patient is not capable of appropriate bi-directional verbal interactions
  • EKG + defib available (should)
• Personnel:
  
  • Person responsible for monitoring other than operator
  • May do other tasks

Question 17

Deep level of sedation: Cognitive Function, Physiological Function, Monitor, Personnel

Answer 17

• Cognitive Function:
  
  • Depression
  • Not easily aroused
• Physiological Function:
  
  • Potential loss of airway reflexes
  • CV may be affected
• Monitor:
  
  • O2 sat
  • HR
  • EKG
  • Capnography recommended
  • Intermittent BP + RR (recorded q5min)
• Personnel:
  
  • Person responsible solely for monitoring

Question 18

Sedation - fatal trio

Answer 18

• Hypovolemia = Patients are NPO, verify “not over NPO” but as close to guidelines as possible
• Hypoxia = Recognize respiratory obstruction/distress immediately
• Hypercapnia = If hypoxia persists, hypercapnia may result + make patient more prone to cardiac arrhythmias

Question 19

How often do you calibrate inhalation equipment (sedation)

Answer 19

Annually

Question 20

Where do you do submucosal injection

Answer 20

B/w 1st and 2nd primary molar in maxillary vestibule

Question 21

N2O-O2 induction + recovery

Answer 21

• Induction = 5min
• Recovery = 10min

Question 22

Relative contraindications for N2O-O2 (may be used following med consult)

Answer 22

• Wheezing (moderate-severe asthma)
• Nasopharyngeal obstruction
• Tuberculosis, cystic fibrosis
• Sickle cell disease (due to lowered oxygen tension in blood)
• Acute otitis media
• Methionine synthetase deficiency
• 1st trimester pregnancy

Other contraindications: COPD, narrow angle glaucoma, pneumothorax, small obstruction, middle ear surgery, retinal surgeries

Question 23

Chronic exposure/abuse of N2O-O2

Answer 23

May result in peripheral neuropathies

Question 24

Chloral hydrate

Answer 24

• Sedative/hypnotic
• CNS depression – minimal CV or respiratory effect
• Mucosal irritant
• Gastric irritation a side effect; unpleasant taste
• Onset: 30-60min
• Peak: 60min
• Duration: 5hr
• Working time: up to 60min
• 10-50mg/kg PO to 1g max (as sole agent; reduced doses if used in combination w/ other sedatives)
• Metabolized to trichlorethanol in liver; excreted by kidney
• Arrhythmias in higher doses (usually >75mg/kg)
• No reversal agent
  
  • When combined w/ other sedates, this is why CH dose should be loweer

Question 25

Diazepam

Answer 25

* Sedative/hypnotic * CNS depression – minimal CV or respiratory effect * Amnesia, ataxia (acts in cortex, limbic system thalamus, hypothalamus) * Onset: **45-60min** * Peak: **60min** * ½ life: **20-40hr** * **0.25-0.3mg/kg PO (\<10mg total dose)** * Reversal: **Flumazenil (0.01mg/kg and can be repeated up to a total of 1mg)** * IV preferred, but can be IM or submucosal – onset of reversal doesn't occur for up to 1-2min assuming circulation is occurring * Contraindications: **Narrow angle glaucoma** * Half-life **20-40hr** w/ sedative metabolite

Question 26

Midazolam

Answer 26

* Sedative/hypnotic * CNS depression – minimal CV or respiratory effect * **Anterograde amnesia potential feature** * Onset: **15min** * Working time: **30-40min** * **0.5-0.75mg/kg to 15mg total – orally** * **0.2-0.3mg/kg – nasally** * Reversal: **Flumazenil (not to exceed a cumulative dose of 0.05mg/kg or 1mg, whichever is lower)** * IV preferred, but can be IM or submucosal – onset of reversal effect does occur for up to 1-2min * **3-4x potency of diazepam** * **Respiratory depression w/ higher doses or rapid IV bolus**

Question 27

Hydroxyzine

Answer 27

* Antiemetic/antihistamine * CNS depression – anxiolytic, bronchodilator * Analgesia – dry mouth * Onset: **15-30min** * Duration: **2-4hr duration** * **0.5-1mg/kg orally** * Used often w/ chloral hydrate, meperidine or midazolam

Question 28

Meperidine

Answer 28

* Narcotic * CNS, CV, respiratory depression * Reversal: **Naloxone (0.1mg/kg; max 2.0mg)** * IV preferred, but can be IM or submucosal – onset doesn't occur for up to 1-2min * Sedation, analgesia, lowers seizure threshold * Caution in patients w/ * Pulmonary complications * Head trauma * Seizures * Hepatic/renal disease * Airway obstruction * Concomitant LA dose consideration is very important * Onset: **30min** * Peak: **1-2hr** * Duration: **2-4hr** * **1.0-2.0mg/kg PO** * **50mg max PO, SM, IM** * **Metabolized by liver, excreted by kidney** * Side effects: * Dizziness * Xerostomia * Sweating * Nausea/vomiting * Seizures * Respiratory depression * **NOT to be used in patients w/ h/o asthma → may shift production in respiratory tree from prostaglandins to leukotrienes which are bronchial irritants**

Question 29

Physiologic monitoring based on behavior: Screaming/yelling vocalizations

Answer 29

* Clinical signs: * Few tears * Controlled breathing * Struggling against immobilization * Pre-cordial: Take earpiece out * Capnogaph: Not needed * Pulse ox: * keep stabilized * Set upper HR limits to **230bpm**

Question 30

Physiologic monitoring based on behavior: Mild crying

Answer 30

* Clinical signs: * Some tears, eyelids open, some ptosis * Pre-cordial: Take earpiece out * Capnogaph: Not needed * Pulse ox: * keep stabilized * Set upper HR limits to **230bpm**

Question 31

Physiologic monitoring based on behavior: Quiet (responsive)

Answer 31

* Clinical signs: * Eyes closed, open when requested or mildly stimulated * Breathing WNL * Possible occasional crying * Pre-cordial: Earpiece in + listening, attentive to gurgling or snoring (adjust head tilt) * Capnogaph: * Place/monitor probe * Monitor adequacy of ventilation paying attention to head position * Pulse ox: * **Heightened awareness for incidence of desaturation (changing pitch of pulse ox)** * Assess ventilation + head position

Question 32

Physiologic monitoring based on behavior: Quiet (unresponsive)

Answer 32

* Clinical signs: * Eyes closed, partial ptosis w/ possible divergent eyes * Does not open eyes on command * Breathing shallow * Subtle respiratory movements * Pre-cordial: * Earpiece in + listening, attentive to gurgling or snoring (adjust head tilt) * Keen focus on airway sounds, indication of obstruction or restriction or airway * Capnogaph: * Be cognizant of frequency of breathing, expired concentrations of CO2 + indications of apneic episodes * Pulse ox: * **Heightened awareness for incidence of desaturation (changing pitch of pulse ox)** * Assess ventilation + head position * **_Alter passive immobilization to allow patient assessment_**

Question 33

Basic schema for a deteriorating patient under procedural sedation

Answer 33

* Problem w/ ventilation – respiratory distress * Problem w/ oxygenation – hypovolemia, hypoxia, hypercapnia * Persistent respiratory distress + hypotension → CV arrhythmia (bradycardia)

Question 34

Signs of respiratory distress in a child – sedation

Answer 34

* Chest breathing – non-diaphragmatic * Nasal flaring * Platysma flaring * Grunting * Rocking horse/see-saw respiratory patterns * Use of intercostal muscles for breathing

Question 35

Potential emergencies associated w/ sedation

Answer 35

* Respiratory rate depression or arrest * Upper airway obstruction including laryngospasm * Allergic reaction/overdose * If more than 1 organ system involved (e.g. respiratory + dermatologic) epi instead of diphenhydramine * Bradycardia and/or hypotension * Hypoglycemia * Ensure glucose preoperatively if concern (diabetic) * Have source of glucose (orange juice, frosting) on hand * Vomiting * **Right mainstem bronchus is straight compared to left mainstem and more likely to aspirate** * Seizures

Question 36

SOAPME

Answer 36

Commonly used acronym useful in planning + preparation for a procedure. * S – size appropriate suction catheters * O – Adequate oxygen supply + functioning flowmeter or other devices to allow delivery * A – Size appropriate airway equipment, including but not limited to: BMV, OPA, LMA, NPA, facemasks, endotracheal tubes * P – Pharmacy to include basic life supporting drugs for emergency * M – Monitors (functioning + appropriate for one level deeper than intended sedation) * E – Special equipment such as defibrillator/AED

Question 37

Nitrous usage is a safe, effective technique for:

Answer 37

* Reducing anxiety * Producing analgesia * Enhancing effective communication between patient + healthcare provider

Question 38

Nitrous oxide: Properties

Answer 38

* Analgesic and anxiolytic * Causes CNS depression and euphoria * Little effect on respiratory system * Colorless and odorless gas w/ faint sweet smell

Question 39

Nitrous oxide: Safety

Answer 39

* Patient can respond normally to verbal commands * Causes minimal impairment of any reflexes, thus protecting the cough reflex * No risk of losing protective reflexes * Pt returns to preprocedure mobility after usage * No recorded fatalities or cases of serious morbidity when used within recommended concentration

Question 40

Nitrous oxide: MOA

Answer 40

* **Absorbed quickly** → allows for rapid onset and recovery [2-3 min] * **Analgesic effect** * Initiated by neuronal release of endogenous opioid peptides * These activate opioid receptors and descending gamma-aminobutyric acid type A (GABAA) receptors and the noradrenergic pathways that modulate nociceptive processing at the spinal level * **Anxiolytic effect** * involves activation of the GABAA receptor either directly or indirectly through the benzodiazepine binding site * **Lungs** * Rapid uptake of nitrous → absorbed quickly from alveoli and held in a simple solution in the serum * Relatively insoluble → passes down a gradient into other tissues and cells in the body like the CNS * Excreted quickly from the lungs * **Cardiac** * Causes minor depression in cardiac output while peripheral resistance is slightly increased → thereby maintaining the blood pressure * Advantage when treating patient w/ cerebrovascular system

Question 41

Nitrous oxide: Uses in children

Answer 41

* Analgesia/ anxiolysis may expedite the delivery of procedures that are not particularly uncomfortable, but require that the patient not move * Allow pt to tolerate unpleasant procedures by reducing/ relieving anxiety, discomfort, pain * Increase reaction time and reduces pressure induced pain * Does not affect pulpal sensitivity * The decision to use N2O analgesia/ anxiolysis must take into consideration: * Alternative behavioral guidance modalities * The patient’s dental needs * The effect on the quality of dental care * The patient’s emotional development * The patient’s physical considerations * Causes most children to feel tingling/warm sensation * Appear w/ their hands open, legs limp, trance like expression * In some children → they don't like the feeling of losing control * Claustrophobic children → may find nasal hood confining/ unpleasant

Question 42

Nitrous oxide: Bioenvironmental concerns

Answer 42

* N2O has been associated with bioenvironmental concerns bc of its contribution to the greenhouse effect * Nitrous oxide contributes about 5% to greenhouse effect * Only 0.35-2% of total nitrous released into the atmosphere is a result of medical applications of N2O gas * Natural sources of nitrous * Emitted by bacteria in soils and oceans * Produced by burning fossil fuels and forests * Produced by agricultural practices of soil cultivation and nitrogen fertilization

Question 43

Nitrous oxide: Objectives

Answer 43

1. Reduce or eliminate anxiety 2. Reduce untoward movement and reaction to dental treatment 3. Enhance communication and patient cooperation 4. Raise the pain reaction threshold 5. Increase tolerance for longer appointments 6. Aid in treatment of the mentally/physically disable or medically compromised patient. 7. Reduce gagging. 8. Potentiate the effect of sedatives

Question 44

Nitrous oxide: Disadvantages

Answer 44

1. Lack of potency. 2. Dependent largely on psychological reassurance. 3. Interference of the nasal hood with injection to anterior maxillary region 4. Patient must be able to breathe through the nose 5. Nitrous oxide pollution

Question 45

N2O: Indications

Answer 45

1. A fearful, anxious, or difficult patient. 2. SHCN 3. A patient whose gag reflex interferes with dental care. 4. A patient for whom profound local anesthesia cannot be obtained. 5. A cooperative child undergoing a lengthy dental procedure.

Question 46

What should be assessed in patient's med hx before usage of N2O?

Answer 46

1. Allergies and previous allergic or adverse drug reactions. 2. Current medications including dose, time, route, and site of administration. 3. Diseases, disorders, or physical abnormalities and pregnancy status. 4. Previous hospitalization to include the date and purpose. 5. Recent illnesses (e.g., cold or congestion) that may compromise the airway.

Question 47

N2O: Contraindications

Answer 47

1. Some chronic obstructive pulmonary diseases 2. Current upper respiratory tract infections 3. Recent middle ear disturbance/surgery 4. Severe emotional disturbances or drug-related dependencies. 5. First trimester of pregnancy 6. Treatment with bleomycin sulfate 7. Methylenetetrahydrofolate reductase deficiency 8. Cobalamin (vitamin B12) deficiency

Question 48

When should you consult MD to use N2O?

Answer 48

* Pt has significant underlying med condition * Severe obstructive pulmonary disease * Congestive heart failure * Sickle cell disease * Acute otitis media * Recent tympanic membrane graft * Acute severe head injury * Pt is pregnant → contact their pre-natal med provider

Question 49

N2O: Technique of administration

Answer 49

* Only administered by trained/ licensed individuals who can perform appropriate reversal response [must have training to manage an emergency if pt falls into moderate sedation] * Or under direct supervision of [differs per state law] * Choose the right size nasal hood * **_Flow rate → 5-6 L/min generally acceptable to most pts_** * Can adjust after observation of reservoir bag * The bag should pulsate gently with each breath and should not be either over- or underinflated * Introduction of 100% oxygen for 1-2 minutes followed by titration of N2O in 10% intervals is recommended * Nitrous concentration should not exceed 50% * Studies have demonstrated that gas concentrations dispensed by the flow meter vary significantly from the end-expired alveolar gas concentrations; it is the latter that is responsible for the clinical effects. * For sedated effect: * Prevent pt from talking and mouth breathing * The scavenging vacuum should not be so strong as to prevent adequate ventilation of the lungs with N2O * 30-40% N2O to achieve ideal sedation * Decrease N2O concentration for easier procedures, and increase for harder * **Always monitor pts respiratory rate and level of consciousness** * Effects of nitrous dependent on psychological reassurance * Important to continue behavior guidance during tx * After tx completed → administer 100% oxygen until pt has returned to pretreatment status

Question 50

N2O: Monitoring

Answer 50

* Pt’s response to commands → serves as a guide to their level of consciousness * Continual clinical observation of the patient’s responsiveness, color, and respiratory rate and rhythm must be performed

Question 51

N2O: Adverse effects

Answer 51

* Acute/chronic adverse effects is rare * Most common adverse effects: nausea and vomiting [0.5-1.2% of pts] * Higher incidence noted w: * Longer admin of nitrous * Fluctuations in nitrous oxide levels * Lack of titration * Increased concentrations of nitrous oxide * A heavy meal prior to administration of nitrous oxide * Fasting isn’t necessary, but can recommend lighter meal before admin * Other less common adverse effects * **Silent regurgitation and silent aspiration** are rare but occur * Concern lies whether pharyngeal- laryngeal reflexes remain intact * Avoid this problem by not allowing pt to go into unconscious state * **Diffusion hypoxia** * **Can occur as a result of rapid release of nitrous oxide from the bloodstream into the alveoli, thereby diluting the concentration of oxygen** * **Can lead to headache, disorientation, and nausea** * Can be avoided by administering 100% O2 when the nitrous has been terminated * **Negative outcomes associated with N2O \>50% and as an anesthetic during major surgery**

Question 52

N2O: Documentation

Answer 52

* Get informed consent prior to administration of nitrous * Pts record should include indication for nitrous, the dosage, duration of procedure and post tx oxygenation procedure

Question 53

N2O: Facilities, personnel, equipment

Answer 53

* **Inhalation equipment must have the capacity for delivering 100%, and never less than 30%** * Inhalation equipment must have a fail-safe system that is checked and calibrated regularly according to the practitioner’s state laws and regulations * Must have an appropriate scavenging system to minimize room air contamination and occupational risk * Because moderate sedation may occur, practitioners should have the appropriate training and emergency equipment to manage this * An emergency cart should be readily available * Should have equipment to resuscitate a non-breathing, unconscious pt and provide continuous support until ER personnel arrive * **A positive pressure oxygen delivery system capable of administering greater than 90% oxygen at a 10 L/min flow for at least 60 minutes (650 L, “E” cylinder) must be available**

Question 54

N2O: Occupational safety

Answer 54

* Long-term exposure to N2O used as a general anesthetic has been linked to bone marrow suppression and reproductive system disturbances * Appropriate scavenging is effective in reducing the reproductive system effects * To avoid health hazards → use effective scavenging systems * Clinicians should try to minimize the patient’s talking and mouth breathing during N2O administration to prevent expired gas from contaminating the operatory

Question 55

What has long-term N2O exposure as a general anesthetic been linked to?

Answer 55

Bone marrow suppression + reproductive system disturbances

Question 56

What medicaments should be used as first line interventions for pain management?

Answer 56

APAP (acetaminophen)/NSAIDs

Question 57

Pain: Definition

Answer 57

* **_Pain:_** (International Association of the Study of Pain) An unpleasant sensory + emotional experience associated w/ actual or potential tissue damage or described in terms of such damage. * Acute * Chronic * Subjective, emotional, cultural component

Question 58

Gate Theory of Pain

Answer 58

* Melzack + Wall – 1965 * The substantial gelatinosa in dorsal horn acts as a “gate” which modulates transmission of sensory information from primary afferent neurons to transmission cells in spinal cord * Small-fiber activity “opens” gate while large-fiber activity “closes" gate * Descending pathways modify gate – activation of large fiber sensory neurons can modify pain perception

Question 59

What are infants + young children more sensitive to pain?

Answer 59

* Ascending pathways intact allowing full transmission of pain * Descending modulating pathways poorly developed + unable to attenuate pain * Do not have cognitive skills to modulate pain

Question 60

What are effects of improperly managed pain?

Answer 60

* Significant stress rxn w/ ⇡in catecholamines, corticosteroids, suppression of insulin, significantly more complications post-operatively * Long-term neurologic change * Changes in brain achitecture * Changes in dorsal horn (plasticity) → hyperalgesia later in life * **Plasticity acts as implicit memory of pain**

Question 61

What patients are at higher risk of experiencing pain?

Answer 61

* H/o uncontrolled procedural pain or h/o frequent medical intervention * Infants + very young children * H/o prematurity * Past h/o physical, sexual, or psychological abuse

Question 62

Wong-Baker FACES Pain Scale

Answer 62

Self-reported pain scale – Children **\>3yo**

Question 63

Visual Analogue Scale

Answer 63

Self-reported pain intensity scale – Children **\>6yo**

Question 64

FLACC

Answer 64

* FLACC = Faces, Legs, Arms, Crying Consolability Scale * Observational pain scale for children + adults * Requires trained observer

Question 65

Sucrose + Non-Pharmacologic procedural pain management

Answer 65

* Effective for minor pain in young infants * **Sucrose has same pathway as opioids; efficacy wanes at 6mo**

Question 66

Ice precooling injection site vs. benzocaine

Answer 66

Ice precooling has been shown to be more effective than benzocaine

Question 67

Topical anesthetic effect – What is the depth of the effect?

Answer 67

* **Pharmacologic + psychological** * Effective on surface up to **2-3mm** * Subjects who are told they will receive topical for comfort anticipate less pain

Question 68

How may topical anesthetic be most effective?

Answer 68

* Dry mucosa * Longer duration is more effective (5min \> 2min \> 30 sec) * More effective in buccal fold than on palatal tissue OR for deep tissue injections

Question 69

What type of anesthetic is topical benzocaine (up to 20%)?

Answer 69

Ester

Question 70

What is the reason for the FDA warning w/ benzocaine?

Answer 70

* Children \<2yo (i.e. teething gels) due to **methemoglobinemia** * Ferrous iron in the hemoglobin molecule is oxidized to the ferric state to become methemoglobin * Cannot carry O2

Question 71

What other types of topical anesthetic may be used?

Answer 71

20% benzocaine, 5% lidocaine, 4% tetracaine

Question 72

Compound topical anesthetics

Answer 72

* Not regulated by FDA * FDA issued warning about use of compounded topical anesthetics + risk of methemoglobinemia w/ benzocaine and/or prilocaine * Various formulations (usually higher doses) of tetracaine, lidocaine, benzocaine, prilocaine, and/or phenylephrine * Systemic absorption of topical anesthetics must be considered when calculating the total amount of anesthetic dosage administered

Question 73

LA MOA

Answer 73

Reversibly bind to Na+ channels of nerve cells preventing depolarization + impulse propagation

Question 74

**2% lidocaine (xylocaine) 1:100k epi:** Duration, Max dosages, mg/1.7mL cartridge

Answer 74

* Duration (in minutes) * Max infiltration * Pulp = **60** * Soft tissue = **170** * Mand block * Pulp = **85** * Soft tissue = **190** * Max dosage = **4.4mg/kg** – Total = **300mg** * mg/1.7mL cartridge = **34mg**

Question 75

**3% mepivacaine (carbocaine) plain:** Duration, Max dosages, mg/1.7mL cartridge

Answer 75

* Duration (in minutes) * Max infiltration * Pulp = **25** * Soft tissue = **90** * Mand block * Pulp = **40** * Soft tissue = **165** * Max dosage = **4.4mg/kg** – Total = **300mg** * mg/1.7mL cartridge = **51mg**

Question 76

**4% articaine (septocaine) 1:100k epi:** Duration, Max dosages, mg/1.7mL cartridge

Answer 76

* Duration (in minutes) * Max infiltration * Pulp = **60** * Soft tissue = **190** * Mand block * Pulp = **90** * Soft tissue = **230** * Max dosage = **7.0mg/kg** – Total = **500mg** * mg/1.7mL cartridge = **68mg**

Question 77

**4% prilocaine pain:** Duration, Max dosages, mg/1.7mL cartridge

Answer 77

* Duration (in minutes) * Max infiltration * Pulp = **20** * Soft tissue = **105** * Mand block * Pulp = **55** * Soft tissue = **190** * Max dosage = **6.0mg/kg** – Total = **400mg** * mg/1.7mL cartridge = **68mg**

Question 78

**0.5% bupivacaine (marcaine) 1:200k epi:** Duration, Max dosages, mg/1.7mL cartridge

Answer 78

* Duration (in minutes) * Max infiltration * Pulp = **40** * Soft tissue = **340** * Mand block * Pulp = **240** * Soft tissue = **440** * Max dosage = **1.3mg/kg** – Total = **90mg** * mg/1.7mL cartridge = **8.5mg**

Question 79

Epi in LA

Answer 79

* ⇓bleeding in area of injection * ⇓toxicity by slowing rate of resorption of anesthetic into CV system * Recommended, esp when tx includes 2+ quadrants

Question 80

What is the preservative in LA that patients may have an allergic rxn to? What do we give for LA to patients w/ this allergy?

Answer 80

**Bisulphite preservative** is used in anesthetics w/ epi. ## Footnote **_Use anesthetic w/o epi in patients w/ this allergy._**

Question 81

Contraindication] for epi in LA?

Answer 81

Hypothyroidism

Question 82

When should you send a med consult for use of LA?

Answer 82

* Diabetes * Significant CV disease * Thyroid dysfunction * Patients on tricyclic antidepressants, monoamine oxidase inhibitors, phenothiazines

Question 83

Where is articaine (septocaine) metabolized?

Answer 83

Liver + plasma Has the shortest half-life

Question 84

FDA approval for use of articaine (septocaine) in children at what age?

Answer 84

≥4yo

Question 85

Which amide LA is associated w/ paresthesia?

Answer 85

Articaine (septocaine) + prilocaine

Question 86

What amide LA is associated w/ a disproportionate number of pediatric LA systemic toxicity reports?

Answer 86

Mepivacaine (carbocaine)

Question 87

Indications for mepivavaine (carbocaine)?

Answer 87

* Significant CV disease * Hyperthyroidism * Bisulphite sensitivity

Question 88

Prilocaine

Answer 88

* Can induce formation of methemoglobinemia * W/o vasoconstrictor has a higher pH than lidocaine, but no difference in injection pain

Question 89

Contraindications for prilocaine use

Answer 89

* Patients w/ various anemias * Symptoms of hypoxia * Taking acetaminophen

Question 90

Why is bupivacaine (marcaine) not typically used in pediatric dental patients?

Answer 90

Due to the long duration of soft tissue anesthesia + ⇑risk of post-operative soft tissue trauma

Question 91

Indication for bupivacaine (marcaine)?

Answer 91

Anticipated post-op pain OR for adolescent patient w/ a “hot” tooth

Question 92

Infiltration vs. block (in relation to the nerve)

Answer 92

Infiltration = terminal branches of nerve Block = main nerve trunk

Question 93

IANB

Answer 93

* Innervates primary + permanent mandibular teeth * **Foramen is 7mm above mandibular plane in adults** * **More inferior + posterior in young children** * Bilateral blocks **_are not_** associated w/ ⇑post-anesthetic soft tissue trauma

Question 94

PSA nerve block

Answer 94

* Advocated by some for 2nd primary + 1st permanent molars in primary + early mixed dentition due to thick zygomatic bone that overlies apices * **_Highest risk of hematoma_** * Efficacy over infiltration has been questioned

Question 95

Greater palatine block

Answer 95

* Anesthetizes palatal tissue from tuberosity to canine region * Indicated for EXT, long procedures where palatal gingiva is manipulated, or when post-op analgesia is needed * **Level w/ distal cusp of permanent 1st molars + between tooth and midline of palate** * **If no 1st permanent molar present, injection should be made _10mm_ distal to primary molar**

Question 96

If no 1st permanent molar is present, where should you drop LA for greater palatine block?

Answer 96

If no 1st permanent molar present, injection should be made **_10mm_ distal to primary molar**

Question 97

Nasopalatine injection

Answer 97

* Innervates palatal tissue of maxillary incisors * **Most painful injection**

Question 98

PDL injections in animal model studies

Answer 98

* May be an adjunct to other forms of LA or used alone for single tooth anesthesia * **⇑pressure injections associated w/ permanent tooth bud damage in animal models can lead to hypomineralization** * **Injury to succedaneous tooth is not associated w/ computer controlled LA delivery**

Question 99

Intrapulpal injection

Answer 99

* Direct deposition into the pulp when other forms of anesthesia are inadequate * Effective **_only_** when injected under pressure * **Short duration of action = 15-20min**

Question 100

What are hallmarks of inflammatory pain?

Answer 100

* Swelling * Hyperthermia * Activation of biochemical cascades

Question 101

How is pain processed?

Answer 101

Sensory signals travel along **_afferent trigeminal nerve fibers**_ and relay information to the _**brainstem and higher structures_** involved w/ pain perception.

Question 102

What is peripheral sensitization?

Answer 102

Local increase in nerve membrane activity/excitability → enhanced neuronal response **_Primary hyperalgesia:_** Exaggerated response

Question 103

Central sensitization

Answer 103

Enhanced functional status of pain circuits + pain processing at the level of the CNS * Characteristics * **Secondary hyperalgesia:** ⇑pain intensity to noxious stimuli outside the area of tissue damage * **Allodynia:** Pain perception following innocuous stimuli like light touch

Question 104

Pain modulation

Answer 104

* Occurs through **_CNS excitatory + inhibitory processes._** * Ascending facilitating and descending inhibitory processes enhance or suppress pain experience respectively. * Both pharmacologic + nonpharmacologic methods target these processes to alter pain processing.

Question 105

How is pain assessed?

Answer 105

* Self-report * Behavioral (vocalization, facial expression, body movement) * Biological (heart rate, transcutaneous oxygen, sweating, stress response)

Question 106

What questions should you ask regarding pain?

Answer 106

Onset, provoking factors, palliative factors, quality or character, region or location, severity or intensity, timing or duration, and impact on daily activities.

Question 107

At what age can patients likely quantify pain based on a series of faces? (Reference Manual)

Answer 107

4-12yo

Question 108

At what age can patients mark pain using a VAS or numeric scale? (Reference Manual)

Answer 108

\>7yo

Question 109

Validated instruments for pain assessment (Ref Manual)

Answer 109

* Faces Pain Scale (Revised) * VAS * Numeric rating scale * Faces, Legs, Activity, Cry and Consolability score (FLACC) * Revised Faces, Legs, Activity, Cry and Consolability (r-FLACC) * McGill Pain Questionnaire

Question 110

Diagnostic categories of pain

Answer 110

* Somatic * Visceral * Neuropathic

Question 111

What type of pain do we typically encounter in dentistry? (Our patients, not referring to the emotional pain of the providers lol)

Answer 111

* Typically inflammatory * Somatic * Periodontal, alveolar, mucosal * Visceral * Pulpal

Question 112

Acute vs. Chronic Pain

Answer 112

* Acute pain that fails to respond to treatment may become chronic over time. * Chronic pain: Dysfunctional and persists beyond the time for typical tissue healing (i.e. TMD).

Question 113

Profound anesthesia prior to starting tx decreases \_\_

Answer 113

⇓central sensitization

Question 114

Pain reduction during LA injection

Answer 114

* Distraction techniques (i.e. jiggling the patient’s cheek) take advantage of the Aß-fiber signal dominance and can significantly reduce the intensity of pain-related C-fiber signaling. * Buffering or decreasing acidity of LA with sodium bicarbonate can decrease injection site pain and postop discomfort by increasing pH of the anesthetic. * Decreasing LA delivery rate.

Question 115

GA w/o LA may result in what?

Answer 115

* Pain is not experienced during GA, but central sensitization occurs when peripheral nerves are stimulated. * **Operating w/o LA may result in priming CNS neurons and increased future pain sensitivity.** * Central sensitization is minimized w/ pre-emptive analgesia or anesthesia. * Regional block or infiltration is commonly done prior to surgical procedures to decrease postop pain. * Pharmacologic + cardiac considerations along with avoiding the numb sensation and potential for self-inflicted oral trauma are reasons providers may choose not to provide LA during GA.

Question 116

At what age are distraction/imagery techniques most effective?

Answer 116

* \>8yo * Cognitive (counting, non-procedural talk) * Behavioral (videos, games) * Significantly effective when measuring pulse rates, respiratory rates, and self-reported pain. * Lowers pain perception in younger children.

Question 117

NSAIDs: Properties

Answer 117

Anti-inflammatory, analgesic, antipyretic antiplatelet properties.

Question 118

NSAIDs: MOA

Answer 118

* Inhibit prostaglandin synthesis * COX (cyclooxygenase)

Question 119

What is included in NSAIDs?

Answer 119

* Salicylic acid: Aspirin * Acetic acids: Ketolorac (IV or IN) * Useful in moderate-severe acute pain in patients unable to take PO * Proprionic acids: Ibuprofen, naproxen * COX-2 selective: Celecoxib

Question 120

NSAIDs: Adverse effects

Answer 120

* Inhibition of bone growth and healing * Gastritis w/ pain + bleeding * Decreased renal blood flow * Inhibition of platelet function * Increased incidence of CV events * Specific concern: Potential to exacerbate asthma due to a shift in leukotrienes. Due to shared pathways, NSAIDs and steroidal anti-inflammatory medications should not be routinely co-administered.

Question 121

Why should NSAIDs + steroidal anti-inflammatory meds not be routinely co-administered?

Answer 121

Due to shared pathways, NSAIDs and steroidal anti-inflammatory medications should not be routinely co-administered.

Question 122

What is APAP (acetaminophen) efficacious for?

Answer 122

Mild to moderate pain, antipyretic Centrally-acting No effects on gastric mucosal lining or platelets

Question 123

APAP (acetaminophen): MOA

Answer 123

Blockade of prostaglandin + substance P production

Question 124

Why does rectal administration of APAP (acetaminophen) have higher bioavailability + faster onset than PO?

Answer 124

It partially bypasses hepatic metabolism

Question 125

What is multimodal therapy (w/ NSAIDs)?

Answer 125

Alternating/staggering NSAIDs

Question 126

Common uses for opioid analgesics

Answer 126

* Pain w/ cancer * Sickle cell disease * Osteogenesis imperfecta * Epidermolysis bullosa * Neuromuscular disease

Question 127

Major concerns of opioid analgesics

Answer 127

Efficacy, safety, misuse, accidental deaths

Question 128

Opioid Analgesics: MOA

Answer 128

* Interact w/ differentially w/ μ, 𝛋, and 𝛅 receptors in the CNS. * Opioid antagonists act on receptors located in the brain, spinal cord, and digestive tract. * Pathways of opioid receptor signaling are multiple and include G-protein receptor coupling, cAMP inhibition, and calcium channel inhibition.

Question 129

What does activating opioid receptors cause?

Answer 129

* Respiratory depression * Pupil constriction (miosis) * Euphoria * Sedation * Physical dependence * Endocrine disruption * Suppression of opiate withdrawal * Pruritis (itching) may also occur due to histamine release that accompanies some opioid analgesics

Question 130

Naloxone

Answer 130

μ opioid receptor competitive antagonist usually administered parenterally to counter opioid overdose

Question 131

Opioids w/ active metabolites: Which opioids and by what enzyme?

Answer 131

Codeine, tramadol, hydrocodone are broken down in the liver into active metabolites by highly variable cytochrome CYP2D6.

Question 132

Why have the FDA + European Medicines Agency have issued warnings + contraindications statements on codeine and tramadol?

Answer 132

* Ineffective in some children due to poor drug metabolism. * Hyper-metabolizers break these prodrugs into their active forms too quickly, potentially resulting in overdose, respiratory depression and death. * Hydrocodone also relies on cytochrome p450 metabolism and has similar adverse effects * Evidence is not convincing that these medications provide appropriate analgesia, especially with concerns of safety.

Question 133

2017 – FDA issued a warning for codeine + tramadol

Answer 133

* Not safe for patients \<12yo. * 12-17yo age group, should not be used in high-risk patients (e.g. obesity, OSA, lung tissue disease) * Should not be used when breastfeeding due to active metabolites present in breastmilk

Question 134

What opioids do not have active metabolites?

Answer 134

Naturally occurring morphine + synthetics oxycodone and fentanyl do not have CYP2D6 considerations since they do not contain CYP2D6 metabolites

Question 135

Morphine

Answer 135

* Rapid relief of severe pain for 2-3 hours * Associated w/ histamine release + respiratory depression

Question 136

Fentanyl

Answer 136

* 100x more potent than morphine * Ultra-short acting * Used for invasive procedures + sedatives Adverse reaction: **Chest wall rigidity**

Question 137

Adverse reaction to fentanyl

Answer 137

Adverse reaction: **Chest wall rigidity**

Question 138

Codeine

Answer 138

* Rapidly acting codeine has a longer half-life than morphine and is more potent. * Single agent vs. combined with aspirin, ibuprofen, acetaminophen * Considered off label in children 12yo and younger

Question 139

Opioid Concerns + CDC and Prevention Recommendations

Answer 139

* Limit opioids for moderate to severe pain * Restrict prescription to 3 days * Provide concurrent pharmacologic and non-pharmacologic therapy * Advises against overlap benzodiazepines + opioid prescriptions because of increased risk for potential respiratory depression.

Question 140

Caution with commercial opioids combined w/ acetaminophen

Answer 140

Commercial opioids often combined with acetaminophen, the potential for hepatic failure from toxic levels of acetaminophen also must be considered

Question 141

Phentolamine mesylate

Answer 141

* Reversible, non-selective alpha adrenergic antagonist which results in vasodilation and redistribution of LA away from injection site * Reduces duration of soft tissue anesthesia by approximately half * **FDA approval for children \>6yo** * **Should not be used to reverse LA toxicity**

Question 142

FDA approved use for phentolamine – at what age?

Answer 142

\>6yo

Question 143

LA Overdose: Causes

Answer 143

* Inadvertent intravascular injection at a rapid rate * Excess dosage

Question 144

Signs of LA overdose

Answer 144

* Biphasic clinical manifestation * Initial excitatory reaction (inhibitory neurons are depressed) * Circumoral tingling, dizziness, tinnitus, increased heart rate, and BP * Later depressive reaction * Drowsiness, loss of consciousness, seizure, cardiovascular collapse Other: Needle breakage, prolonged anesthesia or paresthesia, facial nerve paralysis, trismus, hematoma

Question 145

Ibuprofen

Answer 145

* NSAID * First line for dental pain if not contraindicated * Associations between development of asthma + maternal and infant use of acetaminophen + ibuprofen, but further research is needed * Efficacy equivalent to morphine w/ fewer side effects

Question 146

Aspirin in children

Answer 146

* Not recommended for children * Some teething gels contain aspirin-like product called choline salicylate

Question 147

Naproxen OTC use by children

Answer 147

Not recommended for OTC use in \<12yo

Question 148

Naproxen: MOA

Answer 148

Reversibly inhibits COX-1 and 2 enzymes resulting in decreased formation of prostaglandin precursors

Question 149

Opioids MOA

Answer 149

Bind to opioid receptors in CNS, causing inhibition of ascending pain pathways, altering perception of and response to pain; cause generalized CNS depression

Question 150

Metabolism of codeine, hydrocodone, and oxycodone

Answer 150

Catalyzed in the liver by cytochrome P450 enzymes **CYP3A4 + CYP2D6**

Question 151

Drug-drug interactions that occur with opioids

Answer 151

* Drug-drug interactions can occur with opioids and CYP3A4 inhibitors leading to an increase in drug concentration and potential toxicity * CYP3A4 inhibitors: * Macrolide antibiotics * Proton pump inhibitors * Selective serotonin reuptake inhibitors * Natural supplements like St. John's wart + Echinacea

Question 152

Opioids: Adverse effects

Answer 152

* Nausea/vomiting * Constipation * Sedation/cognitive function * Respiratory depression

Question 153

Codeine: FDA Blackbox warning

Answer 153

* Ultra-rapid metabolizers have polymorphism of liver cytochrome enzyme CYP2D6 + convert codeine to high levels of morphine rapidly. * FDA blackbox warning due to death following tonsillectomy * Contraindicated in children at risk for sleep apnea

Question 154

Poor metabolizers may have inadequate pain control with codeine because? What is codeine's metabolite?

Answer 154

Codeine is a prodrug, meaning that its analgesic effect is due to its metabolite, morphine

Question 155

DEA Schedule for Codeine?

Answer 155

FDA Schedule IV allows it to be called into a pharmacy and does not require a written prescription

Question 156

Hydrocodone

Answer 156

* Both parent drug + metabolite have analgesic effects, though parent drug is a weak analgesics * **CYP2D6 converts hydrocodone into hydromorphone, a more potent opioid**

Question 157

DEA Schedule for Hydrocodone?

Answer 157

DEA Schedule II requires a written prescription

Question 158

DEA Schedule for oxycodone

Answer 158

DEA Schedule II requires a written prescription

Question 159

Systemic analgesics dosing

Answer 159

* “Around the clock” is preferred to PRN for first 36-48hrs * Alternating ibuprofen + acetaminophen every 3hrs is safe for short term use with compliant caregivers

Question 160

What type of injuries occur in more than half of child abuse cases?

Answer 160

Craniofacial, head, face and neck injuries

Question 161

What is the most common site for inflicted oral injuries?

Answer 161

Lips (54%), followed by the oral mucosa, teeth, gingiva, and tongue

Question 162

An intercanine distance measuring more than __ is suspicious for an adult human bite

Answer 162

3.0 cm

Question 163

More than __ of children who are victims of human trafficking still see a health care professional

Answer 163

One quarter

Question 164

Child trafficking victims have __ risk for dental problems because they “often suffer from inadequate nutrition leading to retarded growth and poorly formed teeth, as well as dental caries, infections and tooth loss.”

Answer 164

Twice the risk

Question 165

Orientation to dental environment

Answer 165

* The non-clinical office staff plays an important role in behavior guidance. * first point of contact * The tone of the communication should be welcoming. * From a behavioral standpoint, many factors are important when appointment times are determined. * Appointment-related concerns include patient age, presence of a special health care need, the need for sedation, distance the parent/patient travels, length of appointment, additional staffing requirements, parent’s work schedule, and time of day. * Appointment duration should not be prolonged beyond a patient’s tolerance level solely for the practitioner’s convenience. * A child- friendly reception area (e.g., age-appropriate toys and games) can provide a distraction for and comfort young patients. * **These first impressions may influence future behaviors.**

Question 166

What are the 4 essential ingredients of communication?

Answer 166

* the sender, * the message, including the facial expression and body language of the sender, * the context or setting in which the message is sent, and * the receiver

Question 167

What to do if the parent refuses treatment after discussing risks/benefits and alternative of proposed treatment and behavior guidance techniques?

Answer 167

* If the parent refuses treatment after discussions of the risks/benefits and alternatives of the proposed treatment and behavior guidance techniques, _an informed refusal form should be signed by the parent and retained in the patient’s record._ * If the dentist believes the informed refusal violates proper standard of care, he should recommend the patient seek another opinion and/or dismiss the patient from the practice.

Question 168

Frankl behavioral rating scale

Answer 168

1. - - Definitely negative. Refusal of tx, forceful crying, fearfulness, or any other overt evidence of extreme negativism. 2. - Negative. Reluctance to accept tx, uncooperative, some evidence of negative attitude but not pronounced (sullen, withdrawn). 3. + Positive. Acceptance of tx, cautious behavior at times, willingness to comply with the dentist, at times with reservation, but patient follows the dentist's directions cooperatively. 4. ++ Definitively positive. Good rapport with the dentist, interest in the dental procedures, laughter and enjoyment.

Question 169

Goals of behavior guidance

Answer 169

1. establish communication, 2. alleviate the child’s dental fear and anxiety, 3. promote patient’s and parents’ awareness of the need for good oral health and the process by which it is achieved, 4. promote the child’s positive attitude toward oral health care, 5. build a trusting relationship between dentist/staff and child/parent, and 6. provide quality oral health care in a comfortable, minimally- restrictive, safe, and effective manner.

Question 170

Communication and communicative guidance

Answer 170

* asking questions and active/reflective listening can help establish rapport and trust. * The dentist may establish teacher/student roles in order to develop an educated patient and deliver quality dental treatment safely. * Once a procedure begins, bi-directional communication should be maintained, and the dentist should consider the child as an active participant in his well-being and care. * With this two-way interchange of information, the dentist also can provide one-way guidance of behavior through directives. * Use of _self-disclosing assertiveness techniques (e.g., “I need you to open your mouth so I can check your teeth”, “I need you to sit still so we can take an X-ray”)_ tells the child exactly what is required to be cooperative. * The dentist can ask the child ‘yes’ or ‘no’ questions where the child can answer with a ‘thumbs up’ or ‘thumbs down’ response.

Question 171

Positive pre-visit imagery

Answer 171

* Description: Patients preview positive photographs or images of dentistry and dental treatment before the dental appointment * Objectives: * provide children and parents with visual information on what to expect during the dental visit; and * provide children with context to be able to ask providers relevant questions before dental procedures commence. * Indications: Use with any patient. * Contraindication: None.

Question 172

Direct observation

Answer 172

* Description: Patients are shown a video or are permitted to directly observe a young cooperative patient undergoing dental treatment * Objectives: * familiarize the patient with the dental setting and specific steps involved in a dental procedure; and * provide an opportunity for the patient and parent to ask questions about the dental procedure in a safe environment * Indications: Use with any patient. * Contraindications: None

Question 173

Tell-show-do

Answer 173

* Description: verbal explanations of procedures in phrases appropriate to the developmental level of the patient (tell); demonstrations for the patient of the visual, auditory, olfactory, and tactile aspects of the procedure in a carefully defined, nonthreatening setting (show); and then, without deviating from the explanation and demonstration, completion of the procedure (do). * The tell-show-do technique operates with communication skills (verbal and nonverbal) and positive reinforcement. * Objectives: * teach the patient important aspects of the dental visit and familiarize the patient with the dental setting and armamentarium; and * shape the patient’s response to procedures through desensitization and well-described expectations. * Indications: Use with any patient. * Contraindications: None.

Question 174

Ask-tell-ask

Answer 174

* Description: This technique involves inquiring about the patient’s visit and feelings toward or about any planned procedures (ask); explaining the procedures through dem- onstrations and non-threatening language appropriate to the cognitive level of the patient (tell); and again inquiring if the patient understands and how she feels about the impending treatment (ask) * Objectives: * assess anxiety that may lead to noncompliant behavior during treatment; * teach the patient about the procedures and their imple- mentation; and * confirm the patient is comfortable with the treatment before proceeding.

Question 175

Voice control

Answer 175

* Description: deliberate alteration of voice volume, tone, or pace to influence and direct the patient’s behavior. * _An explanation before its use may prevent misunderstanding._ * Objectives: The objectives of voice control are to: * gain the patient’s attention and compliance; * avert negative or avoidance behavior; and * establish appropriate adult-child roles. * Indications: Use with any patient. * Contraindications: Patients who are hearing impaired.

Question 176

Nonverbal communication

Answer 176

* Description: reinforcement and guidance of behavior through appropriate contact, posture, facial expression, and body language. * Objectives: * enhance the effectiveness of other communicative guidance technique; and * gain or maintain the patient’s attention and compliance. * Indications: Use with any patient. * Contraindications: None.

Question 177

Positive reinforcement and descriptive praise

Answer 177

* Description: Positive reinforcement rewards desired behaviors thereby strengthening the likelihood of recurrence of those behaviors. * Social reinforcers include positive voice modulation, facial expression, verbal praise, and appropriate physical demonstrations of affection by all members of the dental team. * Descriptive praise emphasizes specific cooperative behaviors (e.g., “Thank you for sitting still”, “You are doing a great job keeping your hands in your lap”) rather than a generalized praise (e.g., “Good job”). * Nonsocial reinforcers include tokens and toys. * Objective: * to reinforce desired behavior * Indications: Use with any patient. * Contraindications: None.

Question 178

Distraction

Answer 178

* Description: diverting the patient’s attention from what may be perceived as an unpleasant procedure * achieved by imagination (e.g., stories), clinic design, and audio (e.g., music) and/or visual (e.g., television, virtual reality eye- glasses) effects. * Giving the patient a short break during a stressful procedure can be an effective use of distraction before considering more advanced behavior guidance techniques * Objectives: * decrease the perception of unpleasantness * avert negative or avoidance behavior. * Indications: Use with any patient. * Contraindications: None.

Question 179

Memory restructuring

Answer 179

* Description: behavioral approach in which memories associated with a negative or difficult event (e.g., first dental visit, local anesthesia, restorative pro- cedure, extraction) are restructured into positive memories using information suggested after the event has taken place. * This approach was utilized with children who received local anesthesia at an initial restorative dental visit and showed a change in local anesthesia-related fears and behaviors at subsequent treatment visits. * Restructuring involves four components: * visual reminders; * positive reinforcement through verbalization; * concrete examples to encode sensory details; and * sense of accomplishment. * A visual reminder could be a photograph of the child smiling at the initial visit (i.e., prior to the difficult experience). * Positive reinforcement through verbalization could be asking if the child had told her parent what a good job she had done at the last appointment. * The child is asked to role-play and to tell the dentist what she had told the parent. * Concrete examples to encoding sensory details include praising the child for specific positive behavior such as keeping her hands on her lap or opening her mouth wide when asked. * The child then is asked to demonstrate these behaviors, which leads to a sense of accomplishment. * Objectives: The objectives of memory restructuring are to: * restructure difficult or negative past dental experiences; * improve patient behaviors at subsequent dental visits. * Indications: Use with patients who had a negative or difficult dental visits. * Contraindications: None.

Question 180

Desensitization to dental setting and procedures

Answer 180

* Description: psychological technique- diminishes emotional responsiveness to a negative, aversive, or positive stimulus after progressive exposure to it. * Patients are exposed gradually through a series of sessions to components of the dental appointment that cause them anxiety. * Patients may review information regarding the dental office and environment at home with a preparation book or video or by viewing the practice website. Parents may model actions (e.g., opening mouth and touching cheek) and practice with the child at home using a dental mirror. * Successful approximations would continue with an office tour during non-clinical hours and another visit in the dental operatory to explore the environment. * Objectives: * proceed with dental care after habituation and successful progression of exposure to the environment; * identify his fears; * develop relaxation techniques for those fears; and * be gradually exposed, with developed techniques, to situations that evoke his fears and diminish the emotional Responses. * Indications: Use with patients who have experienced fear-invoking stimuli, anxiety, and/or neurodevelopmental disorders (e.g., autism spectrum disorder * Contraindications: None.

Question 181

Enhancing control

Answer 181

* Description: allow the patient to assume an active role in the dental experience. * The dentist provides the patient a signal (e.g., raising a hand) to use if he becomes uncomfortable or needs to briefly interrupt care. * The patient should practice this gesture before treatment is initiated to emphasize it is a limited movement away from the operatory field. * When the patient employs the signal during dental procedures, the dentist should quickly respond with a pause in treatment and acknowledge the patient’s concern. * Enhancing control has been shown to be effective in reducing intraoperative pain. * Objectives: to allow a patient to have some measure of control during treatment in order to contain emotions and deter disruptive behaviors. * Indications: Use with patients who can communicate. * Contraindications: None, but if used prematurely, fear may increase due to an implied concern about the impending procedure.

Question 182

Communication techniques for parents (and age-appropriate patients)

Answer 182

* Because parents are the legal guardians of minors, successful bi-directional communication between the dentist/staff and the parent is essential to assure effective guidance of the child’s behavior. * Communication techniques such as ask-tell-ask, teach back, and motivational interviewing can reflect the dentist/staff’s caring for and engaging in a patient/ parent centered-approach. * These techniques are presented in Appendix 3.

Question 183

Parental presence/absence

Answer 183

* Description: A wide diversity exists in practitioner philosophy and parents’ attitude regarding parental presence/absence during pediatric dental treatment. * Parental involvement, especially in their children’s health care, has changed dramatically in recent years * Practitioners should become accustomed to this added involvement of parents and welcome the questions and concerns for their children. Practitioners must consider parents’ desires and wishes and be open to a paradigm shift in their own thinking. * Objectives: The objectives of parental presence/absence for parents are to: * participate in examinations and treatment; * offer physical and psychological support; and * observe the reality of their child’s treatment. * The objectives: * gain the patient’s attention and improve compliance; * avert negative or avoidance behaviors; * establish appropriate dentist-child roles; * enhance effective communication among the dentist, * child, and parent; * minimize anxiety and achieve a positive dental experience; * facilitate rapid informed consent for changes in treatment or behavior guidance. * Indications: Use with any patient. * Contraindications: Parents who are unwilling or unable to extend effective support.

Question 184

Sensory-adapted dental environments (SADE)

Answer 184

* Description: includes adaptions of the clinical setting (e.g., dimmed lighting, moving projections such as fish or bubbles on the ceiling, soothing background music, application of wrap/blanket around the child to provide deep pressure input) to produce a calming effect. * Objectives: enhance relaxation and avert negative or avoidance behaviors * Indications: Use with patients having autism spectrum disorder, sensory processing difficulties, other disabilities, or dental anxiety * Contraindications: None.

Question 185

Animal-assisted therapy (AAT)

Answer 185

* Description: It is a goal-oriented intervention which utilizes a trained animal in a healthcare setting to improve interactions or decrease a patient’s anxiety, pain, or distress. * Unlike animal-assisted activities (e.g., a pet entertains patients in the waiting area), AAT appointments are scheduled for specific time and duration to include an animal that has undergone temperament testing, rigorous training, and certification. * The animal, which is available for companionship during the dental visit, can help break communication barriers and enable the patient to establish a safe and comforting relationship, thereby reducing treatment- related stress. * For each visit, the goals and results of the intervention should be documented. * Objectives: * enhance interactions between the patient and dental team; * calm or comfort an anxious or fearful patient; * provide a distraction from a potentially stressful situation; * decrease perceived pain The health and safety of the animal and its handler need to be maintained. * Indications: Use AAT as an adjunctive technique to decrease a patient’s anxiety, pain, or emotional distress. * Contraindications: The contraindications for the parent: * allergy or other medical condition (e.g., asthma, compromised immune system) aggravated by exposure to the animal; and * lack of interest in or fear of the therapy animal. * The contraindications for the parent: * a situation that presents a significant risk to one’s health or safety

Question 186

Picture exchange communication system (PECS)

Answer 186

* Description: communication technique developed for individuals with limited to no verbal communication abilities, specifically those with autism. * The individual shares a picture card with a recognizable symbol to express a request or thought. PECS has a one-to-one correspondence with objects, people, and concepts, thereby reducing the degree of ambiguity in communication. * The patient is able to initiate communication, and no special training is required by the recipient. * Objectives: * to allow individuals with limited to no verbal communication abilities to express requests or thoughts using symbolic imagery. * A prepared picture board may be present for the dental appointment so the dentist can communicate the steps required for completion (e.g., pictures of a dental mirror, handpiece). * The patient may have symbols (e.g., a stop sign) to show they need a brief interruption in the procedure. * Indications: * Use as an adjunctive approach to assist individuals with limited to no verbal communication abilities improve exchange of ideas.

Question 187

Nitrous oxide/oxygen inhalation

Answer 187

* Description: safe and effective technique to reduce anxiety and enhance effective communication. * Rapid onset of action, the effects easily are titrated and reversible, and recovery is rapid and complete. * It mediates a variable degree of analgesia, amnesia, and gag reflex reduction. * If nitrous oxide/oxygen inhalation is used greater than 50% or in combination with other sedating medications (e.g., benzodiazepines, opioids), the likelihood for moderate or deep sedation increases. * clinician must be prepared to institute the guidelines for moderate or deep sedation. * Objectives: * reduce or eliminate anxiety; * reduce untoward movement and reaction to dental treatment; * enhance communication and patient cooperation; * raise the pain reaction threshold; * increase tolerance for longer appointments; * aid in treatment of the mentally/physically disabled or medically compromised patients; * reduce gagging; and * potentiate the effect of sedatives. * Indications: * a fearful, anxious, or obstreperous (noisy, unruly) patient; * certain patients with SHCN; * a patient whose gag reflex interferes with dental care; * a patient for whom profound local anesthesia cannot be obtained; and * a cooperative child undergoing a lengthy dental procedure. * Contraindications: * some chronic obstructive pulmonary diseases; * current upper respiratory tract infections; * recent middle ear disturbance/surgery; * severe emotional disturbances or drug-related dependencies; * first trimester of pregnancy; * treatment with bleomycin sulfate; * methylenetetrahydrofolate reductase (MTHR) deficiency * cobalamin (vitamin B-12) deficiency

Question 188

The following need to be considered when deciding on sedation:

Answer 188

* alternative behavioral guidance modalities * dental needs of the patient * the effect on the quality of dental care * the patient’s emotional development * the patient’s medical and physical considerations.

Question 189

Goals of sedation:

Answer 189

* patient safety * minimize physical discomfort and pain * manage anxiety * minimize psychological trauma * maximize the potential for amnesia * manage behavior and/or movement so as to allow the safe completion of the procedure * return the patient to a state in which safe discharge from medical supervision, as determined by recognized criteria, is possible.

Question 190

Indications of sedation

Answer 190

* fearful/anxious patients for whom basic behavior guidance techniques have not been successful * patients who cannot cooperate due to a lack of psychological or emotional maturity and/or mental, physical, or medical conditions * patients for whom the use of sedation may protect the developing psyche and/or reduce medical risk

Question 191

Contraindications of sedation

Answer 191

* cooperative patient with minimal dental needs * predisposing medical and/or physical conditions which would make sedation inadvisable.

Question 192

Documentation of sedation

Answer 192

* informed consent that is obtained from the parent and documented prior to the use of sedation * pre- and post-operative instructions and information provided to the parent * health evaluation * a time-based record that includes the name, route, site, time, dosage, and effect on patient of administered drugs * the patient’s level of consciousness, responsiveness, heart rate, blood pressure, respiratory rate, and oxygen saturation prior to treatment, at the time of treatment, and postoperatively until predetermined discharge criteria have been attained * adverse events (if any) and their treatment * time and condition of the patient at discharge.

Question 193

Protective stabilization

Answer 193

physical limitation of a patient’s movement by a person or restrictive equipment, materials or devices for a finite period of time in order to safely provide examination, diagnosis, and/or treatment

Question 194

Papoose considerations

Answer 194

* Management customized to individual needs of child and desires of parent - may include sedation, GA, protective stabilization, or referral to another dentist * consider patient’s oral health needs, emotional and cognitive development levels, medical and physical conditions, and parental preferences * alternative approaches (ex. treatment options or deferral, sedation, GA) and potential impact on quality of care and the patient’s well-being in discussion * over 50% use and acceptance of protective stabilization devices by board certified pediatric dentists * Practitioner gender, practice setting, region, and perception of parental acceptance - factors for use and acceptance

Question 195

Patient selection for papoose

Answer 195

* prevent or minimize psychological stress and decrease risk of physical injury to patient, the parent, and staff * at least one state (Colorado) requires training after dental school to use protective stabilization

Question 196

Papoose consent

Answer 196

* informed consent * benefits and risks of protective stabilization and alternative treatment options (interim therapeutic restoration [ITR], SDF, treatment deferral) and alternative behavior guidance techniques (ex. sedation, general anesthesia) discussed and assist parent in determining most appropriate approach * should occur on a day separate from treatment * obtained and documented in patient’s record prior to using * behavior change during treatment - further consent obtained and documented * when appropriate - explanation to patient about restraint and allow patient to respond * minor - not have statutory right to give or refuse consent for treatment but child’s wishes and feelings (assent) should be considered * adolescents or adults with mild intellectual disabilities - patient assent for protective stabilization should be considered * 50% of states have adopted the patient-oriented standard * Practitioner liable if parent not received all essential information to accept or reject proposed treatment

Question 197

Papoose – parental presence

Answer 197

* may help child and parent during a difficult experience * 92% mothers in one study believed they should have been with their child when placed on board to increase the child’s security and/ or comfort * 90% recognized that immobilization protected the child from harm * if parents are denied access, they must be informed of the reason with documentation of the explanation in the patient’s chart * parent has the right to terminate use of restraint at any time if believe child may be experiencing physical or psychological trauma due to immobilization * complete treatment to a safe point before ending appointment

Question 198

Papoose techniques

Answer 198

* only when less restrictive interventions are not effective * not to be used as discipline, convenience, or retaliation * should not induce pain * if history of combative behavior that could harm patient and staff * when immobilization is indicated, the least restrictive alternative or technique should be used * need accurate, comprehensive, and up-to-date medical history * conditions (ex asthma) - may compromise respiratory function or neuromuscular or bone/skeletal disorders (may need additional positioning aids due to rigid extremities) * should begin in conjunction with distraction techniques * gradually increase or decrease levels of restriction * Full-body protective stabilization - sequential manner * head hold activated last

Question 199

Ideal characteristics of papoose equipment

Answer 199

* easily used * appropriately sized for patient * soft and contoured to minimize potential injury * specifically designed for patient stabilization (not improvised equipment) * able to be disinfected * stabilization patients extremities: Posey straps, hook and loop straps, seat belts or an extra assistant. * Full body: Papoose Board and Pedi-Wrap * Stabilization for the head - forearm-body support, a head positioner, or an extra assistant * mouth prop in a compliant child is not considered protective stabilization

Question 200

Monitoring of patient in papoose

Answer 200

* awareness/assessment of the patient’s physical and psychological well-being * tightness of the stabilization * severe emotional stress - terminated as soon as possible to prevent possible physical or psychological trauma * removal of restraints - sequentially with short pauses between stages to assess the patient’s level of cooperation * intra-operatively (unplanned intervention), debriefing is beneficial for parent/patient and discuss management for future appointments

Question 201

Patients with SHCN – papoose

Answer 201

* distraction, shaping, modeling, sensory integration, desensitization, and reinforcement – are regarded as alternatives * Non-pharmacological behavior guidance - effective in autism spectrum disorders * Studies - deep pressure from an immobilization device (Papoose board) provided comfort, reduced effects of stressful stimuli, and were observed to be non-harmful to special needs patients * Be cautious when patient receiving multiple medications * potential adverse CNS or cardiac events may increase when protective stabilization is instituted on patients receiving psychotropic or other medications

Question 202

Papoose indications

Answer 202

* requires immediate diagnosis and/or urgent limited treatment and cannot cooperate due to developmental levels (emotional or cognitive), lack of maturity, or medical/physical conditions * urgent care and uncontrolled movements risk the safety of the patient, staff, dentist, or parent without the use of protective stabilization * previously cooperative patient who quickly becomes uncooperative and cooperation, safety and stabilization cannot be regained by basic behavior guidance techniques * uncooperative patient who requires limited (quadrant) treatment and sedation or general anesthesia may not be an option because the patient does not meet sedation criteria or because of a long operating room wait time, financial considerations, and/or parental preferences after other options have been discussed * sedated patient who requires limited stabilization * SHCN with uncontrolled movements that would be harmful or significantly interfere with the quality of care

Question 203

Papoose contraindications

Answer 203

* cooperative non-sedated patient * uncooperative patient when there is not a clear need to provide treatment at that particular visit * patient who cannot be immobilized safely due to associated medical, psychological, or physical conditions * patient with a history of physical or psychological trauma, including physical or sexual abuse or other trauma that would place the individual at greater psychological risk during restraint * patient with non-emergent treatment needs in order to accomplish full mouth or multiple quadrant dental treatment * practitioner’s convenience * dental team without knowledge and skills in patient selection and restraining techniques to prevent or minimize psychological stress and/or decrease risk of physical injury

Question 204

Papoose risks

Answer 204

* consider patient’s emotional and cognitive developmental levels and potential physical and psychological effect * minor bruises and scratches (more serious injuries have been reported) * fewer injuries with passive stabilization compared to active stabilization, and with the use of planned passive stabilization compared to emergent situations * Overheating * never be unattended - can roll off * may not allow for complete extension of the neck - may compromise airway patency, especially in young children or sedated patients (can use neck roll) * significant release of adrenal catecholamines - excessive release may sensitize the heart and cause rhythm disturbances * physical and psychological health of the patient should override other factors (practitioner convenience, financial compensation)

Question 205

Papoose documentation

Answer 205

* indication for stabilization * type of stabilization * informed consent * reason for parental exclusion during protective stabilization (when applicable) * the duration of application * behavior evaluation/rating during stabilization * any untoward outcomes (skin markings) * management for future appointments

Question 206

Classic behavioral theories

Answer 206

* Psychoanalytic * Freud * Erickson * Behaviorism * Pavlov * Skinner * Social learning * Cognitive development theory

Question 207

Psychoanalytic: Freud

Answer 207

* Children progress through predictable psychosexual stages of early childhood development * Child's behavior is oriented towards certain parts of that body

Question 208

Psychoanalytic: Erickson

Answer 208

* Psychosocial development proceeds by critical steps or psychosocial crises that shape personality * Basic trust → autonomy → initiative → industry → identity → intimacy → generativity → integrity

Question 209

Behaviorism: Pavlov

Answer 209

Classical conditioning – one stimulus is associated w/ another through experience

Question 210

Behaviorism: Skinner

Answer 210

Operant – consequence of behavior is in itself stimulus that can affect future behavior

Question 211

Operant conditioning

Answer 211

Question 212

Behaviorism: Social learning

Answer 212

Learning can occur through observing others in addition to direct experience

Question 213

Piaget's stages of cognitive development: **Sensorimotor**

Answer 213

* Age: **0-2yo** * Experience is through movement + senses * Cognitive changes: **Categorize things, enhance memory** * **Object permanence:** If you cannot see it, then it is not there * **Symbolic play** * Emotional changes: **Fear of strangers (7-12mo) + separation anxiety (6-18mo)**

Question 214

Piaget's stages of cognitive development: **Preoperational**

Answer 214

* Age: **2-7yo** * Children use language literally + are egocentric * Cognitive changes: * **Preconceptual (2-4yo):** Mental imagery, concentration * **Intuitive thoughts (4-7yo):** Classification, reading + writing, longer attention span * Emotional changes: * **Self control (3-6yo):** Conscious * **Aggression**: Inability to demonstrate self control, instrumental aggression to accomplish a goal, hostile aggression to harm another * Social: **Play, gender identity, toxic stress**

Question 215

Piaget's stages of cognitive development: **Concrete operational**

Answer 215

* Age: **7-11yo** * Children can think logically but not abstractly * Cognitive changes: **Literacy, mental representations of actions (think about what they can do or what they have done)** * Emotional changes: **Accepting societal norms, delayed gratification, body image, peer relationships** * Social: **Positive attitude, self-confidence, peer influences, meaningful friendships**

Question 216

Piaget's stages of cognitive development: **Formal operational**

Answer 216

* Age: **11+yo** * Children can think abstractly + are increasingly concerned about the opinion of others * Cognitive changes: **Abstract thinking, analysis of information, “rebel, complainer, accuser,” idealism leading to disillusionment, introspective + analytic, egocentric, opinionated, argumentative** * Emotional changes: **Attractive vs. unattractive, loved vs. unloved, masculine vs. feminine, sexuality, love** * Social: **Ability to establish + maintain loving relationships, bullying, alcohol, substance abuse, sexual promiscuity, gender**

Question 217

Common characteristics of 2yo

Answer 217

* Gross motor skills; just developing self-help skills * Very attached to parent * Plays alone; rarely shares * Limited vocab

Question 218

Common characteristics of 3yo

Answer 218

* Less egocentric * Likes to please * Active imagination * Closely attached to parent

Question 219

Common characteristics of 4yo

Answer 219

* Tries to impose power * Develops small social groups * Expansive period – reaches out from parent * Many independent self-help skills

Question 220

Common characteristics of 5yo

Answer 220

* Deliberate * Takes pride in possessions * Relinquishes comfort objects * Plays cooperatively with peers

Question 221

Erickson's stages of psychosocial development is based on what?

Answer 221

Freud's psychosexual stages

Question 222

Erickson's stages of psychosocial development – Eight stages of man

Answer 222

* Basic trust - 0-18mo * Autonomy - 18mo-3yo * Initiative - 3-6yo * Industry - 7-11yo * Personal identity - 12-17yo * Intimacy, Generativity, Ego integrity - all adult stages

Question 223

Erickson's eight stages of man: **Basic trust**

Answer 223

**Basic Trust: 0-18mo** * Bonding b/w parent + child * “Maternal deprivation” connection to “failure to thrive” * “Separation anxiety” – reflection of success in this stage * Failure to develop = mistrust

Question 224

Erickson's eight stages of man: **Autonomy**

Answer 224

**Autonomy: 18mo-3yo** * “Terrible twos” * Development of individual identity * Allowing choices is a good thing * “Consistently enforced limits on behavior at this time allow the child to further develop trust in a predictable environment” * Failure to develop = Shame

Question 225

Erickson's eight stages of man: **Initiative**

Answer 225

**Initiative: 3-6yo** * Increase autonomy, planning + pursuit * Extreme curiosity + questioning * Aggressive talking * Modeling behavior – feeling of accomplishment * Failure = Guilt

Question 226

Erickson's eight stages of man: **Industry**

Answer 226

**Industry: 7-11yo** * Academic + social skills * Mastery of skills, competition, cooperation * Decrease of parents as role models * Increase peers as influences * Failure = Inferiority

Question 227

Erickson's eight stages of man: **Personal identity**

Answer 227

**Personal identity: 12-17yo** * Feelings of belonging * Romantic relationships * Responsibilities * Separation from family + peer group * Failure = Role of confusion

Question 228

Erickson's eight stages of man: **Intimacy, Generativity, Ego Integrity**

Answer 228

All adult stages

Question 229

Most motor skills are before __ of age

Answer 229

Most motor skills are before **25mo** of age

Question 230

Variables influencing dental behavior

Answer 230

* **Parental anxiety:** related to child dental anxiety * **Mother** more often than fathers * **Greatest in the children \<4yo** * Stress: Normal + necessary for survival * **Toxic stress:** stress that continues over a prolonged period + has lifelong effects * Child abuse, chronic exposure to drugs/violence in the home, parental depression, mental illness, economic * Affects long term outcomes * **Dandelion vs. orchid child:** Some are more sensitive to the envt, some are resilient no matter the situation * Medical experiences: Positive visits are correlated w/ positive dental behaviors * “Adultified” so many visits that are little adults * Pain during previous health care visits * Parental attitudes * Awareness of dental problem – when a child knows that they have teeth issues + behave negatively * General behavior problems * Dental fears are correlated w/ general fears * Some children have behavior problems only in the dental envt bc of poor experiences * Dental fear: 9-20% report dental fear * Temperament: Impulsivity + negative emotionality is associated w/ behavior problems * Easy, difficult, slow to warm up

Question 231

Parenting styles: Baumrind typology

Answer 231

* Authoritative * Authoritarian * Permissive/indulgent * Neglectful/uninvolved

Question 232

Authoritative parenting style

Answer 232

* **High affection, high rules** * Clear standards, assertive * Disciplinary methods are supportive * Decisions made by adult authority * **This style is associated w/ more desirable child behavior**

Question 233

Authoritarian parenting style

Answer 233

* **High rules, low affection** * Obedient + status oriented * Well-ordered, structured envts w/ clear rules * **Decisions made by adult authority**

Question 234

Neglectful/Uninvolved parenting style

Answer 234

* **Low demand, low response** * May include rejecting-neglecting + neglectful * Low parental involvement + low expectations for behavior

Question 235

Permissive/Indulgent parenting style

Answer 235

* **Low rules, high affection** * Decisions made by child * Nontraditional lenient * Does not require mature behavior * Allows considerable self-regulation + avoidance of confrontation * Democratic vs. nondirective

Question 236

Behavior shaping

Answer 236

State the goal, explain necessity, divide the explanation for the procedure, give explanations at the child's level of understanding, use successive approximation, reinforce appropriate behavior, disregard minor inappropriate behavior

Question 237

Operant conditioning

Answer 237

Response to past behaviors influence future behaviors

Question 238

Positive reinforcement

Answer 238

Pleasant stimulus w/ reward

Question 239

Omission or time out

Answer 239

Pleasant stimulus withdrawn

Question 240

Negative reinforcement (escape)

Answer 240

Unpleasant stimulus withdrawn

Question 241

Punishment

Answer 241

Unpleasant stimulus introduced