Behaviour Management

Behaviour management in paediatric dentistry is all about helping children deal with the experience of a dental visit, procedure, or treatment. It is vital in ensuring the young patient has an enjoyable and pleasant experience related to dentistry, which will encourage their future oral hygiene behaviours. Behaviour management techniques can range from simple communication techniques to more advanced behaviour management techniques, which may include psychological interventions and pharmacological management of behaviour, depending on their age, maturity and emotional needs. Paediatric dentists can create a calm, co-operative environment for patients which will help alleviate anxiety and fear level, build rapport, foster trust and improve treatment outcomes.

The major goals of behaviour management are effective communication, reduction of fear and apprehension, and the development of a positive attitude towards dental care. Many children at their first visit to the dentist exhibit anxiety, fear and non-co operation to some degree. Previous experiences, for example traumatic experiences that occurred in the dental care setting can also affect patients' response to their first dental visits or subsequent care experiences. Furthermore if patients exhibit unmanaged behaviours during dental treatment, it is possible that the dentist will not be able to make an appropriate diagnosis. Due to the fear response it will delay treatment and create the very real potential for physical harm to the child during the course of treatment. By applying behaviour management techniques, paediatric dentists can:

1. Minimization of distress and discomfort.
2. Enhancement of patient cooperation.
3. Safe and efficient completion of dental treatment.

Behaviour management strategies are helpful for:

• Children with dental anxiety or phobia.
• First time dental patients.
• Children with special healthcare needs (SHCN).
• Patients who have negative experiences with dental providers.
• Reluctant or fearful children aged 2-12.

These strategies are based on the individual temperament, psychological development, and the required treatment of the child.

There are many different types of behaviour management approaches used in paediatric dentistry and can be classified as non-pharmacological techniques and pharmacological techniques.

1. Non-pharmacological techniques

• Tell-Show-Do: Describe the procedure, demonstrate with a model, and then perform with the child.
• Positive Reinforcement: Praise or reward for cooperation.
• Distraction: Videos, toys, or stories can be used to distract children.
• Voice Control: The dentist varies tone and volume to influence behaviour.
• Modelling: Letting a child observe another child being treated.
• Parental Separation: Parental separation can sometimes be effective.

2. Pharmacological

• Nitrous Oxide Sedation (Laughing gas)
• Oral Sedation
• Intravenous Sedation
• General Anaesthesia (more complicated or extreme cases)

• The behaviour management process begins at the initial consultation with the dentist. The procedure usually runs as follows:
• Initial Assessment: Dentist collects, and assesses the child's medical and behavioural history.
• Parent Interview: Understanding previous dental experiences, parental expectations etc.
• Selecting Techniques: Based on the child's age and emotional state and complexity of dental procedure.
• Carrying Out the Procedure: Non-pharmacological management: Communicate and engage with the child by employing visual or verbal cues.                                                   Sedation or anaesthesia: Appropriate consent, monitoring and recovery protocols are followed.
• Feedback and Follow-Up: After treatment, both parents and the child are given feedback to create a degree of reinforcement for positive behaviour for further visits.

• Less traumatic and more child-friendly.
• Safer especially during complex procedures.
• More efficient as it will reduce the appointment numbers.
• More effective as it promotes full cooperation and focus on treatment.
• Preventive as it reduces long-lasting dental anxiety.

Behaviour management is not a purely pharmacological method. Behaviour management methods are skill based and do not rely on drugs and do not lead to sedated experiences. Both methods, when taught to a child, empower the child to:

• Develop coping strategies.
• Create a relationship of trust and confidence.
• Have dental experiences without drugs or sedation.
• Can culturally accommodate the approach to dental treatment procedures in India where there is much diversity.

Non-pharmacological techniques can occur immediately at general visits. Sedation based methods take roughly 15 to 45 minutes including preparation and monitor, and general anaesthesia procedures can take several hours including recovery.

The cost of behaviour management varies in India, depending on the technique used:

• Non-pharmacological methods: Typically included in the consultation or treatment fees.
• Nitrous Oxide Sedation: ₹2,000–₹5,000 per visit per session.
• Oral Sedation: ₹3,000–₹6,000. IV Sedation: ₹6,000–₹15,000.
• General Anaesthesia: ₹25,000–₹60,000 depending on hospital infrastructure.
• Costs may vary between cities, dental clinic infrastructure and the child’s condition.

Behaviour management is usually safe, and risks include encountering:

• Emotional distress if the interventions are not fitted to the individual child.
• Over reliance on sedation.
• The possibility of an adverse reaction to the sedative or anaesthesia.
• Parental dissatisfaction if the interventions are misaligned with their expectations.
• Dentists should always obtain informed consent especially for pharmacological methods.

• Time and patience is required specifically for the first visit of a child.
• Not fit for all children especially with severe behavioural disorders.
• Severe behaviour may limit urgent treatment if uncooperative behaviour exceeds reasonable limits.
• Pharmacological interventions require trained professionals to administer.

If behaviour management is either not successful or feasible may include:

• Deferring treatment until the child matures.
• General anaesthesia setting up the appointment for a child's dental visit in a hospital setting.
• Referral to a paediatric specialist.
• Use of protective stabilization (rare and ethically debated).
• Alternatives should always be considered based on the child's needs and health urgency for treatment.