MANAGING CHILD IN DENTAL OFFICE BY NON-PHARMACOLOGICAL BEHAVIOR MANAGEMENT TECHNIQUES

Behaviour management of a child in the dental office refers to methods of obtaining a childs approval of treatment in the dental chair which is based on proper communication, patient/ parent education with empathy, coaching and listening. The concept behind guiding a childs behaviour is treating them rather than just operating the tooth alone. The outcome of these techniques could maintain a proper communication or extinguish disruptive behaviour related to dental treatment.


Data gathering and observation:
It involves collecting the type of information about a child and his/her parents that can be obtained by a formal or informal office interview or by a written questionnaire. Observation involves perceiving overt and subtle behavioral characteristics of a child which provide clues as to how he should be approached by the dentist and his staff. Observation begins with noting the waiting room behaviour of the child, including the interaction with the parent. Observation should be a continuous activity. At each appointment, the dentist should be prepared to modify their approach to a child as the child's behaviour changes and/or as the dentist's perception if it is changed.

Structuring:
Structuring refers to the establishment of guidelines of behaviour which are communicated by the dentist to the child. With proper structuring, children should know what to expect and how to react during the dental experience. Jenks describes several ways in which the dentist may provide structure to the dental appointment. The dentist should explain to the child, in language that the child can understand, the purpose to the dental treatment. Example: Use of a second language (Euphemisms). Euphemisms are terminologies which are used for making the children cooperative during dental procedures. The different terminologies given in this context are as follows (table 1).

Mouth mirror
Tooth mirror

Externalisation:
It is a process by which the child's attention is focused away from the sensations associated with the dental treatment. The local Injection procedure is an example of when externalisation is often required. There are two methods of externalising the patient's attention: first, involve them in verbal activity; and second, involve them in the dental activity. Example: by giving the child a hand mirror with which they can observe most of the dental procedure.

Empathy and support:
It is the capacity to understand and to experience the feelings of another without losing one's objectivity. Dentists must have the sensitivity to respond to children's feelings by allowing children to express their feelings. There are 550 ways in which dentists can provide this kind of support include: (i) Permitting children to express their feelings of fear or anger, and their desires, without rejecting them. (ii) Communicating to children that their reactions are understood. (iii) Comforting children when it is appropriate. This can be done by careful choice of words,by the tone of the voice or by touching the child and giving a reassuring pat or hug.

Flexible authority:
Dentist's authority must be tempered with a degree of flexibility and should be sufficiently flexible to allow him to modify his tactics at the same time or at future visits. The dentist must consider whether the behaviour is due to the child's personality or lack of maturity, or whether he himself has contributed to the situation by his approach to the child.

Education and training:
Any dentist who treats children should implement a programme that educates children to constitutes good dental health.

Effect of the dentist's attire:
The attire worn by dentists varies from a surgical gown or white clinic jacket to a shirt and tie or open-necked shirt. The use of child friendly colors as attires may help in reliving dental anxiety and aid in better communication. According to Umamaheshwari et al (2013) [11] , Vijaya Prasad et al (2015) [12] and Prashant Babaji et al (2017) [13] , where they have concluded that the use of child friendly colours like -yellow‖ or -blue‖ in the dental workplace could enhance the positive dental attitude in the child's mind and help to manage the anxious child in a more proper way.

Effect of the length and time of an appointment:
The earlier dental literature has stressed that appointments for children should be short, possibly because of the short attention span of children. The early morning appointments are preferable for young children because they are more rested and cooperative while in the afternoon they may be tired from missing a nap.

Reactions to the first dental visit:
The child's first dental visit to the dental office is usually between 3-4 years of age. It has been found that the degree of cooperation is more in preschool children in their first dental visit. Therefore, the first visit should only include an examination, radiographs and possibly an oral prophylaxis along with topical fluoride treatment. [14,15] Factors Out Of The Control Of The Dentist: [16] Growth and development: If there is a deficiency in physical growth and development or congenital malformations, e.g., cleft lip, as awareness of the deformity increases it leads to psychological trauma due to rejection by the society. Mental retardation, epilepsy, cerebral palsy etc., make the child mentally handicapped. Here, the child cannot react to the requirements of the mother and expectations of the society. Hence, there is a failure of cognitive development and therefore variations in the behaviour are encountered. Also, a very young child reacts very differently and the same response may be transformed to a positive behaviour, as the child grows older. Thus the intellectual age of 3 years seems to be that point in developmental progress that signifies a maturational readiness to accept dental treatment.

Past medical and dental experiences:
Any past unpleasant dental experience, prior hospitalization, surgical intervention, sickness etc., are associated with a higher degree of uncooperative behaviour. Therefore the emotional quality of past visits rather than the number of visits is significant. Thus more time should be given to this kind of patient to adapt well to the dental environment.

School environment:
Fifty per cent of the child's development is affected by the school and the remaining 50% by the home environment. In school, teachers and peers help to influence the behaviour of the younger children. Also, seniors become role models to the juniors. Thus the regular dental campaign has to perform in the schools to educate the teachers as well as the students and they should be advised not to portray wrong image of the dentist in front of the child. Rather, inform them to give a clear picture of the dental procedure to the child.

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Socioeconomic status: High socioeconomic status child may develop normally because the family can provide all the necessary requirements to aid in a normal psychological development because these parents are well educated to know the good or bad of their children. On the other hand, this child may also become spoilt if he always gets what he wants. While a low socioeconomic status child often gets little attention because of less less income and less knowledge of their parents as they were unable to fulfill the needs of their children in a proper manner. It can also directly affect the child's attitude towards the value of the dental health.

Factors Under The Control Of The Parents: Home environment:
The home is the first school where a child learns to behave. All the individuals at home influence the child's behaviour but none so much as the mother, e.g., in case of a broken home, the child may feel insecure, inferior, apathic and depressed. Mother-child relationship has been described as one-tailed. Postnatal behaviour of the child depends on the prenatal emotional status of the mother.

Family development and peer influences:
Position and status of the child in the family and parental attitudes can influence the child's behaviour. Overindulgence by parents can lead to a spoilt behaviour in the child who may show sudden outbursts and temper tantrums. Internal family conflicts affect children's behaviour. The child can sense disharmony in the family and this can emotionally frustrate the child. The younger child always tries to follow the model of the older sibling and family members, thus showing the same behaviour of siblings.

Effect of maternal attitudes:
Maternal attitudes can adversely affect the child's developing personality (figure 1). [17] It can be sub-grouped as under:

Overprotective mother:
Mother exhibits extreme love and affection for their children. Possible factors for an overprotective mother: [16] 1. History of previous miscarriages. 2. Delay in conception. 3. Death of another sibling. 4. In case of mother cannot have more children. 5. A serious illness to the child. 6. Paternal absence due to death or divorce. 7. Possible signs for an overprotective mother: She gives excessive care to the child in terms of feeding, dressing, bathing. 8. Overprotective mother can affect the normal psychologic maturation of the child and tends to -infantize‖ him. 9. Dominating overprotective mother exhibits a -submissive child‖ while overindulgent overprotective mother shows aggressive behavior in the child. These parents should be approached with a gentle discussion of the 554

Non-Verbal Communication:
It is also called Multisensory Communication. When the child enters the operatory, they should be greeted with a smile, handshake and a gentle pat. Even during the treatment, occasional patting or smiling relaxes the child and makes him more obedient. The child is very sensitive to expression changes, so keeping the expression neutral is important. This technique involves a number of psychological components including building trust in the dentistpatient interaction and providing the patient with a sense of control. Thus the technique has been shown to be effective in reducing a patient's experience of anxiety.

Ask tell ask:
This technique involves inquiring about the patient's visit and feelings toward or about any planned procedures (ask); explaining the procedures through demonstrations (tell); and again inquiring if the patient understands the treatment plan (ask).

Modeling/ Direct Observation:
It is based on the -observational learning theory‖ by Bandura given in 1969.Here the child is allowed to see either the live treatment of another child (live modeling) or is shown an audio-visual of child treatment to remove the fear of dental treatment. This helps in removing the fear of dental treatment that is the most common cause for child non -cooperation and treatment refusal. [16,17] (figure 2)

Objectives:-
To familiarize the patient with the dental settings and specific steps involved in a dental procedure and give the patient and parent an opportunity to ask questions about the dental procedure. Performing the procedure.

Modifications of TELL-SHOW-DO for hearing and visual impaired children: Visually impaired children:
A -tell, feel, do‖ technique can be used instead of the -tell, show, do‖ technique to demonstrate the ongoing procedures to the patient by Mohan R. et al, (2016). He suggested that once the patient becomes familiarized with the sounds, tastes, and smells, treatment should be commenced with short verbal guidance only.
An ‗Audio tactile performance technique' (ATP) and multisensory health education method is a very effective communication tool to educate them. [22] Hearing impaired children: Technique -Tell-Show-Do‖ modified into Show-Do and "Hand over Hand" as the best strategy for modeling the desired behavior. The method named as -Do as I do‖. The training process needs a lot of patience and persistence in order to build proper oral hygiene habits [23] Objectives:- The objectives are to teach the patient important aspects of the dental visit and familiarize the patient with the dental setting.

Voice control:
This technique was given by Pinkham, 1985. The children who are not very cooperative, voice modulation is required. The pitch of voice is slightly raised and with a firm voice, the child is given clear instructions. This technique is very effective in getting the desired behaviour from the willful or resistant child. Even in late infancy and the early toddler years, a sharp, loud, shouted command can be incredibly effective at gaining the child's attention. However when the child obeys the instructions, they should be praised each time.

Objectives:
To gain the patient's attention and compliance. [17] Retraining/ Desensitization: Systematic desensitization was developed by South African psychologist Joseph Wolpe in 1950s. It is one of the most effective methods for reducing maladaptive anxiety. A hierarchy of fear-provoking stimuli should be put together in collaboration with the child or young patient. Once the patient has been taught and learned how to relax, then they should be gradually introduced to the low-to-high fear stimuli at a pace determined by the patient with support from the clinician.

Objectives:
To help children who had a bad previous medical or dental experience to overcome. [17] Distraction: Distraction is the technique of diverting the patient's attention from what may be perceived as an unpleasant 556 procedure by allowing them to watch audio-visual cartoons during the treatment or by giving the patient a short break during a stressful procedure can be an effective use of distraction prior to considering more advanced behavior guidance techniques. Example: use of virtual-reality device (VR-box) in the dental operatory during dental procedure.

Objectives:
To decrease the perception of unpleasantness and avert negative or avoidance behavior.

Parental Presence/Absence:
The presence or absence of the parent sometimes can be used to gain cooperation for treatment. The parents will expect to be with their infants and young children during examinations as well as during treatment. Parent's desire to be present during their child's treatment does not mean they intellectually distrust the dentist; it might mean they are uncomfortable if they visually cannot verify their child's safety. Practitioners should understand and become accustomed to this added involvement of parents and welcomes the desires and wishes of them.

Objectives:
The objectives: For parents are to participate in infant examinations or treatment and observe the reality of their child's treatment.
For practitioners to gain the patient's attention and improve compliance and enhance effective communication among the dentist, child, and parent. [24] Contingency management: The presentation or withdrawal of reinforcers is termed as -contingency management‖.It is based on -Operant Conditioning theory‖ by BF Skinner, 1938. It is of 4 types:

Positive reinforcement:
Presentation of a pleasant stimulus to bring about the desired behaviour. Here the child is rewarded for presenting the desired behaviour. Ex: like toy, toothpastes, toothbrushes etc.

Objectives:
To reinforce desired behavior.

Negative reinforcement:
Removal of unpleasant stimulus that brings about the desired behaviour. Eg-sight of white apron, facemask, injection or sharp instruments.

Objectives:
to strengthen the behavior by removing unpleasant stimulu

(a) Omission:
Removal of pleasant stimulus to bring out the desired behaviour. Eg-if a child is not cooperating in the presence of his parent, then he is told that the parent would be sent outside, if he does not cooperate.

(b) Punishment:
Presentation of unpleasant stimulus to the child like: hand over mouth technique (HOME) and Protective stabilization. [17] Audio analgesia or white noise: The technique consists of providing a sound stimulus of such intensity that the patient finds it difficult to attend to anything else (Morosko et al, 1966). It was introduced by Gardner and Icklider in 1959.

Objectives:
To reduce the stress or anxiety by providing a sound stimulus. [25] 557

Hypnosis:
Hypnosis seems to be most effective in the presence of anxiety. It was first suggested by Franz A Mesmer in 1773. It is defined as a state of mental relaxation and restricted awareness in which subjects are usually engrossed in their inner experiences such as imagery, are less analytical and logical in their thinking and have enhanced capacity to respond to suggestions in an automatic and dissociated manner.
Uses: Hennon outlined the following uses: To reduce nervousness and apprehension.
To eliminate defense mechanisms of the patients.
To control functional or psychosomatic gapping. [26] Coping: Coping is defined as the cognitive and behavioural efforts made by an individual to master, tolerate or reduce stressful situations by Lazaue, 1980. The normal coping systems followed by the dentists are friendliness, support and reassurance.Coping strategies can be divided into three major categories: (a) Active coping: The examples of active coping are: Biofeedback: It is a group of therapeutic procedures that utilizes electronic or electromechanical instruments to accurately measure, process, and -feed back‖ to person's information.
Music therapy as distraction: Music helps to accomplish individual goals within a therapeutic relationship. [20] Problem solving: Problem solving therapy is a form of cognitive-behavioral therapy that has been shown to be especially useful in the treatment of such disorders as depression and anxiety.
(c) Avoidance: If the person has decided that there is no stressor, and therefore there is no need to change behavior, perception, or emotional response. Example: initially disbelieving that someone has died: -Who died? I can't believe it. I just saw him. [27] Home: The technique was introduced by Dr Evangeline Jordan in 1920 who wrote -If a normal child will not listen but continues to cry and struggle-hold a folded napkin over the child's mouth and gently but firmly hold the mouth shut. The purpose of the technique is to gain the attention of a child to allow communication. HOM, although a very effective when used correctly, but is no longer endorsed by the American Academy of Paediatric Dentistry (AAPD) [Guidelines, 2008]. However, many believed hand over mouth was still an acceptable technique by Oueis et al. (2010). [17,28] Techniques: When all avenues of communication have failed and the child's behavior remains uncontrolled, HOM is applied. The dentist places their hand to stifle the noise of a child and allow effective communication and at the same time the Dental assistant restraints any flailing limbs.
There is a variation of HOM where the child's airway is deliberately restricted, named hand-over-mouth with airway restriction (HOMAR). The nose is pinched along with the hand over mouth. The child will stop screaming to breathe and the tantrums will decrease. It should not be employed for more than 15 seconds. But this is not accepted as a method universally.