Behaviour Management

Hand-over-mouth exercise (HOME) is contraindicated for any patient as it can cause psychological trauma and is no longer recommended by AAPD. Positive reinforcement, tell-show-do, and voice control can all be appropriately modified for patients.

Gradual decrease N2O while maintaining flow rate, then 100% O2 for 5 minutes minimum. Maintaining total flow rate while gradually decreasing N2O prevents rapid awakening and anxiety. Immediate termination or abrupt changes can cause distress. Skipping 100% O2 risks diffusion hypoxia.

Tell-Show-Do is the foundational technique that should be attempted first before progressing to more advanced methods. It helps establish trust and reduce anxiety by familiarizing the child with the dental environment in a non-threatening way. Voice control is a more advanced technique that could escalate anxiety if used too early. Hand-over-mouth was once used as a behavior management tool in pediatric dentistry, but it has since been removed from the American Academy of Pediatric Dentistry's clinical guidelines. Nitrous oxide sedation should not be the first-line approach for basic defiant behavior.

Immediate, specific praise for desired behaviors is most effective as it helps children understand exactly what they did well and encourages repetition of positive behaviors. General praise, delayed rewards, or material rewards alone are less effective in shaping behavior.

Social reinforcement (verbal praise, facial expression, physical demonstrations of approval) combined with appropriate token reinforcement shows the highest success rate. Immediate positive feedback helps children connect their good behavior with the reward. Using only material rewards can create dependency and expectation. Intermittent praise alone may not provide enough motivation, while continuous material rewards can lose effectiveness.

Control of breathing combined with audiovisual distraction shows the highest success rate in this age group. Simple distraction like counting isn't engaging enough for this age group during injections. Verbal-only distraction may not be sufficient to override anxiety, and television alone may not provide enough engagement during uncomfortable procedures. The combined approach gives the child both a sense of control (breathing) and effective distraction (audiovisual).

While parental presence can sometimes interfere with child-dentist communication, research shows that denying parental presence during the first visit can increase anxiety and decrease trust. The best approach is to allow the parent to stay but establish clear guidelines for their role. Forcing separation or immediate dismissal can damage the dentist-parent relationship.

The correct sequence is: First, TELL the child about the "tooth shower" (handpiece) and explain it removes "sugar bugs" using child-friendly language. Then, SHOW the handpiece running on a napkin or finger demonstrating the water spray and sound. Finally, DO the procedure as explained. Starting with the demonstration or using technical terms first can increase anxiety. Skipping the "show" step eliminates the crucial desensitization phase. The "do" step should never come before explanation and demonstration.

For a cooperative child with mild apprehension, pharmacological management is not indicated. Basic behavior guidance techniques should be sufficient. Explaining this to parents while demonstrating successful basic techniques helps build trust and prevents unnecessary sedation risks.

For moderate sedation, clear liquids: 2 hours, light breakfast: 6 hours, regular meals: 8 hours. A light breakfast is considered a light meal, requiring 6 hours fasting. This guideline is based on gastric emptying times and aspiration risk. The 2-hour rule only applies to clear liquids. 4 hours is insufficient for any food intake, and 8 hours would be excessive for a light meal.

Using age-appropriate terminology and demonstrating on a toy first can enhance the effectiveness of tell-show-do. Simply repeating the same approach or switching to voice control may escalate anxiety. Immediate protective stabilization would be premature.

Having the child observe a cooperative similarly-aged peer undergo a similar dental procedure is most effective. The demonstration patient should be close in age to facilitate identification and should display excellent behavior. Observing a sibling can be complicated by family dynamics. Watching a video is less effective than live observation. Adult models are less relatable for young children.

Inability to breathe through the nose (nasal obstruction) is the primary contraindication as it prevents effective administration of nitrous oxide. Mild anxiety and young age are not contraindications if the child can cooperate with nasal breathing. ADHD may actually be an indication for N2O use.

After exhausting basic behavior guidance techniques, nitrous oxide/oxygen inhalation is typically the next step before considering more advanced pharmacological management. It's minimally invasive, has a rapid onset/recovery, and can help build confidence for future visits. General anesthesia and protective stabilization are more aggressive options that should be reserved for when other methods fail.

Administer 100% oxygen for minimum 5 minutes and monitor oxygen saturation. Diffusion hypoxia occurs during recovery when N2O leaves blood faster than O2 can diffuse in. Continuing N2O would worsen condition. Room air alone is insufficient. Emergency services aren't typically needed unless other complications present.

IAN block with 2% lidocaine with 1:100,000 epinephrine, maximum 4.4mg/kg (1 cartridge = 36mg). Infiltration alone is insufficient for pulp therapy. 3% mepivacaine has shorter duration and no vasoconstrictor. Articaine is not recommended for block in children under 7 due to increased paresthesia risk. The calculation should include weight-based dosing, not just cartridge numbers.

Informed consent must be obtained before implementing any form of protective stabilization. While all other options are important, without proper informed consent, the use of protective stabilization could result in legal issues. The consent should detail the risks, benefits, and alternatives to protective stabilization.

The sudden, controlled change in voice volume and tone is the key element that makes voice control effective. It should be an abrupt change that attracts attention and conveys authority, but is not scary or threatening. Maintaining the altered voice throughout treatment can diminish its effect. Yelling or showing anger is never appropriate and can traumatize the child. Using a continuously soft voice defeats the purpose of the technique.

Single tooth isolation with #14 Ivory clamp, non-latex rubber dam, and frame. Non-latex material is essential for asthmatic patients to prevent potential reactions. Multiple tooth isolation can be overwhelming and unnecessary for a single tooth restoration. Wingless clamps may provide insufficient retention, and latex dam risks allergic reaction.

Voice control with direct, firm commands is the most appropriate immediate response to prevent injury and establish control. Physical restraint should only be used if voice control fails. Stopping the procedure entirely may reinforce negative behavior, while continuing without addressing the behavior risks safety. Nitrous oxide takes time to administer and isn't an immediate solution.

Maximum N2O should not exceed 50%, and minimum O2 must be at least 30% at all times. The 50% N2O maximum ensures safety while maintaining efficacy. Higher N2O concentrations increase risk without proportional benefit. 40% O2 is unnecessarily high, while 20% O2 is dangerously low. The 70% N2O option would leave insufficient oxygen.