Transcript BEHAVIOR MANAGEMENT OF A PEDIATRIC DENTAL PATIENT

1426 McPhillips St
Winnipeg, MB
Behaviour Management
and Local Anesthesia
Fadi Kass
DMD, Msc, FRCD(c)
April 4th 2008
Who is more afraid?
• Child
• Dentist
Objectives of treating a
child patient
• Perform the necessary
task
– Efficiently
– Safely
• Instill positive attitude
towards the dental
team and oral habits
How can we do this?
• Pharmacological
techniques
– Sedatives
– General anesthesia
• Non-pharmacologic
– Restraint
– Behaviour
Managment
Behavior Management
Techniques:
• Humour
• Distraction
• Tell Show Do
• Positive reinforcement
• Adverse reinforcement
– Voice Control
– Parental Abscence
IF THE PARENT
IS AFRAID ...
THE CHILD
WILL ALSO BE
AFRAID.
Word
Shot
Anaesthetic
Drill
Explorer
Rubber dam
Substitute
Pinch, push
Sleepy water
Cleaner, Tickler
Tooth counter
Raincoat
Child Psychology
• Many publictions in the psychological
literature on parent-child relationship.
• We can learn 2 major skills:
– Reflective listening
– Using descriptive praise
Communication through
reflective listening:
• 1951, Carl Rogers introduced us to
reflective listening or 'active'
listening as it is referred to today.
• It is the process where you mirror the
emotional communication of the child
through verbal or nonverbal means.
'active' listening
• In a situation where there are
strong emotional overtones
• Unlike adults who are socialized
to conceal their fears of oral
health, children do not.
• As clinicians treating children, we
all too often deny kids their
feelings instead of acknowledging
them.
• Child: “I'm scared”
• Dentist: “there is nothing to be scared of”
• Children feel what they feel. Their feelings
are a fact. Do not deny them this.
• These feelings must be mirrored by the
clinical staff so that they appreciate that
their feelings are being recognized.
• Accepting the child's emotions permits
them to develop the sense that their
feelings are not all that strange.
• Feelings must be addressed before
behavior can be improved.
• Child: “I'm scared”
• Dentist: “I understand. Sometimes
new things are scary. It is okay to be
scared. Sometimes I'm scared of
things I do not understand or have not
done before”
• Reflective listening has the positive
effect of reassuring children that
what they are going through is a
normal part of the human experience.
• It permits children to 'own' their
feelings, thus respecting a child's
autonomy.
• Never argue with what the children
are feeling – don't attempt to convince
them what they are feeling or sensing
is not so.
Reinforcing behavior through
descriptive phrase
• Positive reinforcement as we know is a very
useful tool to promote good behavior
• There are however, appropriate and
inappropriate ways of doing so.
• According to Ginott, “The single most
important rule is that the praise deal only
with the child's efforts and
accomplishments . . . not with their
character and personality”
• All too often, in attempting to gain
children's cooperation, we use phrases such
as “good boy” or “you're a wonderful kid”
• Praise of desirable behaviors is consistent
with the principle of operant conditioning as
outlined by Skinner.
• However, with kids, the child understands
that the clinician is in an evaluative role
relative to their behavior and that the
child's behavior can easily be 'bad' at a
future point in time.
• Such evaluative praise can create a
sense of anxiety in the child over
possible failure in the future.
• Use descriptive praise, where you are
not judging the character of the child
but more their actions.
• Rather than saying “good boy”, say “It
make my job so easy when you hold
still like that, we can work so much
faster as a team”.
Local
Anesthesia . . .
Objectives…
• Local Anaesthetics &
Behaviour Management
– When do you need to use
LA?
– Acceptable language?
– How do you make an
injection less painful?
– Adequate anaesthesia?
– Anaesthetizing a
frightened/ anxious child
Objectives…
• Properties of Common Local
Anaesthetics
– Topical anaesthetics
– Types & duration of anaesthesia
– Calculating the maximum dose of local
anaesthetic
• Complications
– Local
– Systemic
When to use LA?
• Not required for:
– Sealants
– Preventive resin restorations
– Buccal restorations (majority)
– Disking teeth
– Fitting bands or cementing appliances
• Required for:
– Amalgam or composite restorations extending > ¼
of the way into dentin
– Stainless steel crowns
– Pulpotomy / pulpectomy
– Extractions
Never lie to a child . . .
• Need to gain child’s trust
• Side step any questions such as “am I
getting a needle?”
– “Good question, let me count your teeth
first”
• Never surprise a child.
• “Ok now, I’m going to push here . . .”
• use terminology you feel will be better
received by the child -- e.g. “Sleepy juice”
• Let the child know what the anaesthetic
will make their cheek/lip/tongue feel like
– Puffy, soft, tingly, fat, etc…
• AVOID the words hurt, pain, pinch,
mosquito bite, etc…
How to make an injection less painful
• Most important: DISTRACT
• Use topical
• Warm the anesthesia solution, makes a
huge difference
• Infiltrate with 30 gauge, block with 27
gauge
• Shake the cheek
• Inject slowly and smoothly, do not rush
Adequate anaesthesia?
• Ask the child where it feels - numb, tingly,
sleepy, fat, itchy, weird, different – and any
other word you think they might choose to
describe it…
• Have them point to the area that feels
“different”
• Gold standard: induce a painful stimulus in
the area you believe is anaesthetized (e.g.
explorer tip into the gingiva) – watch
eyes/reaction
Anatomic Variations
• Mandible
- Mandibular foramen in children 4 years old and less is
below the plane of occlusion. The foramen moves
superiorly in the ramus with the eruption of 6’s
Adults
Children
Approximate duration of action of Local
Anaesthetics
• Use the shortest acting
local that will allow you
to complete the job
• Soft tissue anesthesia
always longer than
pulpal
• I block with mepivicaine
(no epi) lasts 2-3 hours
• Infiltrate with
lidocaine 3-4 hours
Calculating the maximum dose of
Local Anaesthetic for a child
Maximum Recommended Dose (mg/kg) x Child’s Weight (kg)
Anaesthetic Concentration (mg/ml) x Volume of Carpule (ml)
e.g. The maximum amount of 2% Lidocaine with 1:100,000 epi for a 17
kg child would be:
4.4 mg/kg x 17 kg
= 74.8 mg
20 mg/ml x 1.8 ml
36 mg
= 2.08 carpules
Rule of thumb – 1 carpule per 20 pounds
Complications - Local
• Masticatory trauma
– Use short acting local
anaesthetics; post-op
instructions
• Needle breakage in soft tissue
– Avoid bending needle; minimize
movement in tissue; don’t
submerge needle to the hub
• Haematomas
• Trismus
• Infections
• Nerve damage from needle
Complications – Systemic
• Allergic Reaction
– Extremely rare with amide anaesthetics
– Methylparaben is a preservative used to
increase the shelf-life of epinephrine
containing anaesthetics – possible allergen
– If the patient/parent is truly worried about
an allergy to local anaesthetic, refer them
to their physician for testing
Local Anaesthetic Toxicity Cont’d
• Minimal to moderate overdose levels:
- Talkativeness, apprehension, excitability, sweating, vomiting,
disorientation, increased blood pressure, heart rate, and
respiratory rate
• Moderate to high overdose levels:
– Tonic-clonic seizure activity followed by generalized CNS
depression, depressed blood pressure, heart rate, and respiratory
rate
– Death.
• Treatment of anaesthetic overdose:
– #1 treatment - prevent it from occurring!
– Mild cases: stop LA, administer O2
– Moderate-severe: activate EMS, administer O2
Some Tips…
• Pass the syringe behind
where the child does not
see it
• Talk a lot, don’t stop talking
• ALWAYS have your
assistant gently restrain
(“hold”) the patient’s
hands/arms to avoid sudden
movements
Thank You