• Attitude to dentistry of parents, siblings and peers
• Negative portrayals of dentistry in the media
• Previous medical or dental experiences
• Communication or learning difficulties

It is important to ascertain a child’s previous medical and dental experience and how well they coped with these.

The non-clinical environment is a critical aspect of the initial patient experience for a dental appointment. The reception staff should be welcoming, with a calming decor in the waiting room, and a selection of child-friendly toys and books available.

These can provide both distraction and a positive first impression to help shape both the child’s and parents’ expectations. When calling the patient in from the waiting room, the tone of voice should be welcoming and pleasant.

All members of the dental team must establish a warm and welcoming environment; body language and communication skills are critical to creating a positive experience and establishing trust from the family.

The appearance of Dentist and staff such as colour of tunic does not seem as important as general neatness and apparent cleanliness.

Protective equipment, if placed on after the child has met the dentist, has less of an influence on subsequent behaviour, thus enabling the dentist to explain why they are required.

When speaking to children, it is important to find words and terms that children can relate to. These are described as “Childrenese” and can be used to describe the equipment in the dental setting. Throughout your dental career you will add more of your own names to describe clinical items, below is a list of common phrases. The key is choosing terminology which conjures little or no negative feelings.

Childrenese terms according to (Fayle 2002):

• Slow hand piece = Buzzy Bee
• Bur = Diamond toothbrush
• Rubber dam = Rubber raincoat
• Rubber dam clamp = Clip or ring
• Inhalation sedation = Magic wind
• Aspiration = Hoover
• Extraction = Wiggle out
• Topical anaesthesia = Sleepy jelly
• Water rinse = Tooth shower
• Anaesthesia = Asleep
• Pre-formed metal crown = Silver hat princess crown
• Injection = Spray with sleepy juice
• Examination = Count teeth

The manner in which the dental team communicates with the child and family is significant. A dentist with a calm, caring and empathetic approach is much more likely to be successful in management of the anxious child.

• Greet the child first and find out what name they like to be called by.
• Engage with the child by asking who they have brought with them for the appointment (this also helps clarify relationships for the dentist who might otherwise assume that it is mum or dad who has brought the child)
• Maintain good eye contact with the child during communication.
• Provide clear, direct instructions and avoid open questions.
• Question for feeling during procedures: How does that feel? Does that feel ok?
• Give feedback about the child’s behaviour: ‘Oh I like you’re helping me by opening your mouth so wide today’.
• Physical contact can reinforce positive behaviour, such as placing a hand on a child’s shoulder or offering hand to hold after a particularly difficult procedure.

• Unsolicited reassurance such as “Don’t worry, this isn’t going to hurt” or “It’s just a small scratch”. This inadvertently passes on the message that this actually might hurt.
• Criticising, ridiculing or belittling a patient are highly ineffective.
• Non-dental chitchat with another person (dental nurse or parent).

Frankl assessed the behaviour exhibited by each child during different phases of treatment, and recorded their level of cooperation on a rating system known as the Frankl scale (see table below). On each visit, the dentist documents the child’s cooperation, by recording their scores on the Frankl scale; this can aid clinicians in determining whether the child has made any improvements in acclimatisation to the dental setting and monitoring compliance with individual treatments.

FRANKL BEHAVIOUR RATING SCALE
1	—	Definitely negative, Refusal of treatment, Forceful crying or any evidence of extreme negativism.
2	–	Negative. Reluctance to accept treatment, uncooperative, some evidence of negative attitude but not pronounced, sullen withdrawn.
3	+	Positive. Acceptance of treatment, cautious behaviour at times, willingness to comply with dentist, a t times with reservation, but patient follows the dentist’s directions cooperatively.
4	++	Definitely positive. Good rapport with the dentist, interest in the dental procedures, laughter and enjoyment.

Behaviour shaping has been described as:

“developing appropriate behaviour by reinforcing successive approximations to the desired behaviour until the desired behaviour is achieved”.

During this process the aim is to discourage behaviour that is not conducive to what we are trying to achieve. The process of behaviour-shaping usually involves a basic “tell, show, do” approach, but with desired behaviour being encouraged, or “reinforced” by strategies such as praise and approval, and with undesired behaviour being made less likely to occur, or “extinguished” by discouraging or ignoring it. The key psychological principle of this type of strategy is the phenomenon of “reinforcement”, which is where a pattern of behaviour is strengthened in such a way that it increases the probability of that behaviour being displayed again in the future.

1. ‘Tell, Show, Do’

This popular technique can be highly successful in providing a simple strategy to overcome the fear of the unknown (Addleton 1959). This experience helps to shape the patient’s response to procedures through de-sensitisation, well-described action and visual tactile demonstrations. The first part is to ‘Tell’: explaining the procedure using simple vocabulary suited to the child’s age; this is followed by ‘Show’: providing a demonstration. With the final stage “Do!”: here the procedure is performed. A simple example which can be used on any patient is the prophy brush. The aim is to teach the patient the importance of the dental procedure, and to familiarise the patient with this to facilitate acceptance of the treatment.

• Tell – Describe what is to happen
• Show – Demonstrate the procedure
• Do – Do it!

2. Positive Reinforcement

This is the process of providing appropriate feedback to the patient, including use of facial expression, verbal expression and appropriate physical demonstrations of affection by members of the dental team which can aid treatment success.

Descriptive phrases can emphasise a specific cooperation “ Thank you for opening your mouth so wide” “You’re doing very well keeping still” rather than generalised praise such as “ Well Done”, and can reinforce a desired behaviour.

These reinforcement techniques are more effective than stickers and gifts which are less specific, with access to activity post treatment (TV, toys etc.) are usually out of direct control.

3. Negative Reinforcement Techniques – (parent in/parent out)

Negative reinforcement is the reinforcement of a behaviour by removing something which is perceived as negative by the patient as soon as positive behaviour is exhibited.

For example, if a parent has agreed to leave the surgery due to negative behaviour by the patient, allowing the parent to come back in as soon as the patient shows positive behaviour means that the negative (the parent being outside) is removed, thus reinforcing the positive behaviour.

4. Enhancing Control

A simple option to enhance control is to provide the child with a stop signal such as raising of the arm. This behaviour management technique provides a degree of control through the period of treatment.

It is essential to practice this with the child prior to treatment so the dentist can respond. The dentist must respond promptly when used. It is worth noting that some patients may use this as a distraction technique in an attempt to delay treatment.

5. Ask, Tell, Ask

It is important to build up a conversation with patients and develop a rapport to gauge how they might find each part of the treatment in order to help to address any challenges that may arise. A simple exercise is to ask the patient about the proposed treatment, tell them in simple language and ask how they feel about that and whether they would they be able to manage that treatment, then reassess at the end by asking anything else.

This teaches the patients about the proposed procedure and how this will be achieved. It is important to establish whether the patient is comfortable with the proposed treatment prior to commencement to maintain clear communication.

6. Distraction

This form of behaviour management is where the attention is drawn to a totally different sensation or action, in order to divert attention from a potentially stress-inducing procedure. Whilst it is important not to breach trust by deliberately trying to deceive a child, distraction of attention from one thing to another can be useful. For example, drawing attention to the sensations of lip pulling, etc. during local analgesic needle penetration. Giving the patient a short break during a stressful procedure can also be an effective use of distraction.

7. Positive Pre-visit Imagery

For some children, a change to a routine can be extremely distressing; to support these patients visual aids can be provided such as positive photographs of dentistry and the clinic to provide children and parents with visual information about what to expect during the dental visit.

8. Modelling

Modelling is an effective form of behaviour management which follows the physiological principle that children learn about their environment by observing behaviours.

A child would observe the behaviour exhibited by another patient (usually someone who is relatable e.g. sibling or friend of similar age). This theory maintains that by observing a behaviour the likelihood of that observed behaviour being adopted is increased.

This behaviour management strategy would familiarise the patient with the specific steps involved in the proposed dental treatment.

9. Systematic Desensitisation

The basic principle of this technique is to allow a patient to gradually come to terms with a particular fear or phobia by repeated contacts. A hierarchy of fear-producing stimuli is constructed and the patient is exposed to them in an ordered manner starting with the lowest threat.

Dental Update 2015: provides a simple overview for the use of this technique on local anaesthetic. The technique is useful for a child who can clearly identify their fear and who can verbally communicate. In most cases simple dental-based acclimatisation should be initiated first.

10. Parental Involvement

Parental behaviour and attitudes towards dentistry have been shown to have key effect on a child’s behaviour and anxiety regarding dental treatment. It is important to provide specific information about the parental role during dental treatment.

Parents that frequently interrupt the flow of communication during treatment can cause distraction and confusion and lead to disruptive behaviour. Parents’ attempts of non-dental chit-chat or instruction/encouragement to the child are often provided in an attempt to help, but can expose parents’ own underlying anxieties about dental treatment.

Children are very perceptive to parental non-verbal and verbal anxieties. Frankl explains the importance of how a passively observing mother can aid a child, and provide support as the “silent helper”.

This a good form of behaviour management as having parents in the surgery can help avoid any misunderstanding if a child becomes upset during dental treatment, and helps parents to appreciate how well their child has tolerated treatment or to recognise the limitations of their compliance.

11. Voice Control

Voice control is the deliberate alteration of voice volume, tone and pace to influence a child’s behaviour. It has been shown that young paediatric patients respond to the tone of voice rather than the choice of vocabulary. It is useful for the cooperative but inattentive child; however is inappropriate for children who are too young to understand or who have either an emotional or intellectual impairment. This method of behaviour management is unlikely to be acceptable to most modern parents.

In the very young, and pre-cooperative child, the knee to knee exam is a successful technique to aid clinical assessment.

For some children there is limited compliance in mouth opening. In such cases, a Bedi Mouth Prop can be used, which is used for the administration of medicine. The prop can be a useful aid when held on the finger for a dental exam. These disposable items can be given to the parent to aid those who may need extra help with tooth brushing.

Frankl, S.N., (1962). Should the parent remain with the child in the dental operatory?. J. Dent. Child., 29, pp.150-163.

Fayle, S.A. and Tahmassebi, J.F., (2003). Paediatric Dentistry in the new millennium: 2. Behaviour management–Helping children to accept dentistry. Dental update, 30(6), pp.294-298.

Taylor, G.D. and Campbell, C., (2015). A clinical guide to needle desensitization for the paediatric patient. Dental Update, 42(4), pp.373-382.

Addelston, H.K., (1959). Child patient training. Fort Rev Chicago Pent Soc, 38, pp.27-29.

Fenlon, W.L., Dabbs, A.R., Curzon, M.E. and Dobbs, A.R., 1993. Parental presence during treatment of the child patient: a study with British parents. British dental journal, 174(1), pp.23-28.

Guideline on Behaviour Guidance for the Paediatric Dental Patient http://www.aapd.org/media/policies_guidelines/g_behavguide.pdf