Behaviour Management and Local Anesthesia

1. 1426 McPhillips St Winnipeg, MB • Behaviour Management and Local Anesthesia Fadi KassDMD, Msc, FRCD(c)‏ April 4th 2008

2. Who is more afraid? • Child • Dentist

3. Objectives of treating a child patient • Perform the necessary task • Efficiently • Safely • Instill positive attitude towards the dental team and oral habits

4. How can we do this? • Pharmacological techniques • Sedatives • General anesthesia • Non-pharmacologic • Restraint • Behaviour Managment

5. Behavior Management Techniques: • Humour • Distraction • Tell Show Do • Positive reinforcement • Adverse reinforcement • Voice Control • Parental Abscence

6. IF THE PARENT IS AFRAID ... THE CHILD WILL ALSO BE AFRAID.

7. WordSubstitute • Shot Pinch, push • Anaesthetic Sleepy water • Drill Cleaner, Tickler • Explorer Tooth counter • Rubber dam Raincoat

8. Child Psychology • Many publictions in the psychological literature on parent-child relationship. • We can learn 2 major skills: • Reflective listening • Using descriptive praise

9. 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.

10. '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.

11. 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.

12. 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”

13. 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.

14. 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”

15. 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.

16. 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”.

17. Local Anesthesia . . .

18. 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

19. Objectives… • Properties of Common Local Anaesthetics • Topical anaesthetics • Types & duration of anaesthesia • Calculating the maximum dose of local anaesthetic • Complications • Local • Systemic

20. 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

21. 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 . . .”

22. 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…

23. 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

24. 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

25. Adults Children 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

26. 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

27. 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 = 2.08 carpules 20 mg/ml x 1.8 ml 36 mg Rule of thumb – 1 carpule per 20 pounds

28. 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

29. 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

30. 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

31. 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

32. Thank You