COMMUNICATIVE MANAGEMENT

Communicative management is universally used in

pediatric dentistry with both the cooperative and uncooperative child (Chambers, 1976)

Types of Communication
Verbal Non verbal Body language Smiling Eye contact Expression of feelings without speaking Showing concern By touching the child Giving him a pat Giving a hug Both using verbal and non-verbal.

How to Communicate?
Communication should be comfortable and relaxed. Language that is chosen should contain words that express pleasantness, friendship and concern. Verbal effects are delineated through selection of words and/ or sounds, tone of voice and voice inflection (Korch 1972).

 Verbal communication is best for younger than

more than 3 years of age. Voice that is used should be constant and gentle tone of voice can express empathy and firmness.
compliment him about his appearance. Sitting and speaking at the eye level

 Use of euphemisms: Euphemisms are substitute words

Choice of words, which is used by the dentist or staff influence the emotional status of the child Anesthetic solution is referred as water to put the teeth to sleep. Caries is referred to as a tooth bug. Rubberdam as a rain coat. Radiograph as, tooth picture.

Reframing: It is defined as taking a situation outside the frame that up to that moment contained the individual in different conditions, and visualize (reframe) it in a way acceptable to the person involved and with this reframing, such that both the original threat and the threatened situation can be safely abandoned (Benjamin Peretz, 1999).

BEHAVIOR SHAPING
It involves the use of selected reinforcers that being learned will hopefully change a child's behavior from an inappropriate to an appropriate form. This is based on the "stimulus-response" theory. For example, when a child enters the reception room and associates this with a previous dental experience which was unpleasant, the child's internal responses would be fear and anxiety while the external response would be crying.

Behavior Modification Involves Three Techniques

Desensitization Modelling

Contingency management

Desensitization
Joseph Wolpe (1975) used to remove fears and tension in children who have had previous unpleasant dental experience or negative behavior.

Method popularly used nowadays for modifying the behavior by desensitization in children is Tell-Show-Do technique (TSD)

Addleslen (1959) introduced the concept of Tell, Show, Do.

 indications

a) First visit b) Subsequent visit when introducing new procedure c) Fearful child d) Apprehensive child because of information received from parents/peers

Modeling
1ntroduced by Bandura (1969)
Modeling can be done by: a) Live models - siblings parents of child etc. b) Filmed models c) Posters d) Audiovisual aids

Contingency management
method of modifying the behavior of children by presentation or withdrawal of reinforcers. a) Positive reinforcer: is one whose contingent presentation increases the frequency of behavior (Henry W Fields, 1984). b) Negative reinforcer: is one whose contingent withdrawal increases the frequency of behavior (Stokes and Kenndy, 1980). Negative reinforcer is usually a termination of an aversive stimulus, e.g., withdrawal of the mother.

Types of reinforcements can be: Social e.g., praise, positive facial expression, physical contact by shaking hand, holding hand, and patting shoulder or back. Material: may be given in the form of toys, games. Activity reinforcers: Involving the child in some activity like watching a TV

Behavior Mangement
The goals of behavior management are to achieve good dental health in the child and to help develop the child's positive attitude towards dental health.

 Audio analgesia or "white noise" is a method of

reducing pain. This technique consists of providing a sound stimulus of-such intensity that the patient finds it difficult to attend to anything else (Gardner, Licklider, 1959)

Biofeedback: involves the use of certain instruments To detect physiological processes

For example, if blood pressure is high the instrument gives stimulation and the subject is taught to control the signals; therefore, it is useful in anxiety and stress related disorders.

Humor
helps to elevate the mood of the child & helps the child to relax. Functions of humor: a) Social: Forming and maintaining a relationship b) Emotional: Anxiety relief in the child, parent and doctor. c) Informative: Transmits essential information in a nonthreatening way. d) Motivation: It increases the interest and involvement of the child. e) Cognitive: Distraction from fearful stimuli

Coping:
It is the mechanism by which the child copes up with the dental treatment. It is defined as the cognitive and behavioral efforts made by an individual to tolerate or reduce stressful situations

Coping effects may be of two types a) Behavioral: are physical and verbal activities in which the child engages to overcome a stressful situation. b) Cognitive: The child may be silent and thinking In mind to keep calm.

Voice control
It is the modification of intensity and pitch of one's Voice in an attempt to dominate the interaction between the dentist and the child.

Relaxation:
This technique is used to reduce stress and is based on

the principle of elimination

Relaxation involves a series of basic exercises

which may take several months to learn, and which require the patient to practise at home for at least 15 min per day.

Hypnosis:
Hypnosis is an altered state of consciousness characterized by a heightened suggestibility to produce desirable behavioral and physiological changes.

Implosion Therpy
Sudden flooding with a barrage of stimuli which have affected him adversely and the child has no other choice but to face the stimuli until negative response disappears. Implosion therapy mainly comprises HOME, voice control and physical restraints.

Aversive conditioning
child who displays a negative behavior and not respond to moderate behavior modification technique falls into the category of Frankel's definite negative behavior.
Two common methods used in the clinical practice are HOME and physical restraint

HOME (Hand-Over-Mouth Exercise)

Introduced by Evangeline Jordan,1920

Indications A healthy child who can understand but who exhibits defiance and hysterical behavior during treatment. 3-6 years old. A child who can understand simple verbal commands. Children displaying uncontrollable behavior.

Contraindications
Child under 3 years of age

Handicapped child/immature child, frightened child

Physical, mental an emotional handicap

Factors to be Considered Before Applying HOME Technique not be used as a routine procedure for the management of the child. Inform the parents about the procedure. Consent of the parents is very Important. pediatric dentists should be aware of the changing laws that govern informed consent

 It should be noted that the child's airway is not

restricted while performing the technique

should not last for more than 20-30 sec

Several variants of HOME

Hand

over mouth with the airway unrestricted Hand over mouth arid the nose 'and the airway restricted Towel held over the mouth only Dry towel held over the nose and mouth Wet towel held over the nose and mouth

HOMAR(Belarige,1993)
Together with hand over mouth, nostrils are pinched

for 15 sec.

Physical Restraints
Last resort for handling uncooperative patients or handicapped patients. Restraints are usually needed for children who are hypermotive, stubborn or defiant (Kelly, 1976)

It can be: Active - restraints performed by the dentist, staff or parent without the aid of a restraining device. Passive - with the aid of restraining device.

Types of Restraint For body: pedi wrap Papoose board For extremities Posey straps For extremities Velcro straps Towel and tape For the head Head positioner Forearm body support Mouth Mouth blocks Banded tongue blades Mouth props