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BEHAVIOUR MODIFICATION

TECHNIQUES

Dr.M.Ganesh,MDS(Pediatric
Dentistry)

Behavior modification techniques:

Introduction - Definition
- Classification of behavior management modalities
Behavior management techniques:- Desensitization Introduction
- Definition
- Indications
- Technique
- Tell, Show, Do
- Verbal communication
- Conclusion
- Modeling Introduction
- Requirements
- Technique
- Contingency management Definition
- Reinforcers
- Types of reinforcers
Key points.
Conclusion.
References.
Dr.M.Ganesh,MDS(Pediatric
Dentistry)

BEHAVIOR MODIFICATION:The attempt to alter human behavior and emotion in a


beneficial way and in accordance with the laws of learning.
BEHAVIOR SHAPING:The procedure which slowly develops behavior by reinforcing
a successive approximation of the desired behavior until the
desired behavior comes into being.
BEHAVIOR MANAGEMENT:The means by which the dental health team effectively and
efficiently performs dental treatment and thereby instills a
positive dental attitude.

Dr.M.Ganesh,MDS(Pediatric
Dentistry)

Behavior management modalities: Non pharmacological (psychological


approach)
Pharmacological

Dr.M.Ganesh,MDS(Pediatric
Dentistry)

Non-pharmacological methods of
behavior management:1.
Communication
2.
Behavior modification (shaping)
a) Desensitization
b) Modeling
c) Contingency management
3.
Behavior management
a) Audio analgesia
b) Biofeedback
c) Voice control
d) Hypnosis
e) Coping
f) Humor
g) Relaxation
h) Aversive conditioning
Dr.M.Ganesh,MDS(Pediatric
Dentistry)

Pharmacological methods of
behavior management:1. Pre-medication
a) Sedatives and hypnotics
b) Anti-anxiety drugs
c) Antihistamines
2. Conscious sedation
3. General anesthesia

Dr.M.Ganesh,MDS(Pediatric
Dentistry)

SYSTEMIC DESENSITISATION

Dr.M.Ganesh,MDS(Pediatric
Dentistry)

SYSTEMIC DESENSITISATION
Introduced by Joseph
Wolpe.
Reciprocal Inhibition
Process by which a
person experiencing
anxiety in association
with a certain stimulus
is made to experience
a response that
inhibits anxiety to that
same stimulus.
Dr.M.Ganesh,MDS(Pediatric
Dentistry)

Behavior therapists have found that


systemic desensitization is one of the most
effective methods for reducing
maladaptive anxiety.
The technique has been found not only
useful in dental situations, but also in the
treatment of other phobias such as the fear
of heights, crowded places and isolation.
Dr.M.Ganesh,MDS(Pediatric
Dentistry)

Systemic desensitization is effective because the


patient learns to substitute an appropriate,
adaptive , emotional response Relaxation for
an inappropriate maladaptive, response
anxiety.
This Technique is used to remove fears and
tensions in children who have had previous
unpleasant dental experiences or negative
behavior.
Dr.M.Ganesh,MDS(Pediatric
Dentistry)

The Technique: 1) Training the patient to relax


2) Constructing a hierarchy of fear
producing stimuli related to the patients
principal fear.
3) Introducing each stimuli in the hierarchy
in turn to the relaxed patient, starting with
the stimulus that causes least fear and
progressing to the next only when the
patient no longer fears that stimulus.
Dr.M.Ganesh,MDS(Pediatric
Dentistry)

Technique in its classical form: Teach the patient how to relax; to induce a state
of deep muscle relaxation.
Introduce imaginary scenes related to his fears,
presented in a graduated fashion so that the
scenes only provoking minimal anxiety are
described.
Gradually more stressful situations are
presented.
Anxiety is minimized through the use of
relaxation.
Dr.M.Ganesh,MDS(Pediatric
Dentistry)

Basis of the childs fear: Childs fear General fear ( Fear of the
dental environment)
-- Specific fear ( Fear of the
drill or the needle)
When this information is known, a
hierarchy of fear producing stimuli can be
constructed.

Dr.M.Ganesh,MDS(Pediatric
Dentistry)

Fear of the dental environment in


general:

1.
2.
3.
4.
5.

Desensitization include successive


introduction of the child to the following
stimuli:Reception and waiting room
Dentist and nurse
Dental chair
Oral examination
prophylaxis
Dr.M.Ganesh,MDS(Pediatric
Dentistry)

Fear of the drill and of the


needle:
1.
2.
3.
4.

Selected stimuli may be:Brushing the childs teeth with a prophylaxis brush held in hand.
Brushing with a prophylaxis brush in slow speed hand piece.
Using a fine finishing bur in a slow speed hand piece revolving in
the mouth but not in contact with teeth.
Applying the finishing bur gently to a tooth surface.
Desensitization from the needle fear is more difficult, especially
with young children, who cannot be expected to react favorably to
the sight of a needle, even less ,to its introduction into their
mouth.
Some dentist prefer to show the patient the cotton roll with topical
anesthetic and avoid sight of the needle, while others consider
some for of sedation.

Dr.M.Ganesh,MDS(Pediatric
Dentistry)

TELL, SHOW, DO TECHNIQUE


(TSD)
Concept of TSD was
introduced by
Addleson (1959)
Most common
method of behavior
shaping used by
many professionals
who work with
children.
Dr.M.Ganesh,MDS(Pediatric
Dentistry)

Indications of the technique: During a childs initial


dental visit.
Subsequent
appointments when
new procedures are
being carried out.
Fearful child.
Patients not
familiarized with certain
dental techniques.
Dr.M.Ganesh,MDS(Pediatric
Dentistry)

Components of this technique: TELL:- Telling the child about the new
situation and what is going to be done.
SHOW:- Showing the child the new
environment; Demonstration for the
patient of the visual, auditory and tactile
aspect of the procedure.
DO:- Doing what the child was told would
be done.
Dr.M.Ganesh,MDS(Pediatric
Dentistry)

VERBAL COMMUNICATION

Communication should be
comfortable and relaxed.
Language which is preferred
by the child, containing words
that express pleasantness,
friendship and concern.
Voice that is used should be
constant and gentle. Tone of
voice can express empathy
and firmness.
Patient prefers being
addressed by his name.
Use of euphemisms.

Dr.M.Ganesh,MDS(Pediatric
Dentistry)

Euphemistic Language The term "euphemism", derived from the


Greek EW (well) and Phanai (to speak), originally meant "to use
words of good omen."
, the use of euphemisms is particularly indicated in place of:
a) fear-provoking or threatening words, and
b) technical terms
The use of threatening and technical language is a frequent barrier
to communication between dentist and patients.
It either creates apprehension and confusion or intensifies them if
already existent. In order to prevent potential problems that can
result from the use of emotionally-charged language

Dr.M.Ganesh,MDS(Pediatric
Dentistry)

Dental Nomenclature
Euphemisms :

Amalgam - silver filling


Anesthesia - sleepy water
Bur - germ chaser
Dental caries - tooth bugs
Dental explorer - tooth
counter
Topical fluoride - tooth
vitamins
Matrix band - Queen's
crown

Prophylaxis paste toothpaste


Radiograph - tooth
picture
Rubber dam - raincoat
Stainless steel crown shiny cap
X-ray - machine camera

Dr.M.Ganesh,MDS(Pediatric
Dentistry)

For whatever treatment TSD is being employed,


it is important to ensure a smooth continuity
through the T-S-D stages.
The explanations should not be detailed or
protracted, as this would tend to confuse the
child and perhaps arouse anxiety; they should
be given simply and casually.
Similarly the demonstration should be given
briefly so that the actual treatment follows
without undue delay.
A positive reinforcement should be given
immediately to a child who follows TSD
successfully.
Dr.M.Ganesh,MDS(Pediatric
Dentistry)

MODELLING

Dr.M.Ganesh,MDS(Pediatric
Dentistry)

MODELLING

Introduced my Bandura in
1969.
He stated that learning occurs
only as a result of direct
experience which can be
vicarious- witnessing the
behavior and the outcome of
that behavior for other people.
He found earlier that children
exposed to an aggressive
model will imitate that type of
behavior both verbally and
nonverbally.

Dr.M.Ganesh,MDS(Pediatric
Dentistry)

Types of models:

Live models ( siblings, parents, etc).


Posters.
Filmed models.
Audiovisual aids.

Dr.M.Ganesh,MDS(Pediatric
Dentistry)

Modeling technique requirements: Concentrated attention must be expended toward the


witnessing of the model. Brief exposure to the modeling
procedure is not productive.
There must be sufficient retention of the desirable
behavior in the absence of a model.
Physical guidance of the desired behavior may be
necessary.
One must be able to reproduce effectively the behavior
modeled.
The newly acquired behavior must be appropriately
rewarded to retain it.
Dr.M.Ganesh,MDS(Pediatric
Dentistry)

The basic modeling procedure involves allowing a patient


to observe one or more individuals (models) who
demonstrate appropriate behavior in a particular situation.
The patient will frequently imitate the models behavior
when placed in a similar situation.

Dr.M.Ganesh,MDS(Pediatric
Dentistry)

Modeling made more effective:a) When the observer is


in a state of arousal,
b) When the model has
relatively more
prestige or status, and
c) When there are
positive consequences
associated with the
models behaviour.

Dr.M.Ganesh,MDS(Pediatric
Dentistry)

Modeling serves 4 basic


functions: Stimulation of a new behavior.
Facilitation of behaviors already in the
patient in a more appropriate manner or
time.
Disinhibition of behaviors avoided
because of fear.
Extinction of fears.
Dr.M.Ganesh,MDS(Pediatric
Dentistry)

CONTINGENCY MANAGEMENT
The presentation or withdrawal of
reinforcers is termed contingency
management
Behavior therapists define dispensing a
reinforcer contingently as giving a
reinforcer after a desired behavior has
been performed.
(Do not confuse Contingent:- dependant
on chance)
Dr.M.Ganesh,MDS(Pediatric
Dentistry)

Reinforcer:

By definition, reinforcers always increase the frequency of a


behavior
Reinforcement is the strengthening of a pattern of behavior,
increasing the probability of that behavior being displayed again in
the future.
Two types of reinforcers:a) Positive
b) Negative
A positive reinforcer is one whose contingent presentation
increases the frequency of a certain behavior.
A negative reinforcer is one whose contingent withdrawal increases
the frequency of a desired behavior

Dr.M.Ganesh,MDS(Pediatric
Dentistry)

Reinforcers also classified as:Reinforcers


Material

Social

Dr.M.Ganesh,MDS(Pediatric
Dentistry)

Activity

Material Reinforcers: They are perhaps the most effective for children.
Suitable items would be balloons, coloring sheets,
stickers, toothbrushes, games, etc. ( Try and keep the
item of dental significance)
Candy, sweets, chocolates, etc, are contraindicated as
they are baneful to oral health.
A present should be given at the end of a session as a
sign of approval of good behavior.
Items should not be offered as a bribe in hope of
encouraging good behavior, and certainly not be given if
the child has not been cooperative.
Dr.M.Ganesh,MDS(Pediatric
Dentistry)

Social reinforcers: Social reinforcers probably represent the majority of all


reinforcing events affecting human behavior.
Praise, positive facial expressions, nearness, and
physical contact are effective reinforcers because people
have learned to value other people.
For best effect, positive reinforcement , like praise,
needs to be given throughout the session immediately
after appropriate behavior is demonstrated.
Praise at the end alone does not seem to work: you
must make it clear to the child which behavior is being
rewarded.
Dr.M.Ganesh,MDS(Pediatric
Dentistry)

Common social reinforcers:1)

Praise:
Good
Thats right
Excellent
Exactly
Good job
Great
Thank you

2) Facial expressions:
Smiling
Winking
Laughing
3) Physical contact:
Patting head, shoulder, or
back.
Shaking/ holding hand
Hugging

Dr.M.Ganesh,MDS(Pediatric
Dentistry)

Activity Reinforcers: Activity reinforcers


involve the opportunity or
privilege of participating
in a preferred activity
after performance of a
preferred behavior.
First you work , then you
may play principle.

Activity Reinforcers:
Seeing a movie.
Having a friend stay
overnight.
Having a party.
Going shopping.
Going out to play.
Playing games with
friends.
Staying up late.

Dr.M.Ganesh,MDS(Pediatric
Dentistry)

Little application of
activity reinforcers in the
dental office, but they
may be used with
significant success in the
home for programs such
as habits or plaque
control if the parents can
be trained to observe and
reinforce appropriate
behavior.
Dr.M.Ganesh,MDS(Pediatric
Dentistry)

Some application of
activity reinforcement in
the dental operatory can
be used, and this is due
to childrens inherent
curiosity.
Following appropriate
behaviors children maybe
allowed to observe
treatment in a hand
mirror, or participate in
procedures by holding
instruments (not anything
sharp).
Dr.M.Ganesh,MDS(Pediatric
Dentistry)

Key Points: Aim of behavior management is to instill a lifelong,


positive attitude to dental health.
Facial expression, touch, body language and voice tone
are all critical elements of child management.
tell, show, do can be used for all patients, but
remember to make language appropriate for each child.
Let the patients know you care. Talk to them. Ask if they
are all right.
Remember to smile. It shows in your eyes and can be
heard in your voice.

Dr.M.Ganesh,MDS(Pediatric
Dentistry)

Conclusion: Desensitization, Modeling and


Contingency management techniques
have been found useful in the dental
office.
Application of these techniques ,
separately or in combination, will
frequently enable the dentist to elicit
successively more appropriate behaviors.
Dr.M.Ganesh,MDS(Pediatric
Dentistry)

References: Child taming Barbara Chadwick & Hosary.


Management of dental behavior in children
Ripa & Barenier.
Manual of Pediatric dentistry Churchhill &
Livingstone.
Dentistry for children and adult - McDonald &
Avery.
Textbook of Pedodontics Shoba Tandon.
Child dental health Holloway.
Journal of Pediatric dentistry vol.22 (2000)
Dr.M.Ganesh,MDS(Pediatric
Dentistry)

THANK YOU.

Dr.M.Ganesh,MDS(Pediatric
Dentistry)

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