10 • Best practice


CHILD’S


Stuart Davidson and Michael Dhesi offer a helpful perspective on dealing with anxious children in the dental chair


T • •


HE management of the paediatric patient in dental practice is a challenge faced by general dental practitioners on a daily basis. Treating children can be particularly rewarding but


like all aspects of dentistry it requires good communication skills, clinical knowledge and a degree of practice! Children account for a significant proportion


of the population and developing a rapport at an early age will help establish a good long-term practitioner-patient relationship and hopefully result in a healthy, functional, stable and attractive dentition. This is not achieved without a degree of effort and here we offer an overview of both the non-pharmacological and pharmacological techniques that can be utilised to help tiny terrors become pleasant patients. First it is essential to have a good understanding of the factors affecting anxiety in children. Often for children this is a fear of the unknown. The dental surgery is full of unfamiliar people and strange objects that often produce frightening noises and can induce a ‘fight-or-flight’ response. Guidance from The Royal College of


Surgeons of England suggests that the behaviour of children in clinical situations can be categorised in three ways:


Co-operative: the child is able to participate in dental care.


Potentially co-operative: the child may be able to participate in dental care with the adjunct of appropriate behaviour management techniques.


•


Lacking co-operative ability: the child is pre-co-operative, for example, very young children.


It is essential that the clinician takes time to


evaluate the child’s stage of development in order to appropriately plan the overall management strategy. This involves setting achievable goals and working with children and their parents towards attaining these goals.


Non-pharmacological techniques Below are a number of communication-based


Relaxation Simple relaxation techniques using breathing exercises or progressive muscular relaxation can be useful but require a degree of co-operation. This technique may be more useful in teenage or adult patients.


Systematic desensitisation This is a four-step technique to reduce the anxiety associated with a specific stimulus.


techniques used to manage the anxious child patient.


Tell-Show-Do This technique is extremely popular and is helpful in acclimatising children to the dental surgery and treatment. There are three phases: initially an explanation of the equipment or procedure, followed by a demonstration (e.g. polishing the child’s nail) before proceeding with the treatment.


Positive reinforcement This technique involves acknowledgement, praise and reward for positive behaviour (whilst ignoring negative behaviour). For example, stickers or bravery certificates.


Distraction Changing the focus of the child’s attention away from the anxiety-causing factor can be effective. A useful example of distraction is having the child choose the music played in the surgery. The band One Direction is increasingly popular in my surgery at the minute!


Non-verbal communication These are non-verbal signals and cues which can help to reassure the child and provide a sense of control to the patient. A particularly effective example is the use of stop signals. A signal is agreed between dentist and patient to indicate that he or she would like to stop treatment. It is essential that if this technique is used the clinician does stop when requested, as often the child will test the ‘deal on offer’ before committing to treatment.


Modelling This is a particularly useful technique for an anxious child with a co- operative sibling/parent. The child can watch the ‘model’ taking part in treatment and feel reassured by a positive experience. Often this can remove a fear of the unknown.


1. 2. 3.


Identify the stimulus and any factors that contribute to anxiety.


Utilise relaxation techniques.


Establish a hierarchy of fear – patient scores experiences out of 10. For example seeing the LA syringe may cause an anxiety score of 4/10 whereas having LA administered may give a score of 10/10.


4. Over a period of weeks the patient then uses relaxation techniques to progress through the hierarchy. It is essential the patient completes one stage while maintaining a relaxed mindset before proceeding.


Hypnosis This can be an extremely useful technique if the case is selected appropriately. Some controversy exists in relation to the effectiveness of hypnosis for behaviour management in children. A Cochrane review published in 2010 concluded that on the basis of the studies that met the inclusion criteria there was not yet enough evidence to suggest beneficial effects.


Pharmacological techniques Conscious sedation techniques can be used with great effect to reduce fear and anxiety in children. Guidance from the Scottish Dental Clinical Effectiveness Programme defines conscious sedation as “a technique in which the use of a drug or drugs produces a state of depression of the central nervous system enabling treatment to be carried out, but during which communication is maintained and the modification of a patient’s state of mind is such that the patient will respond to command throughout the period of sedation.”


Inhalational sedation or relative analgesia (RA) This technique has a wide margin of safety and is generally viewed as the first port of call of the pharmacological techniques. A mixture of nitrous oxide and oxygen is used to achieve relaxation, sedation and a level of analgesia. The level of nitrous oxide is titrated until the patient is confident to start treatment. It is essential that the gas mixture is used alongside verbal support and reassurance from


Page 1  |  Page 2  |  Page 3  |  Page 4  |  Page 5  |  Page 6  |  Page 7  |  Page 8  |  Page 9  |  Page 10  |  Page 11  |  Page 12  |  Page 13  |  Page 14  |  Page 15  |  Page 16