INTRODUCTION TO
DENTAL SURGERY
PSYCHOLOGY OF CHILD
DEVELOPMENT
Was thought of as series of well-defined phases
Continuous process
Development ---- lifelong process which is uneven and Influenced
by periods of rapid bodily changes
John Bowlby’s attachment theory
• Child development could best be understood within the framework
of patterns of interaction between the infant and the primary
caregiver.
• If there were problems in this interaction, the child was likely to
develop insecure and/or anxious patterns that would affect the
ability to form stable relationships with others, to develop a sense of
self-worth, and to move towards independence.
PSYCHOLOGY OF CHILD
DEVELOPMENT
The psychological literature contains many details of the
changes accompanying development.
A general outline of the major ‘psychological signposts’ of
which the dental team should be aware is presented in next
section
MOTOR DEVELOPMENT
• Develop rapidly
• By age 2 the majority of children can walk
• Eye–hand coordination gradually becomes more precise and
elaborate with increasing experience
• The dominance of one hand emerges at an early age and is
usually linked to hemisphere dominance for language
processing
CONT’D
• Children aged 6–7 years usually have sufficient coordination
to brush their teeth reasonably well
• Preventive guidelines recommend parental involvement in
brushing prior to age 7 years and supervision of brushing
thereafter
COGNITIVE DEVELOPMENT
The Swiss psychologist Piaget formulated the ‘stages view’
of cognitive development on the basis of detailed
observations of his own children and suggested that children
pass through four broad stages of cognitive development
Also known as Piaget’s stages
PIAGET’S STAGES
SENSORIMOTOR
• This stage lasts until about 2 years of age.
• The prime achievement is ‘object permanence’.
• The infant can think of things as permanent—which
continue to exist when out of sight—and can think of objects
without having to see them directly
PIAGET’S STAGES
PREOPERATIONAL THOUGHT
This runs from 2 to 7 years of age
Cognition further developed allowing to predict outcomes
of behaviour
Thought patterns are not well developed --- being
egocentric, unable to encompass another person’s point of
view, single-tracked and inflexible (sums up most politicians,
some dental professors, and hospital administrators)
PIAGET’S STAGES
CONCRETE OPERATIONS
This stage runs from 7 to 11 years of age
Children can apply logical reasoning
Can consider another person’s point of view
Can assess more than one aspects to a particular situation
Can understand that areas and volumes remain the same despite
changes in position or shape.
PIAGET’S STAGES
FORMAL OPERATIONS
Last stage in the transition to adult thinking ability
This stage runs from 11 years onward
Development of logical abstract thinking occurs so that
different possibilities for an action can be considered.
PERCEPTUAL DEVELOPMENT
Studies have shown that, with increasing age, scanning
becomes broader and larger amounts of information are
sought
Compared with adults, 6-year-old children cover less of
the object, fixate on details, and gain less information
By the age of 7 years, can determine which messages
merit attention and which can be ignored
Parents should be the main focus of any information
given on oral healthcare at this stage
By 9 years of age, child becomes more efficient in
discriminating between different visual patterns
The majority of perceptual development is a function of the
growth of knowledge about the environment in which a
child lives, hence the necessity to spend time explaining
aspects of dental care to new child patients
LANGUAGE DEVELOPMENT
A lack of appropriate stimulation will retard a child’s
learning, particularly language.
Newborn children show a remarkable ability to distinguish
speech sounds, and by the age of 5 years most children can
use 2000 or more words
Dentistry has a highly specialized vocabulary
The key to successful communication is to pitch your advice
and instructions at just the right level for different age
groups of children
Communication is more than the words we use, and for
children with limited vocabularies, the tone and body
language are as important as the words
ADOLESCENCE
• The waning of parental influence can be seen in the final stage
of child development—adolescence
• It is conceptualized as a period of emotional turmoil and a time
of identity formation
• However, in most societies, childhood ends and adult
responsibilities are offered at a relatively early age
• Treat them as independent from their parents and recognize
them as individuals in their own right
• Don’t criticize them excessively as this may compromise their
future oral health
• These patients are looking for support and reassurance.
• Remember that their personal behavior patterns are usually not
related to health issues.
PARENTS AND THEIR INFLUENCE
ON DENTAL TREATMENT
Socialization
Primary socialization can have a profound and lasting effect
Every attempt should be made to involve parents when attempting
to offer dental care or change a child’s health habits
PARENTS AND THEIR INFLUENCE
ON DENTAL TREATMENT
Avoid victim blaming
Positive reinforcement rather
victim blaming
Programs designed to reduce
parental guilt and guiding
families in improving oral
hygiene of their children
Brushing charts, gold star for
brushing, extra pocket money,
diet sheets are all useful tips
for parents
SHOULD PARENTS JOIN
CHILDREN IN THE SURGERY?
One of great debate
Arguments have been given both for and against it
CONT’D
DENTIST–PATIENT
RELATIONSHIP
Each patient is a unique individual
People like friendly dentists
STRUCTURE OF THE DENTAL
CONSULTATION
Greeting
Preliminary chat
Preliminary explanation
Business
Health education
Dismissal
?
GREETING
Greet the child by name
Avoid using generalised terms such as “Hello, sunshine”
If parents are present, include them in the conversation but
child should be central to developing relationship
A greeting can be spoilt by proceeding too quickly to an
instruction rather than an invitation
The greeting should be used to put the child and parents at
ease before proceeding to the next stage
PRELIMINARY CHAT
Has three main objectives:
To assess whether the patient or parents have any
particular worries or concerns
To settle the patient into the clinical environment
To assess the patient’s emotional state
Begin with non dental topics
Ask open questions
By talking generally and taking note of what the child
is saying you are offering a degree of control and
reducing anxiety
PRELIMINARY EXPLANATION
To explain what the clinical or preventive objectives are in
terms that parents and children will understand
Establishes the credibility of the dentist as someone who
knows what the ultimate goal of the treatment is, and is
prepared to take the time and trouble to discuss it in non-
technical language
BUSINESS
Give clear instructions
Avoid the trap of asking questions which cannot be
answered because of a mouthful of instruments
But avoid silence and underline and praise behavior that is
helpful
At the end of the business stage, summarize what has been
done and offer aftercare advice.
HEALTH EDUCATION
The key ways to improve the value of advice sessions are as
follows.
(a) Make the advice specific; give a child a personal problem to solve.
(b) Give simple and precise information.
(c) Suggest goals of behaviour change that the patient has capacity to
achieve.
(d) Check that the message has been understood and not misinterpreted
(e) Offer advice in such a way that does not threaten or blame the child or
parent.
(f) Avoid theoretical discussions; offer a practical demonstration, for example
oral hygiene.
(g) At follow-up visits reinforce the advice and offer positive reinforcement.
The final part of the health education activity ---- goal-setting.
The dentist sets out in simple terms what the patient should try to
achieve by the next visit
DISMISSAL
Final part of the visit and should be clearly signposted so
that everyone knows that the appointment is over
The patient should be addressed by name and a definite
farewell offered
The objective should be to ensure that patient and parents
leave with a sense of goodwill
Clearly, not all appointment sessions can be dissected into
these six stages.
However, the basic element of according patient the
maximum attention and personalizing your comments
should never be forgotten.
ANXIOUS AND UNCOOPERATIVE
PATIENT
Anxiety
A vague unpleasant feeling accompanied by a premonition that
something undesirable is going to happen
Multifactorial problem made up of a number of different
components, all of which can exert an effect.
Despite the dental team’s best efforts, anxiety may persist and
routine dental care is compromised
An increasingly popular choice is the use of pharmacological
agents
APPROACHES TO MANAGING
ANXIETY
Alternatives to the pharmacological approach are:
1. Reducing uncertainty
A. Tell-show-do
Tell: Explanation of procedures at the right
age/educational level.
Show: Demonstrate the procedure.
Do: Following on to undertake the task. Praise is
an essential part of the exercise
B. Behaviour shaping & positive reinforcement
Acclimatization programmes --- gradually
introducing the child to dental care over a number of
visits have been shown to be of value
APPROACHES TO MANAGING
ANXIETY
Reinforcement --- in the form of praise
Reinforcers work best immediately after the required
behaviour, so continuous praise throughout the
appointment highlighting the desired behaviour and
ignoring undesired is recommended.
Time consuming and does little for the really nervous
child
C. More information for parents
Send a letter home explaining all the details of the
proposed first visit
Parental anxiety, rather than the child’s anxiety, is
changed by pre-information
APPROACHES TO MANAGING
ANXIETY
2. Modelling
Modelling makes use of the fact that individuals learn much
about their environment from observing the consequences of
other people’s behaviour
A child could be shown that it is possible to visit the dentist,
have treatment, and then leave in a happy frame of mind, which
reduces anxiety due to ‘fear of the unknown’
Following points should be taken into consideration when
setting up a programme
Ensure that the model is close in age to the nervous child
The model should be shown entering and leaving the surgery to prove
that treatment has no lasting effect
The dentist should be shown to be a caring person who praises the
patient
APPROACHES TO MANAGING
ANXIETY
3. Cognitive approaches
A number of cognitive modification techniques have been
suggested, the most common of which are:
Asking patients to identify and make a record of their negative thoughts
Helping patients to recognize their negative thoughts and suggesting
more positive alternatives—‘reality based’
Working with a therapist to identify and change the more deep seated
negative beliefs
Distraction --- another form of cognitive approach
Involves shifting attention from the dental setting towards some
other kind of situation
Cartoon videos help children cope with dental treatment and
threat to switch off the video usually required to maintain
cooperation
APPROACHES TO MANAGING
ANXIETY
4. Relaxation
Consists of bringing about deep muscular relaxation
Requires the presence of a trained therapist
Usually not done in paediatric dentistry clinic
5. Systematic desensitization
Involves allowing the patient to come to terms gradually
with a particular fear or set of fears by working through
various levels of the feared situation, from the ‘mildest’ to
the ‘most anxiety’
APPROACHES TO MANAGING
ANXIETY
6. Protective stabilization
Involves physical restraint of children in order to undertake
clinical dental care
Controversial
APPROACHES TO MANAGING
ANXIETY
Reducing uncertainty
Modelling
Cognitive approaches
Relaxation
Systematic desensitization
