| PEDIATRIC BEHAVIOR MANAGEMENT |
| Slide 2 |
| Slide 3 |
| Two Purposes |
| Required Health Care | |
| Make First Experience Positive |
| The First Visit |
| Education | ||
| Parent and Child | ||
| Risk Assessment | ||
| Anticipatory Guidance | ||
| Positive Experience | ||
| Pathology | ||
| Growth and Development | ||
| Habits | ||
| Caries, Periodontal Pathology | ||
| Systemic Manifestations | ||
| Fear Reactions |
| Of the Known | ||
| Past Experiences | ||
| Rumor...Peers and Siblings | ||
| Of the Unknown | ||
| Individual Psychology/Development | ||
| Ego Defense Mechanisms | ||
| Slide 7 |
| Slide 8 |
| Slide 9 |
| Slide 10 |
| TELL, SHOW, DO |
| Keep it Simple | |
| Describe What is to be Done | |
| Provide Example | |
| “Do” Exactly What Was Described | |
| Develop Trust |
| Slide 12 |
| Slide 13 |
| Share Limited CONTROL |
| “If You Are Tired, Raise Your Hand” | |
| Expect to be Tested! | |
| Which Hand? |
| Slide 15 |
| Slide 16 |
| Reinforce Appropriate Behavior |
| “What an Excellent Patient You Are!” | |
| “That is Exactly What I Want You to Do” | |
| “You are the Best Patient WE HAVE HAD TODAY” | |
| Use Humor | |
| Arrest Inappropriate Behavior |
| At Its Inception | |
| “We Do Not Allow That Here” | |
| Office is NOT a Play Area | |
| Potential for Injury | |
| Friendly but Firm |
| Slide 19 |
| Voice Control |
| Intonation: Who is in Charge?.. | |
| More Volume ? | |
| Think of a Second Grade Teacher! |
| Slide 21 |
| Speech |
| Age 2 - Only 1000 Word Vocabulary | |
| Concrete Interpretations; Literal Meanings | |
| Older Child - Do Not “Talk Down” |
| The First Visit |
| By Age One! | ||
| Education for Prevention | ||
| Parent and Child | ||
| Positive Experience for Both | ||
| Pathology | ||
| Habits | ||
| Caries, Perio, Freni, Other | ||
| Abnormal Growth | ||
| Parental Interactions |
| Dependency Level | |
| “Child Prince/Princess” | |
| Overprotection vs. Right to Know |
| Slide 25 |
| Slide 26 |
| Parental Presence ? |
| YES: | |||
| Knows Child Better Than Anyone; Special Issues | |||
| May Be of Value in Management | |||
| Appreciates the DOCTOR’S SKILLS! | |||
| NO: | |||
| Divides Attention...Doctor’s and Child’s | |||
| Serves as “Court of Appeals” | |||
| Offended by Techniques Not Understood | |||
| e.g. Voice Control | |||
| Health History |
| Detailed, including Dental History | |
| “Never Treat a Stranger” | |
| Review at Each Recall Visit |
| Slide 29 |
| Physical Condition |
| Systemic Illnesses | |
| Disabilities | |
| “Failure to Thrive” | |
| Fatiguability |
| Slide 31 |
| Head and Neck Exam |
| “Open Wide”? | |
| Proceed from Global to Specific | |
| Initially Only Digital Contact | |
| Caries Assessment is Last |
| Slide 33 |
| Habits |
| Digits | ||
| Lip | ||
| Tongue | ||
| “Convenience Bite” | ||
| Occlusal Interferences | ||
| Slide 35 |
| Occlusion |
| Neutrocclusion vs. Malocclusion | ||
| Class I Molar and Canine or Class I Crowded? | ||
| Class II or Distocclusion | ||
| Overjet Division 1; Bugs Bunny | ||
| Overbite Division 2; Deep | ||
| Class III or Mesiocclusion; “Lantern Jaw” | ||
| Slide 37 |
| Intra-oral Examination |
| Peripheral “Inward” | ||
| Soft Tissues | ||
| Freni, Periodontal Pathology, Fistulae | ||
| Tongue, Palate, Tonsils Etc. | ||
| Slide 39 |
| Slide 40 |
| Introduction of Instruments |
| Tongue Depressor | ||
| Mouth Mirror | ||
| Explorer? | ||
| Damage? | ||
| Slide 42 |
| Slide 43 |
| Treatment Plan |
| Emergent Needs First | |
| Preventive Plan | |
| Maxillary Restorations First | |
| Quadrant Sequence | |
| Careful Parental Explanation and Permission! |
| Slide 45 |
| Slide 46 |
| Preventive Plan |
| Risk Assessment | |
| Diet vs. Nutrition | |
| Plaque Removal | |
| Fluorides | |
| Growth and Development |
| Slide 48 |
| Oral Hygiene Instruction |
| Infant | |||
| Soft Cloth/ Commercial Products | |||
| e.g. “TOOTHETTES” | |||
| Soft Brush | |||
| Small Head, Large HANDLE | |||
| For Parent and Child | |||
| Fluoride Toothpaste | |||
| PEA-SIZED AMOUNT | |||
| Parental Responsibility to Age 6 | |||
| Flossing: Good Habit | |||
| 40% Spaced Dentition | |||
| Slide 50 |
| Diet History |
| Diet Vs. Nutrition | |
| Frequency of Ingestion is THE PRIMARY Issue in Caries Rate | |
| Retention is Issue Number 2 | |
| Fluoride is Only Effective Counter Measure |
| Slide 52 |
| Prophylaxis ? |
| Plaque and Stain Removal | ||
| Biological Basis Re: Caries | ||
| Fluoride Rich Surface: 75 Microns | ||
| Introduction to Rotary Instrumentation? | ||
| Fluorides |
| Prenatal? | |||
| Birth to 6 Months? | |||
| Proximal Not Forming Yet | |||
| Systemic: Mechanism is via Saliva! | |||
| Topical | |||
| Applied | |||
| Toothpaste: “Pea Sized” Amount | |||
| OTC Rinses: 0.05% Neutral NaF | |||
| Excessive Ingestion and Fluorosis | |||
| “Ambient” Fluorides | |||
| Fluoride Tray |
| 5 cc Maximum per Tray (5ml = 5cc = 1 Tsp.) | ||
| Position Patient Upright | ||
| Saliva Ejector | ||
| Direct GI Irritant | ||
| Fluorosis | ||
| Slide 56 |
| Slide 57 |
| Behavior Rating |
| 4 = Very Positive | ||
| 3 = Manageable with Clear Directions | ||
| 2 = Difficult; Requires Voice Control and Firmness | ||
| 1 = Physically Resistant; Vocal; | ||
| Restraint? Pre-med.? | ||
| Chart Entry @ Every Visit!!! | ||
| Changes Over Time? | ||
| Rewards Versus Gifts |
| Contingent on Behavior? | ||
| Self Image | ||
| Friendship and Trust | ||
| Restraint Technique |
| Consent | |||||
| Conscious Sedation | |||||
| IS RESTRAINT!* | |||||
| Papoose Board, Pediwrap, Others | |||||
| Slide 61 |
| Slide 62 |
| HOME |
| Hand Over Mouth Exercise | ||
| Legal Issues | ||
| Parental Understanding and Consent | ||
| Ability to Communicate | ||
| Not for under 2 or Devel. Delayed | ||
| NEVER Close Airway! | ||
| Slide 64 |
| Slide 65 |
| Slide 66 |
| Slide 67 |
| Slide 68 |
| Pediatric Local Anesthetic Techniques |
| Slide 70 |
| Slide 71 |
| Slide 72 |
| CAUTION: |
| Local Anesthetics Are Drugs | |
| Record Agent, Dosage, Site |
| Xylocaine 2%* |
| 1.8 cc per Carpule | ||
| x 2% = 36mg. per Carpule | ||
| Max Dosage: 3.2 mg/lb. | ||
| Example: 3 Yr. Old = 30 lbs. (3.2 x 30 = 90) = 90 mg. MAX | ||
| = 2 to 2.5 Carpules | ||
| (36 x 2.5 = 90) *Epi 1:100K | ||
| Signs of Overdose |
| CNS First | ||
| Drowsiness | ||
| Delirium | ||
| Slurred Speech | ||
| Altered Consciousness | ||
| Bradycardia> CPR | ||
| TELL, SHOW, DO |
| Not Recommended for: | ||
| Local Anesthesia | ||
| Less than 5 Years of Age | ||
| Show After? | ||
| Developmentally Delayed | ||
| Emotionally Disturbed | ||
| Chronic | ||
| Acute/Situational | ||
| Slide 77 |
| Slide 78 |
| Continuous Communication |
| Monotone | |
| Positive Reinforcement |
| Topical Anesthetic |
| Use Acceptable Tasting Brand | |||
| 120 Seconds Minimum | |||
| Effective Only on Non-keratinized Areas | |||
| Pressure Anesthesia for Keratinized Areas | |||
| Ball Burnisher | |||
| Increasing Pressure > Blanching | |||
| Slide 81 |
| Gauge of Needle |
| 27 Gauge Larger Than 30 | ||||
| HOW MANY FIT IN A UNIT DIMENSION? | ||||
| Perceptible Pain Difference? | ||||
| Better Aspiration Ability ? | ||||
| 30 Ga. Slows Rate of Injection | ||||
| Long, Short, and Ultra-short | ||||
| Slide 83 |
| Talk, Talk, Talk |
| Communication is Primary | |
| Talk Especially When Cooperation is Occurring |
| Slide 85 |
| Slide 86 |
| Slide 87 |
| Know Anatomy |
| Where is Expected Soft Tissue Anesthesia? | ||
| Test! | ||
| Use Ball Burnisher with Pressure | ||
| Duration of Effect: Soft Vs. Hard Tissue | ||
| Untoward Sequellae; Pterygoid Plexus | ||
| Slide 89 |
| Slide 90 |
| Slide 91 |
| Slide 92 |
| Slide 93 |
| Slide 94 |
| Slide 95 |
| Pediatric Rubber Dam Application |
| Keep it Simple! | ||
| Prevents: | ||
| Aspiration | ||
| Materials Contamination | ||
| Behavior Management Aid | ||
| Excessive Talking | ||
| Tongue Interference | ||
| Slide 97 |
| Slide 98 |
| Slide 99 |
| Rubber Dam Clamp |
| Seat Well Via Finger Pressure | ||
| Breakage | ||
| Occurs at Bow | ||
| Lingual Aspect: Aspiration Danger | ||
| Retrieval: | ||
| Floss Tied through Lingual Forcep Hole | ||
| Slide 101 |
| Slide 102 |
| Area of Isolation |
| Clamp Tooth Distal to Treatment Tooth | |
| Isolate One Tooth Either Side of Treatment Site | |
| Inversion Good but Not Critical |
| Slide 104 |
| Coolant Water Management |
| Evacuated by Assistant | |
| Form Trough in Dam | |
| Hole Through Dam |
| Slide 106 |
| Maxillary Anterior Isolation |
| Avoid 227 Clamp...Traumatic | |
| 2 “Large” Contiguous Holes | |
| Stretch from Canine to Canine | |
| Ligate if Necessary |
| Slide 108 |
| Slide 109 |
| Slide 110 |
| Slide 111 |
| Slide 112 |
| Summary |
| Be Directive | |
| Use Euphemisms | |
| Reinforce!!! |
| Positive Reinforcement |
| Prevention: | |
| Better than Any Cure! |
| “CURE” |
| Confidence | |
| Understanding | |
| Reinforcement | |
| Explanation |
| Slide 116 |