Management of Sobbing Tot In A Pediatric Dental Office- A Review
The most common way by which child expresses fear and anxiety is by crying at dental office. Proper knowledge and understanding is required to deliver effective dental treatment to a child by the application of various behavioral management techniques. Treating a crying child is one of the most demanding and tiring situation encountered in dentistry. Behavior management in a crying child is a comprehensive continuous methodology targeted to build relationship between child, parent and doctor aimed at eliminating fear and anxiety and ultimately building trust. This article was aimed to review the various reasons for stimulation of cry of child in dental office and behavior techniques employed by the dentist for proper management of the child.
Key Words-Anxiety, Behavior Management, Fear
Behavior management is a comprehensive continous methodology targeted to build relationship between child, parent and doctor aimed at eliminating fear and anxiety and ultimately building trust. As most of the young children do not cooperate during dental procedures, thus a dentist plays a crucial role to forestall a positive dental attitude, to guide the child through their dental experience and to perform quality treatment safely. 1
Children and young adults and indeed all patients, exhibit some form of anxiety or fear when about to receive dental care. Many factors have been proposed as contributory to children’s anxiety about dental procedures which include the dental clinic environment, equipments, past dental treatment experience and the attitude of the dental staff. To address these causative factors, various behavior management strategies are being practiced which including verbal and non- verbal communication, tell show do distraction , presence or absence of parents in the surgery, modeling, audio visual aids , positive reinforcement , visual aids, physical restraints, HOME(Hand over Mouth) technique, sedation, general anesthesia etc. 2
Dental anxietyand fear has been a constant dynamic of the child patient. 2 A child patient tends to be anxious and fearful during dental treatment due to previous traumatic experience in dental office or during hospitalization for other purposes. It is very difficult to carry out any dental procedure if a child is uncooperative in dental office. It is crucial that a dentist must understand and share the feelings of a child and show concern before starting any treatment.3 Treating a crying child is one of the most taxing and difficult job for a dentist due to unanticipated attitude of a child during treatment. Delivery of effective dental treatment in a crying child requires incorporation of various behavior modification techniques.
Thus acquisition of skills that allow a dentist to handle such “uncontrollable” situations in the best possible way is of utmost importance. A dentist should take a child’s cry as an advantage rather than a drawback as crying is a mode of expression of the personality traits, hence should be used as a diagnostic tool.3
Dental fear and anxiety is a dilemma concerning pediatric patients, their parents, and dental professionals. Its prevalence in children and adolescents ranges from five percent to twenty percent. Fearful pediatric patients often tend to be uncooperative during dental visits. This renders treatment difficult or even impossible, causes occupational stress among dental staff, and increase the chance of discord between dental professionals and patients or their parents. Dental fear and anxiety are the main cause of dental avoidance that leads to deterioration of one’s oral health and may impair ones psychosocial functioning and quality of life. 4
Dental Fear: Dental fear is defined as an unpleasant emotion caused by the threat of danger, pain, or harm during dental treatment. 5 It is characterized by change in body physiological symptoms due to changes in cardiovascular and respiratory systems. The response of a child usually occurs by a real or imagined threat to his own safety. The patient readies himself in a fight or flight stance to either escape the stimulus or stands and conquer it. Rachman’s model of fear acquisitioning is one of the most accepted theor, which is supported by several studies. This theory has proposed that fear might develop through three pathways: direct conditioning (classical conditioning), vicarious conditioning (modelling), and information/ instruction. The second and third pathways are manifestations of indirect fear acquisition.3
Dental Anxiety: Anxiety is a feeling of worry, nervousness, or unease about something with an uncertain outcome. Dental anxiety is defined as “an abnormal fear of visiting the dentist for any dental procedure and unjustified anxiety over dental procedures” and may have psychological, cognitive and behavioral consequences. Dental anxiety may be a problem in childhood as it is associated with poor oral health outcomes and an increased dependence on costly specialist dental services. Children who show more anxious behavior have a greater chance of having dental diseases as compared to children who are non-anxious in the dental office. Dentists need to understand the anxiety of the child and implement procedures that enhance a feeling of control which include giving child’s choices, helping within treatment or otherwise manipulating dental objects and acknowledging the child’s experience.4
Due to less communication skills exhibited by children, they are not able to properly express their fears and anxieties. When children cannot manage, they attempt to escape the upcoming event. This ultimately leads to crying of a child which also is a way of a child to show their anxiety and discomfort. 3,4 Different anxieties and fears that children have about visiting the dentist are:
Mostly children are anxious during a new experience. There is uncertainty about what is going to happen which increases the child’s restlessness.
Past negative experiences associated with medical treatment may be co-related with more anxiousness in dental treatment as well.
Previous fearful dental visits have also been related to poor behaviour at subsequent visits.
The parents who are unable to contain their own dental anxieties, make the child more conscious.
Mass mediaandcartoonsalso contribute to the negative image of dentist which may lead to development of dental fear.
Management of Crying child during Dental Treatment
Successful treatment of a disruptive child depends partially upon selection of an appropriate behavior management technique. Each child possess different behavior pattern on visiting the dentist. For managing a child in dental office various factors have to be seen like -the type of behavior, the child’s anxiety, age of the child, child rearing techniques, personality variables, parental attitudes toward behavior management techniques, dental treatment to be rendered and the legal implications.6
Behavior management is of children in clinics is an integral part of pediatric dentistry. It is not just the application of individual technique formulated to deal with individuals but rather a comprehensive methodology meant to build a relationship between patient and dental professional. Behavior guidance is based on scientific principles but also requires skills in communication, coaching, tolerance, and active listening.
The aim of the behavior management is to instill a positive dental attitude on patient, alleviate fear and anxiety, deliver quality dental care, build a trusting relationship between dentist, child, and parent and create long term interest on patient’s part so as to facilitate ongoing prevention and improved dental health in the future. Since the child may enter the dental office with some fear and anxiety, the first objective of the dentist should be to put the child at his ease and make him realize that this experience is not unusual. It is better to have morning appointments for patients and dentist should be realistic and reasonable to the child. This may help in developing a positive attitude of the child towards the dentist. Parents exert a significant influence on the behavior of their children. Most of the characteristics of the child like behavior, personality, anxiety and reaction to stress are directly influenced by parent’s characteristics. Parents should be educated before their child’s visit as it may be helpful in promoting a positive dental experience.
Behavior Guidance is a continuum of interaction involving the dentist, the dental team, the patient and the parent directed towards communication and education which ultimately builds trust and allays fear and anxiety. Both non pharmacological and pharmacological behavior guidance techniques may be used by dental health care providers in providing oral health care for infants, children, adolescents, and persons with special health care needs.
Some of the behavior modifications techniques include:-
Communication and communicative guidance
First objective in successful management of a crying child is to establish communication. By involving the child in communication, the dentist not only learns about the patient but also helps in relaxing the patient. The fear and anxiety of the child demands that each step should be explained. Appropriate use of commands may help the child develop a positive attitude toward oral health
Distraction is a newer method of behavior management of diverting the child’s attention from sounds or sight of dental treatment, thereby reducing anxiety. Audio or Audiovisual distraction will help in eliminating dental sounds and sight of the dental treatment, hence helping in gaining control of the child.
Another modification of behavior modification in crying child is controlled alteration of voice volume, tone, or pace to influence and direct the crying child’s behavior. It helps the dentist to gain the patient’s attention and compliance and to avert negative behavior.
Positive reinforcement is an effective technique to reward desired behaviors and, thus, strengthen the recurrence of those behaviors. If a child stops crying or show good behavior he should be rewarded with tokens or toys.
Tell-show-do technique can help in modifying the behavior of a crying child. It is the cornerstone of behavior management given by Addleston in 1959. The technique involves the dentist telling the child what is going to be done in words the child can understand. Second, the dentist demonstrates the child exactly how the procedure will be conducted and then, without deviating from the explanation and demonstration, completion of the procedure.
Nitrous oxide/oxygen inhalation helps in providing a minimally depressed level of consciousness which helps in reducing anxiety and enhancing effective communication in a crying child. Its onset of action is rapid and the child responds appropriately to physical stimulation and verbal commands. The effects are reversible and recovery is rapid and complete. But before giving conscious sedation, proper diagnosis and treatment planning must be done. 6
Other techniques include hand-over-mouth exercise (HOME) and medical immobilization. The behaviors of the dentist and dental staff members play an important role in behavior guidance of the pediatric patient. Successful behavior management enables the oral health team to perform quality treatment safely and efficiently and to nurture a positive dental attitude in the child. 6
Knowing that pain is not the only reason for a child to cry during dental treatment will help parents and dentists to understand why a child’s behavior is managed a certain way. As the children learn to cope with the dental situation, the crying usually eases up. The learning process varies in every child. The role of the pediatric dentist is to help the child to get through his dental experiences so that the child may develop a positive attitude towards dentistry.
The most common emotional upsets exhibited during dental treatment are anxiety and fear and the most common way a child expresses fear is by crying at the dental ofi¬?ce. The pediatric dentist can use an appropriate behavior management technique to make the child cooperative throughout the dental procedure and can help the child to develop a positive attitude towards dentistry.