IOSR Journal of Dental and Medical Sciences (IOSR-JDMS)

e-ISSN: 2279-0853, p-ISSN: 2279-0861.Volume 18, Issue 5 Ser. 10 (May. 2019), PP 18-21
www.iosrjournals.org

Recent Advances in Non-Pharmacological Behaviour

Management Techniques in Children – An Overview
Swarna K1, Prathima GS2, Suganya M3, Sanguida A4, Selvabalaji A5
1,2,3,4,5
Department of Paedodontics and preventive dentistry,Indira Gandhi Institute of Dental Sciences, Sri
Balaji Vidyapeeth (Deemed to be University),Puducherry, India

Abstract: A proper communication combined with a caring attitude develops sound rapport with any
paediatric patient. Non-pharmacological behaviour management techniques enable paediatric dentists to
successfully alleviate behavioural problems by matching their selection of techniques to that of the child’s style
of interaction. On the other hand, few aggressive techniques applied in childhood have been implicated as being
prominent factors in the behaviour of developed adult patients with dental phobias. The aim of instilling positive
reinforcement is achieved by conventional methods but disruptiveness increase with increase in treatment time.
Hence, to overcome this disadvantage newer non-threatening techniques were handled by the paediatric
dentists, which provide long time reinforcement in younger children. This review will focus on enumerating the
recent advances in non-pharmacological behaviour management techniques in children.
Keywords: Audiovisual distraction, Distraction, Virtual reality, Videogames
----------------------------------------------------------------------------------------------------------------------------- ----------
Date of Submission: 07-05-2019 Date of acceptance: 23-05-2019
---------------------------------------------------------------------------------------------------------------------------------------------------

I. Introduction
Successful management of the child patient depends on the ability of the dentist to satisfy immediate
dental needs which emphasize on enhancing the communication and partnering with the child and parent to
promote a positive attitude and good oral health. 1 Behaviour management or child management in the dental
office refers to methods of obtaining a child’s approval of treatment in the dental chair which is based on proper
communication, patient/ parent education with empathy, coaching and listening. 2 The concept behind guiding a
child’s behaviour is treating them rather than just operating the tooth alone.3
Wright (1975) defined behaviour management as the means by which the dental health team effectively
and efficiently performs treatment for a child patient and at the same time instills a positive dental attitude. 2
The commonly used non pharmacological behaviour management techniques are Tell-Show-Do, Non
verbal communication, Voice control, Modelling, Distraction, Positive reinforcement, Hand Over Mouth
Exercise and Protective stabilization.4 Even though these conventional techniques are effective in guiding
children, the invasiveness involved in some techniques limits the acceptability which in turn leads to the
invention of newer non-invasive behaviour management techniques for children. This review article aims in
enumerating the recent advances in non-pharmacological behaviour management techniques for children in the
dental operatory.

II. Material And Methods

The purpose of the present review article is to elaborate the recent advances in non-pharmacological
behaviour management techniques in children. A search on the Pubmed electronic database from 2009 to 2018
was done using the terms: Behaviour and Children, Behaviour management in children, Behaviour management
and Paediatric dentistry, Child behaviour and Paediatric dentistry, Child behaviour and Dental anxiety,
Behaviour management in Dentistry, Non pharmacological behaviour management and Paediatric dentistry,
Child management and Paediatric dentistry, Behaviour modification and Children, Virtual reality and Dentistry,
Audiovisual distraction for children, Videogames and Distraction, Videogames and Virtual reality. Only
articles that pertain to recent behaviour management techniques were included in this review.

III. Background
Behaviour guidance is a comprehensive, continuous technique employed to initiate and nurture the
child-dentist relationship. It aims to establish better communication, alleviate fear and anxiety, deliver quality
dental care, build a trusting relationship between dentist and child and to instill a positive dental attitude towards
oral/dental health and oral health care (AAPD Reference Manual, 2011). The outcome of these techniques could
maintain a proper communication or extinguish disruptive behaviour related to dental treatment. It could be a
combination of behaviour guidance approach individualized for the child. The behaviour guidance techniques
DOI: 10.9790/0853-1805101821 www.iosrjournals.org 18 | Page
 Recent Advances in Non-Pharmacological Behaviour Management Techniques in Children – An ..

should enhance the communication in both cooperative and uncooperative children. Recently technologies were
combined with the behaviour guidance to improve the communication and enhance positive dental attitude in a
stress-free way.5

IV. Recent behaviour management techniques

1. Tell- Play- Do:
The commonly used behavior guidance technique namely Tell- Show-Do was modified by
Vishwakarma AP as Tell-Play-Do in 2017 for children aged 5-7 years. The technique was similar to Tell-Show-
Do but an additional component of allowing the child to play with dental equipments was carried in Tell-Play-
Do. As per the learning theory of Bandura, the child’s anxiety towards the dental equipments reduces, thereby
feels more comfortable and develops cooperative behavior. 6 Since only one study has been reported in literature,
further research is recommended to assess its effectiveness in the dental set-up.

2. Mobile dental app:

In 2017, Patil VH et al utilized mobile dental app for reducing fear and anxiety in children in the dental
set up. An interactive session of using the dental application during the treatment was allowed and the children
were virtually made dentists and allowed to provide different treatments through the application. 7 By this
technique, the fear towards different dental instruments and its use in children could be reduced and more
cooperative behaviour could be achieved. Mobile dental application could be used as an adjunct behaviour
management technique however further research is needed.

3. Audiovisual distraction:
Audiovisual distraction involves the concept of imagery and distraction delivered via audiovisual aids,
thereby removing the focus on the dental procedures, avoiding anxiety provoking stimuli and providing a
relaxing experience throughout the procedure.8
The goals of audiovisual distraction are imagination (helps in distracting children from present
situation), engagement (enables children’s attention to focus on a single thing) and motivation (helps children to
encourage getting treated for dental problems in future). 9
a. Management of dental anxiety: A systematic review by Barreiros D 2018 concluded that audiovisual
distraction is effective in controlling dental anxiety in children.10 Al-Khotani A et al 2016 used videotaped
cartoons for reducing anxiety in children aged 7-9 years during restorative procedure. 11 Kaur R et al 2015
compared audio and audiovisual distraction for reducing anxiety in children during their first dental visit
and found audiovisual distraction reduced anxiety in anxious dental patients. 12
b. Management of pain: Oliveira NCAC et al 2016 found audiovisual distraction could reduce the intensity
of pain during painful puncture procedures.9 Nuvvula S et al 2015 used three dimensional audiovisual
distraction to reduce anxiety during local anaesthesia administration. 13 Fakhruddin KS et al 2015 used
audiovisual distraction with and without video eyewear to reduce dental anxiety in children during
computerized delivery of anesthesia.8 Mitrakul K et al 2015 used audiovisual eyeglasses for reducing pain
and anxiety during restorative treatment in 5-8 year old children.14

Thus, Audiovisual distraction could be an effective method for managing dental anxiety and pain related to
dental procedures.

4. Videogame distraction:
Even though there are a wide range of behaviour management techniques available for managing
highly anxious children, it was impossible to divert the child’s attention during pain perception in invasive
procedures.15
The use of videogame as a distraction tool is based on the principles of cognitive- behavioural therapy
and neurofeed back mechanism for children with anxiety disorders. 15 Videogames are interesting and commonly
available media, which can help in implementing distraction in children by active participation of the child
during the dental procedure.16
a. For health promotion: Aljafari A et al 2017 used Oral health education related videogames for promoting
healthy diet and good oral hygiene for high caries risk children.17
b. Management of dental anxiety: Ko JS et al 2016 used Ipads for reducing anxiety in children during their
orthopaedic visits.18 Sil et al 2013 and Wohlheiter KA et al 2013 used videogames to reduce pain perception
during cold-pressor trials.19,20
Videogames could be an effective distractor and improve oral health related outcomes, however extensive
studies in its applicability in the field of pediatric dentistry is required.

DOI: 10.9790/0853-1805101821 www.iosrjournals.org 19 | Page

 Recent Advances in Non-Pharmacological Behaviour Management Techniques in Children – An ..

5. Virtual reality based distraction:

In 1968, Ivan Sutherland and Bob Sproull invented virtual reality with a head mounted device that was
connected to a computer. Later in 1998, Heim described virtual reality as an interactive computer based
software that can be used to immerse children in the virtual environment which completely obstructs the present
situation.21 The VR equipment contains head mounted display and a tracking device. The head mounted device
contains the display screen which provides the view of virtual reality environment in a 360 0 view. The tracking
device monitors the head movements. The equipment provide an attachment for mouse, joystick or dataglove for
playing games.22

Uses of Virtual reality:

a. For distraction:
The virtual reality environment has abilities to withdraw attention of the child from the thoughts that
are associated with the treatment and provide interactive distraction in a virtual environment. In 2014, Tanja-
Dijkstra K et al used virtual reality distraction for reducing anxiety towards previous dental experiences. 23
Dahlquist LM et al 2010 evaluated videogame and virtual reality with and without head mounted display and
found virtual reality with head mounted display could reduce pain tolerance during cold pressor trials. 24 Factors
that influence the distraction using virtual reality device are the level of interest shown by the child and the level
of immersion of the child into the virtual world.

b. Minor procedures:
Researchers used virtual reality environment for children undergoing invasive procedures requiring
administration of anaesthesia and found there was an improvement in subjective pain tolerance to injections,
anxiety and behaviour stress reduction levels in children and parents. In 2011, Hoffman et al showed that virtual
reality reduced pain perception in children by reducing pain related brain activity. 25 Studies such as Shiri et al,
Ramachandran VR et al and Patterson DR et al concluded that virtual reality could reduce the intensity of pain
in patients with chronic illness.26,27,28 The pain perception in children while using virtual reality was relatively
low compared to conventional techniques.

Contraindications of Virtual Reality:

1. Medically compromised children especially children with epilepsy, migraine and vestibular disturbances.
2. Children with previous history of nausea or dizziness following the use of VR device. 22

Virtual reality technology, an emerging field in the management of pain and anxiety could be used in dental
operatory and clinical studies were indicated to solidify the effect of VR in dental situations.

V. Conclusion
The recent technologies such as audiovisual aids, videogames, mobile apps and virtual reality can be
used as an adjunct for conventional techniques due to its immersive, interesting and innovational capability in
managing children with behavioural problems and allow dentists to perform effective treatment in a stress-free
environment.

References
[1]. Dean J A, Avery D R, McDonald R E, Editors. Dentistry for the child and adolescent. Nineth edition. New Delhi:
Elsevier;2014.p27-40
[2]. Non-Pharmacologic approaches in behavior management. In: Wright G Z, Kupietzky A (Eds.) Behavior management in dentistry
for children. Second edition.Iowa;England: Wiley Blackwell;2014.p63-91
[3]. Managing the patient and parents in dental practice. In: Stephen H Y Wei. Pediatric Dentistry: Total Patient Care. First edition.
Philadelphia: Lea & Febiger; 1988. p140-155
[4]. Nonpharmacologic Behavior Management. In: Marwah N (Ed.) Textbook of pediatric dentistry. Third edition. New Delhi: Jaypee
Brothers medical publishers (P) ltd 2014. p219-241
[5]. American Academy of Pediatric Dentistry: Clinical guideline on behavior management. Pediatr Dent 2015;37(6):180-193.
[6]. Vishwakarma AP, Bondarde PA, Patil SB, Dodamani AS, Vishwakarma PY, Mujawar SA. Effectiveness of two different
behavioral modification techniques among 5–7-year-old children: A randomized controlled trial. J Indian Soc Pedod Prev Dent
2017;35:143-9
[7]. Patil VH, Vaid K, Gokhale NS, Shah P, Mundada M, Hugar SM. Evaluation of effectiveness of dental apps in management of child
behaviour: A pilot study. Int J Pedod Rehabil 2017;2:14-8
[8]. Fakhruddin K S,El Batawi H,Gorduysus MO. Effectiveness of audiovisual distraction eyewear and computerized delivery of
anesthesia during pulp therapy of primary molars in phobic child patients. Eur J Dent 2015;9(4):470-475
[9]. Oliveira NCAC, Santos JLF, Linhares MBM. Audiovisual distraction for pain relief in paediatric inpatients: A crossover study. Eur
J pain 2016;21(1):178-187.
[10]. Barreiros D, de Oliveira DS, de Queiroz AM, da Silva RA, de Paula-Silva FW, Kuchler EC. Audiovisual distraction methods for
anxiety in children during dental treatment: A systematic review and meta-analysis. J Indian Soc Pedod Prev Dent 2018;36:2-8
[11]. Al-Khotani A, Bello LA, Christidis N. Effects of audiovisual distraction on children’s behavior during dental treatment: a
randomized controlled clinical trial. Acta Odontol. Scand 2016;74(6):494-501
DOI: 10.9790/0853-1805101821 www.iosrjournals.org 20 | Page
 Recent Advances in Non-Pharmacological Behaviour Management Techniques in Children – An ..
[12]. Kaur R, Jindal R, Dua R, Mahajan S, Sethi K, Garg S. Comparative evaluation of the effectiveness of audio and audiovisual
distraction aids in the management of anxious pediatric dental patients. J Indian Soc Pedod Prev Dent. 2015;33:192-203.
[13]. Nuvvula S, Alahari S, Kamatham R, Challa RR. Effect of audiovisual distraction with 3D video glasses on dental anxiety of
children experiencing administration of local analgesia: a randomized clinical trial. Eur Arch Paediatr Dent 2015;16(1):43-50
[14]. Mitrakul K, Asvanund Y, Arunakul M, Paka-Akekaphat S. Effect of audiovisual eyeglasses during dental treatment in 5-8 year old
children. Eur J Paediatr Dent. 2015;16(3):239-45.
[15]. Wijnhoven L A, Creemers D H, Engels R C, Granic I. The effect of the videogame mindlight on anxiety symptoms in children with
an Autism Spectrum Disorder. BMC Psychiatry 2015;15:138
[16]. Aljafari A,Rice C, Gallagher JE,Hosey MT. An oral health education videogame for high caries risk children: study protocol for a
randomised controlled trial. Trials 2015;16:237
[17]. Aljafari A,Gallagher JE,Hosey MT. Can oral health education be delivered to high-caries- risk children and their parents using a
computer game? – A randomised controlled trial.Int J Pediatr Dent 2017;15:240
[18]. Ko JS, Whiting Z, Nguyen C, Liu RW, Gilmore A. A Randomized prospective study of the use of Ipads in reducing anxiety during
cast room procedures. Iowa Orthop J 2016;36:128-132
[19]. Sil S, Dahlquist LM, Burns AJ. Case study: Videogame distraction reduces behavioral distress in a preschool-aged child undergoing
repeated burn dressing changes: A single-subject design. J Pediatr Psychol 2013;38(3):330-341.
[20]. Wohlheiter KA, Dahlquist LM. Interactive versus active distraction for acute pain management in young children: The role of
selective attention and development. J Pediatr Psychol 2013;38(2):202-212
[21]. Heim M. Virtual realism. New York: Oxford University Press,1998.
[22]. Lange B, Williams M, Fulton I.Virtual reality distraction during pediatric medical procedures. Pediatric Pain Letter 2006;8(1):1-5
[23]. Tanja-Dijkstra K, Pahl S, White MP, et al. Improving dental experiences by using virtual reality distraction: a simulation study.
PLoS One 2014; 9:e91276.
[24]. Dahlquist LM, Weiss KE, Law EF, Sil S, Herbert LJ, Horn SB, Wohlheiter K, Ackerman CS. Effects of videogame distraction and
a virtual reality type head-mounted display helmet on cold pressor pain in young elementary school-aged children. J Pediatr
Psychol. 2010;35(6):617-25
[25]. Hoffman HG, Chambers GT, Meyer WJ, Arceneaux LL, Russell WJ, Seibel EJ, et al. Virtual Reality as an Adjunctive Non-
pharmacologic Analgesic for Acute Burn Pain During Medical Procedures. Ann Behav Med. 2011 April ; 41(2): 183–191
[26]. Shiri S, Feintuch U, Weiss N, Pustilnik A, Geffen T, Kay B, Meiner Z, Berger I. A virtual reality system combined with
biofeedback for treating pediatric chronic headache—a pilot study. Pain Medicine 2013; 14:621–627.
[27]. Ramachandran VS, Seckel EL. Using mirror visual feedback and virtual reality to treat fibromyalgia. Medical Hypotheses 2013;
75:495–496
[28]. Patterson DR, Jensen MP, Wiechman SA, et al. Virtual reality hypnosis for pain associated with recovery from physical trauma.
The International Journal of Clinical & Experimental Hypnosis 2010; 58:288–300.

Swarna K.” Recent Advances in Non-Pharmacological Behaviour Management Techniques in

Children – An Overview.” IOSR Journal of Dental and Medical Sciences (IOSR-JDMS), vol.
18, no. 5, 2019, pp 18-21.

DOI: 10.9790/0853-1805101821 www.iosrjournals.org 21 | Page