Thursday, June 11, 2015

Cognitive and behavioral strategies to reduce children's pain

Title: Cognitive and behavioral strategies to reduce children's pain
Authors: Kachoyeanos MK and Friedhoff M.
Journal: Am J Matern Child Nurs. 1993 Jan/Feb

Purpose: To review the use of reported strategies to help children deal with pain and distress of hospitalization and invasive treatment procedures. Imagery, distraction, relaxation, play, various tactile techniques and other cognitive and behavioral strategies are known to be effective in managing a child’s pain and distress from cancer related therapies.


Types of Cognitive Strategies:

·      Hypnosis (Guided Imagery) is effective with child three years and older who have an active imagination (example: pain switch; the child is asked to switch off the pain in the area they are experiencing pain)
·      Story telling is another strategy, where the child develops the story and listens to a story
·      Imagery combined with tactile sensation would be the use of magic glove or magic blanket. The child is told that the magic glove will lessen the discomfort from a needle stick
·      Tactile transference is used when the site of pain is not accessible, such as a spinal tap. The nurse strokes the child’s back where the tap is to be done and the child’s hand at the same time. The child is told that at the time of the tap he/she will have their hand stroked and should feel the same soothing sensation where the tap is being placed.
·      Emotive Imagery is active distraction that would involve the child (counting the tiles on the ceiling, a pacifier, blowing bubbles, holding tightly to the parents’ hands.  In passive distraction the child watches something distracting.
·      Music is a good distraction technique. Usually soft, low-pitched instrumental music has been shown to be effective, even comatose children respond to music.
·      Relaxation techniques involving slow deep breathing or blowing out are also effective.

Types of Behavior Strategies

·      With the use of modeling the child learns about the procedure and ways to cope. This could be done live or using videotape.
·      Desensitization exposes the child to the anxiety-provoking experience through play. Such as child playing with syringe before being an injection.

How Cognitive and Behavioral Strategies work:

·      They propose that mechanism in the dorsal horn of the spinal cord act as a gate, and allow or prevent the flow of pain impulses from peripheral fibers to the CNS depending on the extent to which the gate is open.
·      Output of transmission cells must reach a certain threshold before the message of pain can be transmitted to the brain
·      Attention, memory and emotion influence the gating mechanism. If you reduce the emotional and physical impulses you in turn reduce the output of the transmission cells, thus inhibiting pain impulses from reach the brain.
·      There is a need to create the environment for pain reduction, such as training staff in pain reduction procedures through CE workshops

Basic Principles of Cognitive Pain Control:

·      Willingness on the part of the child to learn these techniques
·      Parent involvement and cooperation will further ensure success
·      Regular practice and contact with a profession or parent who knows the techniques will help the child from relapsing and forgetting to use the technique


·      Costs nothing to implement
·      Save staff time
·      The strategies work
·      Children need not suffer needlessly
·      Techniques do require a commitment on the part of the caregivers.

Age of Onset of Dental Anxiety

Authors: Locker, et al.

Journal: J Dent Res 78(3): 790-796, March, 1999

Purpose: To investigate the age of onset of dental anxiety and its etiology.

Hypothesis: Child-onset subjects acquired their dental anxiety through conditioning experiences (exogenous) while dental anxiety in adult-onset subjects is endogenous, meaning that it may be related to an innate anxiety disorder.

Methods: A survey was mailed to 6360 subjects ages 18 and older living in Etobicoke, Toronto. Dental anxiety was measured with the CORAH Dental Anxiety Scale. Subjects were asked to indicate whether they became dentally anxious during childhood, adolescence, or adulthood. They were also asked about negative experiences in the dental setting. They were further asked about negative experiences close family members had had in the dental setting. General fearfulness was also measured with the Fear Survey Schedule II.

Results: The survey was completed by 3055 subjects; 16.4% of subjects were classified as dentally anxious. One half of these subjects reported becoming fearful of dental treatment in childhood, 22% suffered onset in adolescence and 27% became anxious as adults. Overall, 74.8% reported painful dental experiences, 30.7% experiences that were frightening, and 13.3% experiences which were embarrassing. The data further indicates that child-onset subjects were more likely to be exogenous, while adult-onset was more likely to be endogenous.

Conclusion: The dental team needs to take as much care with adult patients and use appropriate communication techniques, which enhance trust and feelings of control. This preventive approach may reduce the incidence of dental anxiety in psychologically vulnerable individuals. Also, information on dental anxiety and age of onset should be collected from dental patients so that dentists may plan appropriate management and/or treatment strategy.

Wednesday, June 10, 2015

Comparing four methods to inform parents about child behavior management: How to inform for consent.


Article title: Comparing four methods to inform parents about child behavior management: How to inform for consent.

Authors: K.D. Allen, et al.

Journal: Pediatric Dentistry 17:3, 1995

·      This study compared four methods for informing parents to gain their consent for eight pediatric dentistry behavior management techniques.
·      The research was designed to determine:
o   How to best inform the parent.
o   Which procedures parents feel should require informed consent.
o   Which management techniques parents were willing to consent and the variables that may influence parental willingness to consent.

·      One hundred twenty (12) parents of children attending the University of Nebraska Pediatric Dental Clinic.
·      Descriptions of eight traditional pediatric behavior management techniques (TSD, nitrous oxide, Passive Restraint, Voice Control, Hand-Over-Mouth, Oral Premedication, Active Rrestraint, and GA) were randomly presented to parents via one of four different methods of information delivery:
o   Video of patient during live office visit with accompanying explanation and description.
o   Video of patient during live office visit without accompanying explanation and description.
o   Written form and description.
o   Oral presentation (memorized presentation of exactly what was in the written form).  After the presentations, participants (the parents) were given the opportunity to mark their approval and consent on the consent form.
·      The results of this study revealed a written explanation resulted in parents who felt less well informed significantly than those in the other conditions.
·      Oral presentation resulted in parents who felt well informed more often than those in the other groups.  
·      No significant differences between the four conditions with respect to parents providing consent, however, exact tests found the oral method produced significantly better consent for some individual procedures. 
·      Overall, the oral method of delivering information was the best method, ensuring the average parent felt informed and was likely to consent.

·      The means of delivery of information to parents about a technique is most likely to result in parents who feel well informed and likely to consent.

An analysis of the phenomenon of increased parental participation during the child’s dental experience

Title: An analysis of the phenomenon of increased parental participation during the child’s dental experience
Author: Pinkham, BS, DDS, MS
Journal/Date: Journal of Dentistry for Children, November-December 1991
Resident: Slowikowski

Major Topic: Parental participation in the child’s dental appointment

Main Purpose:  Focus on parental participation and the child dental appointment; concepts from anthropologist and social biologist.

“Party-line” Philosophy:  within dentistry for children was that parental attendance was not needed; parents present is counterproductive, dentist uncomfortable with managing child with parent present

There have been dramatic changes in parenting styles over the decades.  Margret Mead’s (anthropologist) description of parenting styles are:
·      postfigurative (conventional techniques)
·      configurative (transitional stage - modification of various types and experimental levels are allowed)
·      prefigurative (very contemporary with sometimes day-by-day or even hour-by-hour adjustment to the needs of the child)

Why do parents want to be present?
·      They believe the child will behave better
·      Do preschoolers (3-4 year old) function well in a new environment?
o   According to parenting styles:
§  postfigurative: Behave well because that is the way it is
§  configurative: Parents will do according to their remembrances.  If they were afraid as a child, they will accompany their child.
§  prefigurative: Must solve issues before arrival but if child looks anxious will go with child

Question of trust –
·      Concept of hypertrophic society (rapid growth of preexisting social tendencies within humankind) by Dr. Wilson (social biologist)
·      Today we don’t know the person that lives three door away from us, lack of familiarity, creating a protective parent
·      No intellectually distrust but parent can be uncomfortable if they cannot visually verify child’s safety
·      Dentist are encouraged to understand that, if parents are determined to be in attendance with their child, the decision was made objectively, even though its origin was an emotional one, but also very normal.
·      Dentist can explain events to occur, behavioral management techniques.  Should never explain techniques as a “good” or “bad” thing
With social hypertrophy and prefigurative parenting, we need to change with the times and understand that society is constantly changing.

Tuesday, June 2, 2015

Primary molar pulp therapy – histological evaluation of failure

Title: Primary molar pulp therapy – histological evaluation of failure
Authors: Waterhouse PJ, Nunn JH, Whitworth JM, Soames JV
Classic 100: Article 24
Journal: International Journal of Paediatric Dentistry 2000. 10:313-321.

Objective: To qualitatively compare the clinical, radiographic, and histological outcome of cariously exposed primary molars that were extracted due to unsuccessful pulp treatment from either formocresol or calcium hydroxide. 

Methods: 52 patients, 26 boys and 26 girls were involved in the study. Primary molar teeth requiring pulp therapy were randomly assigned to either to formocresol group or the calcium hydroxide group. In this group, 79 teeth required pulp therapy – 44 in the formocresol group, and 35 in the calcium hydroxide group. Of the teeth treated, 2 of the formocresol teeth, and 4 teeth of the calcium hydroxide teeth were termination from the trial due to clinical or radiographic failure. Of the six teeth extracted, 5 were used in histological studies. 

Key Points: 
- Post-extraction radiographs showed reactionary dentin bridge formation in CaOH2 group.
- Extracted teeth treated with both CaOH2 and FC had narrowing of root canals, indicative of appositional reactionary dentin deposition.
-  Pus cells were evident in all extracted teeth.
-  Histologically, there was resorption of reactionary dentin within the root canal.
-  The average time between treatment and failure was 11 months.
- Radiographic evidence of reactionary dentin should not be an indicator of successful outcome of pulp therapy, but rather a reaction by the traumatized pulp tissue that may serve to act as a partial barrier. 

- The teeth treated were all restored differently, but not separated in the study.
- The authors used amalgam, glass-ionomer cement, composite, and SSCs.
- It would be interesting to see how the failures were restored, and if the restoration used was linked to failure.
- The study looked at a vert limited failure sample, of the 6 only 5 were able to be studied histologically.