Psychological approach to children in dental practice

Psychological approach to children in dental practice

Caring for children is a real challenge for the dentist.

The practitioner often finds himself helpless when faced with the latter’s cries and the parents’ anxiety.

Understanding the child’s cognitive and psychomotor development is the key to successful care.

For this, the practitioner has several behavioral techniques and different approaches depending on the age and character of the child.

1 – Child development:

Child development can be divided into four major periods.

A – Early childhood: from 0 to 2 years old

This period corresponds to Freud’s “oral phase.” The mouth (through sucking) is the primary organ, and it is through it that the child discovers his environment and pleasure.

According to Piaget, this is the stage of intelligence where the child uses perception (for example, reaching for a distant object), and therefore cannot understand the benefit of care.

During these first two years, the child gradually moves from a relationship of total dependence on his mother to a very relative autonomy which allows him to explore the world around him.

To cope with the absence of his mother, the child uses a transitional object, generally called a “comforter,” which can take different forms: a piece of fabric, an item of clothing, or, of course, a stuffed toy. This object comforts and reassures him.

Around the age of 2, he acquires the notion of cause and effect.

The child is afraid (normal at this age) of sudden, noisy, or bright stimuli, as well as of separation and confrontation with strangers. This is a manifestation of developmental anxiety related to self-awareness and socialization processes. Crying is primarily a sign of discomfort.

At the dental office : certain rules can make this first examination easier

• The infant should not be separated from its mother; she carries it lying on her to facilitate the examination.
• The child can also be lying with their head on the practitioner’s lap and their feet on the parent’s lap, which allows them to be in constant visual and physical contact with them.
• The mother or father speaks to him, tells a story in a soft voice to soothe any anxiety.
• The child expresses disapproval of being held in the chair, even by one of his parents, and of opening his mouth. This must be accepted.
• He is unable to understand the benefit of care and cannot consciously cooperate. It is therefore useless to try to reason with him or negotiate with him. But voice modulation can help capture his attention;
• It is important to avoid sudden movements and to anticipate possible reactions to noise and light.
• The practitioner focuses on his little patient and should not be disturbed by parents or staff.
• The session should be short;
• The best time of day for the appointment is in the morning.

B- The preschool period: from 2 to 6 years old

⇒ Between 2 and 4 years:

• According to Freud, this is the anal stage (acquisition of cleanliness), where he acquires sphincter control.
• Around the age of 2, the child appropriates the “I” which allows him to position himself in relation to a third party.
• Around the age of 3, he is exuberant, curious and tries to develop his dominant power; this is the “opposition phase”.

The adult is a source of frustration that limits his actions by often telling him no, he then takes ownership of the “no” and becomes capable of formulating it himself.

The child becomes more physically independent and more exploratory, and functions a lot by imitation.

He continues to exhibit developmental anxiety; this is the time of fear of animals, the dark, fire, threats of danger, imaginary creatures, bodily injury, thieves, and death.

He needs rituals, habits that accompany important moments of the day (meals, bath, falling asleep, etc.) and which help to reassure him, particularly at bedtime.

These developmental rituals decrease between the ages of 4 and 6 and disappear around the age of 8.

At the dental office :

• The child is still very dependent on his parents who remain in the treatment room.
• His ability to pay attention is poor.
• He has no notion of time and the duration of the different operating stages can be counted aloud by the practitioner.
• The practitioner should arouse his curiosity, describe the procedures and ask him to give his own description.
• You have to let him help you: hold a roll of cotton, for example.
• The establishment of “rituals” allows him to be reassured.
• It is always best not to choose appointments during nap times and at the end of the day, periods when the child is particularly irritable.

⇒ The period between 4 and 6 years

• The child begins to identify as a person in his own right, he has a feeling of omnipotence, authoritarian, dominant and impatient.
  • He may have some willingness to be independent and to help.
  • His language is developing and his curiosity is limitless, it is the age of “why?”.
  • He is proud of his family, himself and his achievements.
  • At the end of this period, he begins to have a notion of social limits and prohibitions.

At the dental office:

• A child who is accompanied by a parent at the first session may come alone later.
• The practitioner can show interest in what he wears as clothing and highlight it (especially in girls).
• The child’s attention can be captured by curiosity.

It is important to talk, to explain with pictures and to use stories or characters that he particularly likes and with whom he readily identifies.

• You need to encourage them to help: “I need your help to fix your tooth,” and allow them to participate in the treatment by holding the mirror or a cotton roll.
• The practitioner describes the procedures. To explain the placement of the surgical field, he may say:

“The bandage cannot stick if the tooth is wet.”

• You have to appeal to his vanity: “A dirty tooth…, I’ll clean it and put a pretty pearl in it,” but don’t humiliate him.
• The concept of time is not yet well established. The practitioner works without stopping, avoids breaks, and does not lose control. He constantly channels the child and explains to him that “he is not here forever,” “that it’s like school, once it’s over, he goes home.”

C- The school period: from 7 to 11 years old

• Once in school, the child can remain in the same position for a long time.
• Around the age of 8 or 9, he demands responsibility. He argues and demands things. You have to be firm to ensure he respects the rules.
  • At 10 years old, he shows great emotional and character stability. He accepts discipline and needs a certain direction.
  • At the end of this period, he wants to take charge of himself and others. He is cooperative and likes to be considered a “big boy.”
  • Around the age of 11 or 12, it’s the threshold of adolescence. The child is capable of bursting into tears.

At the dental office

• From 6 to 8 years old, the practitioner identifies subjects that are particularly popular with children; the theme can serve as a common thread throughout the treatment session.
• At this age, he may refuse the effort of the treatment session with phrases like “I don’t want to” or “I don’t want to” and thus defy authority.

The practitioner must find the flaw that will make him give in by appealing to his self-esteem, his pride or his courage.

• At 11 years old, children like to be trusted. But the practitioner must not forget that they are still children with limitations.

D- Preadolescence and adolescence: from 12 to 15 years old

Physical, emotional and hormonal changes make children more or less confused.

It is marked by withdrawal and difficulties in socialization.

It can cause discomfort, low self-esteem and poor body image.

It also corresponds to the period when the use of care is the lowest. The adolescent is not very sensitive to the notion of risk, he will refuse care and dental hygiene.

He likes to define himself as independent from his parents and rejects the parental model, but he needs to be constantly reassured and motivated.

He often opposes adults who “do not understand” him and the practitioner himself is no exception.

At the dental office.

Adolescents are often difficult to motivate unless they have serious problems.

It is important not to openly criticize him or “forbid” him or demonize sugar, but to give him explanations because he has reasoning and deduction skills.

Motivation for oral hygiene should be discussed at each appointment, especially if orthodontic treatment is in progress.

Beware of dental signs that reflect psychological pathologies (bulimia) or addictions (alcohol, tobacco)

2.  The care relationship

It involves three partners: the child, the parents and the practitioner.

1.  A child-centered relationship:
   • Be attentive to the child’s needs and meet their expectations,
   • Analyze your behavior
   • Being empathetic:

⇒ I understand you, I know it’s difficult

⇒ I know you’re scared

⇒ I understand that you are afraid.

But that doesn’t mean you have to accept everything from him. He has to follow certain rules, and he knows it.

2.  The mother

⇒ Overprotective mother: is too present and too possessive. She maintains a close bond with her child, a mother who needs to be reassured, a source of stress for her child, will not be present during the treatment session.

⇒ Permissive mother: behaves indulgently, accepting her child’s whims and mood swings. The practitioner must be firm and directive with her and her child; she must not be present during treatment.

⇒ Authoritarian mother: controls and imposes the child’s behavior according to an “absolute standard”. Make the mother aware of the need for a behavioral approach during care.

⇒ Caring mother: is emotionally available to her child and knows how to value them. Available and attentive, it helps the practitioner during care procedures.

3.  The practitioner

He must be neither too empathetic nor too demanding, otherwise he will fall into therapeutic obstinacy which results in a feeling of incompetence.

3.  Managing child behavior in the dental office:

The child in the dental office is influenced by stimuli

• Auditory – visual – olfactory
• Technology…
• The new asepsis rules,
• And the waiting room….

The practitioner has two techniques at his disposal to familiarize the child with this environment which could seem aggressive to him:

1.  Communication techniques

They help the child develop a positive attitude towards dental care, they can be used simultaneously

1. Non-verbal communication,
2. The “explain-show-do” technique, tell-show-do
3. Distraction
4. Positive reinforcement.
5. Nonverbal communication:

The gaze: eye contact with the child at his/her height (Looking at him/her means that we are giving him/her our full attention).

⇒ Professional attire;

⇒ The smile;

⇒ Touch: It reinforces the verbal message and allows you to show attention.

It is taking the child’s hand, stroking their cheek or placing your hand on their shoulder. It also serves to contain aggression;

⇒ The listening attitude: the position of the body slightly inclined forward, like the head, is a sign of understanding on the part of the practitioner;

⇒ Communication distance: distant at the beginning, gradually reduced;

⇒ Voice modulation: raise your tone to capture attention, lower it to calm it down;

2. The “Tell-Show-Do” technique:

To give verbal explanations of what is going to be done with figurative vocabulary adapted to the child’s age, Talk about:

⇒ Mr. Wind for the air syringe,

⇒ The shower for the spray,

⇒ Umbrella or tooth dress for the dam,

⇒ The magic potion that puts teeth to sleep for anesthesia…;

To show the different aspects of the instrument used during the procedure just described:

⇒ Visual, by presenting the instrument,

⇒ Auditory, by making it work,

⇒ Tactile, by making the child touch it,

⇒ Olfactory and gustatory (contact anesthesia or prophylactic paste).

It is not about deceiving the child but about softening the reality.

c. Distraction: An effective verbal technique for young children

This involves diverting the young patient’s attention at a time when he is likely to feel uncomfortable and getting him interested in something pleasant (questions about his toys, his pet, his holidays, the clothes he is wearing).

d. Positive reinforcement:

Encourage and reward the child: “I appreciate the way you open your mouth to help me”, “I thank you for helping me”, a reward can be offered.

2.  Behavior control techniques:

These are techniques that can be used with all children, but some that may seem aggressive require parental consent.

The choice of method depends on the child’s initial behavior

1. The stop signal
2. Modeling
3. Voice control
4. HOME = Hand Over Mouth Exercise
5. The stop signal:

If the child feels any discomfort, they can interrupt the session.

The practitioner must make him understand that he trusts him and that he must tell the truth and not deceive him.

If there is any doubt about the reality of the answer, he can always place the contra-angle on an adjacent tooth…

2.  modeling

The patient learns to behave in the chair by observing another calm, cooperative child receiving treatment.

If he’s particularly young, grooming the doll can also help gain his trust.

3.  Voice Control:

When the child begins to become uncooperative, raising the voice abruptly can create a surprise effect and make the child stop. Once calm is achieved, the practitioner resumes a normal tone.

This method requires parental consent, especially if it is to be applied throughout the treatment, especially for a difficult child.

4.  HOME or Hand Over Mouth Exercise:

Proven technique for intercepting inappropriate behavior in the dental office.

It is used when basic behavioral approach techniques are no longer effective.

Its goal is to help a hysterical, noisy, or unruly child regain composure so that communication techniques can be re-implemented.

It should only be used in this case and with a child old enough to understand the intended purpose, and with parental consent ++++++++++++

The screams are contained by the practitioner’s hand, applied firmly but without brutality, the patient is held by the assistant, the dental surgeon shows that he is the master of the situation.

The patient’s file must contain informed consent from the parents before any use of this technique.

When faced with a particularly anxious or even phobic child, treatment requires specialized techniques that require specific training or the use of a specialized practitioner: these include relaxation, hypnosis, and behavioral therapies.

4. Interest of the first consultation:

We must not forget that it is not the child who decides to come to the dentist but the adult who takes him there… He has no choice!

The first consultation is essential and determines the future relationship between the child and their practitioner, and the practitioner will not have a second chance to “make a good impression.”

The first impression: identifies the behavior of the child and his parents in order to adapt appropriate behavioral support

Introduce the rotary instruments, suction, polish with a brush and suction in the mouth to accustom the child to the noise and sensations

Motivation for food and oral hygiene

Conclusion :

The care of children in the dental practice presents specificities related to their emotional immaturity and psychological characteristics.

The practitioner must adapt his behavior and adopt a reassuring and caring attitude to reassure the child and gently introduce him into the treatment protocols.

Psychological approach to children in dental practice

  Untreated cavities can cause painful abscesses.
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Misaligned teeth can cause digestive problems.
Dental implants restore chewing function and smile aesthetics.
Fluoride mouthwashes strengthen enamel and prevent cavities.
Decayed baby teeth can affect the health of permanent teeth.
A soft-bristled toothbrush protects enamel and sensitive gums.
 

Psychological approach to children in dental practice