NATIONAL BOARD REVIEW IN BEHAVIORAL SCIENCE

Refer all questions to Dr. Deborah Franklin (room 486, ext. 4291)
Deborah R. Franklin@uth.tmc.edu

GROWTH AND DEVELOPMENT

LIFE STAGES
Life Stages Defined by Age
Infancy: Birth - age 2
Early Childhood: Age 2-6
Middle & Late Childhood: Age 6-12
Adolescence: Age 13-18 or 20
Early Adulthood: Age 21-35
Middle Adulthood: Age 35 or 45-60
Late Adulthood: Age 60-death
4 Stages of Cognitive Development
(Piaget)
SENSORIMOTOR Stage
PREOPERATIONAL Thought
CONCRETE OPERATIONAL
Thought
FORMAL OPERATIONAL Thought

8 Stages of Psychosocial Development

(Erikson)
1. Trust vs. Mistrust
2. Autonomy vs. Shame and Doubt
3. Initiative vs. Guilt
4. Industry vs. Inferiority
5. Identity vs. Identity Confusion
6. Intimacy vs. Isolation
7. Generativity vs. Stagnation
8. Integrity vs. Despair

INFANCY
Birth-age 2

Cognitive: Sensorimotor Stage

Psychosocial: 1. Trust vs. Mistrust
2. Autonomy vs. Shame & Doubt
Features of the Sensorimotor Stage
Infant coordinates sensations with physical movements & actions.
Reflexes become habits.
Object permanence by the age of 2 the child can understand that objects & events
continue to exist even when they cannot directly be seen, heard, or touched.
Developmental Aspects of Infancy
Stranger anxiety peaks at 10-12 months.
If a 2-year-old child needs to be restrained, he/she should be restrained by his
mother, not by the dentist.

EARLY CHILDHOOD
Age 2-6

Cognitive: Preoperational Thought

Psychosocial: 3. Initiative vs. Guilt

Features of Preoperational Thought

2 substages:
symbolic function - child gains ability to mentally represent an object that is not
present. Age 2-4.
egocentrism - inability to distinguish between childs perspective & someone
elses perspective.
animism - inanimate objects have lifelike qualities and are capable of action.
2) intuitive thought - I know what I know, but Im not sure how I know it.
Children of this age ask a lot of questions. Children age 4-7 exhibit magical
thinking believe in Santa Claus, the Tooth Fairy, etc.
Developmental Aspects of Early Childhood
Gender identity the child begins to think of himself/herself as a boy or a girl.
The normal response of a 3-year-old child on his/her first visit to the dentist is
curiosity. He/she should not experience fear or anxiety unless he has had a previous
bad experience in the medical setting or unless he has seen another child have a
bad experience in a medical or dental setting.
PARENTING STYLES
There are 3 styles of parenting. Each style of parenting produces different effects on
childrens behaviors.
1. AUTHORITARIAN - parents view children as having few rights but adult-like
responsibilities, and tend to demand strict adherence to rigid standards of behavior.
Children of such parents are typically obedient and self-controlled, but also
emotionally stiff, withdrawn, apprehensive, and lacking in curiosity.
2. AUTHORITATIVE - parents encourage children to be independent but still place
limits and controls on their actions. Parents are warm and nurturant toward the
child. This is the best kind of parent to be. Children of such parents tend to be
socially competent, self-reliant, socially responsible, independent, assertive, and
inquiring.
3. PERMISSIVE - 2 forms:
1) NEGLECTFUL - the parent is very uninvolved in the childs life.
Children of such parents are socially incompetent, have a serious lack of
self control, and do not handle independence well.
2) INDULGENT - the parents are highly involved with their children but
place few demands or controls on them. These parents let the children do
whatever they want, and the result is the children never learn self-control
and always expect to get their own way.

TYPES OF PARENTS

1. Overprotective insist on remaining with the child in the operatory, regardless of the
situation or the age of the child.
Pointing to the lack of apprehension of a young child and the importance of establishing a
one-to-one relationship between child and dentist usually satisfies most overprotective
parents.
Usually have children who are shy, docile and manageable.
2. Hostile question the necessity for treatment.
This is usually due to distrust, not curiosity.
Try to identify the underlying source of their hostility or anger, and
then address it with them.
This is also true for children: if children are hostile or angry, try to identify the
underlying source of their hostility or anger.
3. Manipulative have excessively demanding attitudes, about everything from
appointment times to trying to direct the course of treatment.
4. Neglectful fail to keep appointments, miss recall visits, or do not concern themselves
with the oral hygiene of the child.
Children with defiant behavior are usually said to be stubborn or spoiled.

MIDDLE & LATE CHILDHOOD

Age 6-12

Cognitive: Concrete Operational Thought

Psychosocial: 4. Industry vs. Inferiority

Features of Concrete Operational Thought

Concrete operation = a reversible mental action on real, concrete objects (3+2 =
2+3).
Ability to classify things into different sets or subsets (red squares, white dogs, etc.)
and to consider their interrelationships (as in a family tree).
Since these children are concrete in their thinking, the best thing to do when talking to
them is to use emotionally neutral words.
Developmental Aspects of Middle and Late Childhood
First grade - transition from home being the center of their life to school being the
center of their life. This is a major transition.
Gender identity sense of themselves as a boy or girl becomes even stronger than in
early childhood.
Self-esteem how we think about ourselves, the regard in which we hold our actions,
talents and skills (basically, whether the child thinks of himself as a good person or a
bad person). The 2 keystones of early self-esteem in childhood are 1)interaction with
parents and 2) interaction with other significant adults.
Self-concept the child begins to have an idea of who he/she is in the world, of what
his/her role is in the world: Im a good student, Im a future vet, Im a good
baseball player, etc.

ADOLESCENCE
Age 13-18 or 20

Cognitive: Formal Operational Thought

Psychosocial: 5. Identity vs. Identity Confusion

Features of Formal Operational Thought

First develops between ages 11-15.
Is Abstract can think about thinking.
Is Idealistic - adolescents begin to think about ideal characteristics for themselves &
others & to compare themselves & others to these ideal characteristics.
Is Logical the beginning of hypothetical-deductive reasoning, where one makes
hypotheses and then tests them (the same type of reasoning we use in the scientific
method.)
Developmental Aspects of Adolescence
Physical changes - puberty, menarche
Body image changes as the body changes.
Transition from middle school to high school students experience the
top dog/underdog phenomenon: In their last year of middle school they are top
dog. Then when they get to high school they have to start all over again on the
bottom rung of the ladder, or as underdog.
Adolescent egocentrism adolescents are just as egocentric as 2-year-olds. They
believe they are the center of the universe. This egocentrism has 2 features:
1) imaginary audience - the adolescent feels that all eyes are on him when he walks
into a room.
2) personal fable -Im so unique nobody understands me (especially their parents).

Adolescents are romantic and more into fantasy than reality.

The opinion of their peers means MUCH more to them than the opinions of their
parents.
Motivation adolescents are very hard to motivate. They have a strong desire to
control their own life. They manifest their independence by showing their ability to
take care of themselves, but sometimes they lack motivation to practice routine
brushing and flossing. What motivates an adolescent? Peers, social acceptance
(pretty smile, fresh breath), role models (I want a smile like Britney Spears has.)
Adolescent Problems
substance abuse
cigarette smoking
pregnancy

sexually transmitted
diseases
eating disorders

gangs
suicide

Adolescent Suicide has increased dramatically in recent years. Suicide is the 3rd
leading cause of death for 15-24 year olds, and the 6th leading cause of death for 5-14
year olds. Teenagers experience strong feelings of stress, confusion, self-doubt, pressure
to succeed and other fears while growing up. Their parents divorcing, moving to a new
community/school are also stressful issues that teenagers face.

Signs that may suggest that a teenager is contemplating suicide

Change in eating and sleeping habits
Withdrawal from friends, family and regular activities
Violent actions, rebellious behavior or running away
Drug and alcohol abuse
Unusual neglect of personal appearance
Decline in the quality of schoolwork
Giving verbal hints and statements about committing suicide
EARLY ADULTHOOD
Cognitive: Formal Operational Thought
Age 21-35
Psychosocial: 6. Intimacy vs. Isolation
Behavioral Methods to Overcome Dental Anxiety In Adults
Iatrosedation use a
systematic
electroanesthesia
calm voice.
desensitization
relaxation
cognitive
acupressure
restructuring
imagery
acupuncture
biofeedback
hypnosis
MIDDLE ADULTHOOD
Cognitive: Formal Operational Thought
Age 35 or 45-60
Psychosocial: 7. Generativity vs. Stagnation
Developmental Aspects
Different personality types affect a persons lifestyle and health.
o Type A, Type B, and Type C personalities
o Stress-resistant personality
LATE ADULTHOOD
Age 60-death

Cognitive: Formal Operational Thought

Psychosocial: 8. Integrity vs. Despair

Developmental Aspects
Decline in physical performance includes walking efficiency, maintaining balance,
sitting down and standing up.
Decline in vision and hearing.
Less sensitive to taste and smell.
Decline in ability to reason abstractly.
Decline in speed of processing information.
Do not perform as well on long-term memory tasks.
Less able to process more than one stimulus simultaneously.
NO DECLINE in ability to learn new things.
NO DECLINE in performance on timed tests.

ALZHEIMERS DISEASE - Short-term memory loss is one of the first signs.

Alzheimers Disease is the most common form of dementia. Dementia is the loss of
intellectual and social abilities severe enough to interfere with daily functioning.
Dementias are characterized by the development of multiple cognitive deficits.
Alzheimers Disease
Affects 2-4% of the population, usually develops in those age 65 or older. Highest
prevalence after the age of 85. There are few cases before age 50.
Cause is not well understood. Brain cells become damaged and die for unknown
reasons. As neurons die, lower levels of neurotransmitters are produced, producing
signaling problems in the brain.
Risk factors: age, heredity, environment.
Gradual onset, continuing cognitive decline it is a progressive degenerative
disease. The rate of progression varies from person to person.
Slightly more prevalent in females than males.
Approx. 10% of people with Alzheimers suffer from seizures.
Average interval from onset to death: 8-10 years. Can range from 3-20+ years.
Indirectly fatal individuals with severe dementia are prone to infectious diseases
and accidents.
Treatment for Alzheimers Disease - There is NO CURE.
Medications and caregiving are the primary treatments.
1) Medications may slow down the disease process, lessening symptoms. Medications
used:
Tacrine (Cognex)
Donepezil (Aricept)
Rivastigmine (Exelon)
2) Caregiving techniques used to care for Alzheimers patients:
Use memory aids.
Enhance communication
Provide structure
Create a safe environment
Monitor wandering
Encourage exercise
Establish a nighttime ritual
SYMPTOMS of Alzheimers Disease: #1 is SHORT-TERM MEMORY LOSS
Early Stage Symptoms
Gradual memory loss
Loss of language & communication
skills
Decline in ability to perform routine
Late
Stage Symptoms
tasks
Gait disorder difficult to walk.
Disorientation in time & space
Lose bladder function.
Impairment of judgment
Lose bowel function.
Personality change
Cant swallow.
Difficulty in learning
6

Totally dependent.

DEPRESSION
Depression is the most common functional psychiatric disorder in the elderly.
(Functional means it is not caused by something organic, like a brain tumor.)
Depression is NOT the most common mental illness in the US anxiety is.
Symptoms of Depression
Mood of sadness, despair, emptiness
Sleep disturbance (sleeping more OR sleeping less than usual)
Appetite disturbance (eating more OR eating less than usual)
Fatigue
Impaired concentration and forgetfulness
Decreased sex drive
Anhedonia (NOTHING gives you pleasure any more)
Etiology of Depression
The current hypothesis about the etiology of depression is that symptoms of clinical
depression are caused by a dysregulation of neurotransmitters (norepinephrine,
dopamine & serotonin) in the brain. Therefore treatment is based on trying to increase
the levels of these neurotransmitters by using medications.
Antidepressant Medications
Patient must take medication for at least 10-21 days before effects are noticed. It is
recommended that patients continue treatment for a minimum of 6 months beyond the
acute phase (6-8 weeks).
Antidepressant drugs are not addictive.
Alcohol can block the effects of antidepressants.
The choice of antidepressant is determined by the side effect profile: the less side
effects, the better.
2 Classes of Antidepressant Medications
1. Typical antidepressants 2 types
a. SSRIs: Selective serotonin re-uptake inhibitors (Examples: Prozac,
Luvox, Zoloft, Celexa, Desyrel, Wellbutrin, Effexor). SOME SSRIs
CAUSE XEROSTOMIA (see below).
b
b. Tricyclic antidepressants CAUSE XEROSTOMIA
2. Monoamineoxidase inhibitors (MAOIs) (Examples: Marplan, Nardil, Parnate)
ANTIDEPRESSANTS THAT HAVE ANTICHOLINERGIC SIDE EFFECTS
CAUSE XEROSTOMIA.
DIFFERENT ANTIDEPRESSANTS HAVE DIFFERENT LEVELS OF
ANTICHOLINERGIC SIDE EFFECTS.
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Antidepressants with NO Anticholinergic Side Effects

Desyrel
Zoloft
Prozac
Effexor
Wellbutrin
Effexor S.R.
Wellbutrin S.R.
Celexa

Antidepressants with MID-LEVEL Anticholinergic Side Effects

Tofranil
Pamelor

Remeron
Vivactil

Aventyl
Surmontil

Vestra
Nardil - MAOI
Parnate MAOI
Marplan - MAOI

Sinequan
Adapin

Antidepressant with HIGH Anticholinergic Side Effects

Elavil
Over-The-Counter (OTC) Products for Treatment of Depression
1. St. Johns Wort: mild depression
2. SAM-e: mild to moderate depression
Appear to have favorable side effect profiles and safety.
Do NOT co-administer St. Johns Wort with MAOIs or SSRIs.
Studies are in progress at NIMH.
NEUROLEPTIC MEDICATIONS = MAJOR TRANQUILIZERS = DRUGS USED
TO TREAT SCHIZOPHRENIA
Neuroleptic medications have 2 main oral effects:
1) Anticholinergic effects they cause xerostomia.
2) Tardive dyskinesia
A side effect of long-term use of neuroleptics is extrapyramidal syndrome. Tardive
dyskinesia is a feature of extrapyramidal syndrome.
Features of tardive dyskinesia
Involuntary smacking and sucking movements of the mouth and lips.
Serious, often irreversible. No cure.
Late onset: Occurs in 1 in 25 people treated with neuroleptics for one year; occurs in
1 in 4 people treated with neuroleptics for 7 years.
SECONDARY GAIN
Benefits that a person unconsciously obtains from a disability. (Example: woman
with TMJ pain might not want to get treatment because husband pays more attention
to her if he thinks she is in pain).

Secondary gain associated with a disorder is the emotional and material payoffs
gained from having the disorder. (Example: someone with a fear of heights might
be using the fear to get out of cleaning the rain gutters.)

LOCUS of CONTROL
A locus of control orientation is a belief about whether the outcomes of our actions
depend on what we do (internal locus of control) or on events outside our
personal control (external locus of control).
Someone with an internal locus of control would generally perceive himself/herself
as responsible for the outcome (her actions would have a direct bearing on the
results), while a person with an external locus of control would most often
blame (or thank) fate, destiny, luck, society or some other force beyond his/her
control.
Example: If a patient says something like: I dont know why I should brush my
teeth theyre going to fall out anyway, or I have soft teeth I know Ill need
dentures, they have an external locus of control.
A patient with an external locus of control is difficult to motivate.
ADDICTION
Addiction doesnt just happen over night. There are several different and distinct stages
that a person goes through prior to the final progression to addiction. The 4 stages of
addiction are:
1. Use (casual drug use) the ingestion of alcohol or drugs without the
experience of any negative consequences. (Example: If you drink a beer at a
party, you have used alcohol.)
2. Misuse (intensive drug use) when a person experiences negative
consequences from the use of alcohol or drugs. (Example: If you drink and drive
and get a ticket for DUI.)
3. Abuse (compulsive drug use) continued use of alcohol or drugs in spite of
negative consequences. (Example: If you get a DUI but dont have a substance
abuse problem, you wont drink and drive again because one DUI is enough of a
deterrent. However, if you get one DUI and continue to drink and drive, this is
considered abuse.)
It is considered ABUSE when your alcohol or drug use disrupts your
normal everyday life (Example: you cant hold down a job, your wife
leaves you, etc.)
4. Addiction (dependency) the compulsive use of alcohol or other drugs
regardless of negative consequences. In this stage, drugs or alcohol appears to
govern a persons behavior. (Example: you receive three DUIs in one year, are
put on probation, and will be sentenced to prison if you are caught drinking and
driving again. You continue to drink and drive. You are clearly addicted to
alcohol because these negative consequences did not impact or deter you from
using alcohol.

During the first and second stages (Use and Misuse), there is no indication that a
person will progress to the later stages of Abuse and/or Addiction.
Once the person reaches the Abuse stage, there is a high probability that they
will progress to the Addiction stage and they should seek professional help.
Remember that alcohol is considered to be a drug.
People can be addicted to many things: drugs, alcohol, cigarettes, food, sex,
excitement, etc.

CIGARETTE SMOKING
Consequences on oral health
Oral cancer the incidence of oral cancer increases in smokers and is related to
both the duration and frequency of smoking. The most common site for cancer in
the oral cavity is the tongue.
Leukoplakia often disappears within a year of smoking cessation. May
develop into cancerous growths.
Effects on teeth yellow-brown stain, loss of teeth due to destruction of
periodontium, increased risk of caries.
Effects on periodontium increased risk of periodontal disease.
Halitosis
Delayed wound healing
Consequences of smoking on general health
Cancer growth oral mucosa, lungs, liver
Lungs cancer, emphysema
SMOKING CESSATION
At least 70% of smokers see a physician each year, and more than 50% see a
dentist. Therefore all clinicians, especially physicians and dentists, are uniquely
poised to intervene with patients who use tobacco.
70% of smokers report wanting to quit.
Smokers cite a health care professionals advice to quit as an important
motivator for attempting to quit smoking.
Unfortunately, more than 1/3 of smokers report never having been asked about
their smoking status or urged to quit by their physician or dentist.
Best approach for treating tobacco dependence is combined behavioral
(behavior therapy and/or programs such as Fresh Start) and pharmacological
therapies (nicotine replacement such as Nicotrol gum or patch, inhalers, nasal
sprays).
Recidivism is high most smokers achieve long-term cessation only after
several unsuccessful attempts.

10

Smoking cessation products

Zyban (the same drug as Wellbutrin) reduces the compulsion to smoke. Do
NOT take Zyban if you are taking Wellbutrin and vice versa you will overdose
on the drug. The chemical name of the drug is buproprion.
Nicorette Chewing Gum
Nicorette Patch
Nicorette Inhaler the inhaler is held in the hand like a cigarette and offers
regular hand-to-mouth activity, so the smoker is less likely to miss the action of
smoking.

The next 3 pages contain tables from Clinical Practice Guidelines

Treating Tobacco Use and Dependence, published by the US Dept. of
Health and Human Services.
The first step in treating tobacco use and dependence is to identify
tobacco users.
It is essential to provide at least a brief intervention to ALL tobacco
users at EACH clinical visit.
The 5 major steps to intervention (the 5 As) are listed in Table 3.
This is followed by Table 4, Clinical guidelines for prescribing
pharmacotherapy for smoking cessation.
This is followed by a definition of each of the Brief Strategies referred
to in Table 3. The strategies are designed to be brief, requiring 3 minutes
or less of chair time.

AGGRESSION 3 types
1. Constructive an act of self-assertiveness in response to a threatening action for
the purpose of self-protection and preservation
2. Destructive an act of hostility unnecessary for self-protection or preservation
that is directed toward an external object or person.
3. Inward destructive behavior that is directed against oneself.

An aggressive personality is a personality with behavior patterns characterized by

irritability, tantrums, destructiveness or violence in response to frustration.
The best way to respond to an aggressive patient: acknowledge what he/she is
frustrated about.

11

STRESS, ANXIETY & FEAR are all negative or aversive emotional states.
Anxiety is the most prevalent mental disorder in the U.S.
Patients who are fearful or anxious will do anything to put off making dental
appointments.
Anxiety & pain are interdependent being in pain increases your anxiety and being
anxious makes your pain worse.
ANXIETY Definition: A state or feeling of apprehension, uneasiness, agitation or
uncertainty whose source is generally unknown or unrecognized (there is no apparent
reason for the feeling). Anxiety usually results from the anticipation of some threat or
danger, usually of intrapsychic (thoughts in your head) rather than external origin.
Physiological changes such as tachycardia, sweating and/or shaking accompany this
feeling of anxiety.
Other Symptoms of Anxiety
Restlessness or
Feeling of choking
Feeling dizzy,
feeling on edge
unsteady,
Being easily fatigued
Chest pain
faint or lightheaded
Sleep disturbances
Palpitations or fast
Fear of losing
heart rate
Difficulty
control
Nausea or abdominal
concentrating
Fear of dying
pain
Irritability
Numbness or
Chills
Muscle tension
tingling
Hot flushes
Shortness of breath
A PANIC ATTACK, the most severe manifestation of anxiety, CAN BE MISTAKEN
FOR A HEART ATTACK. The only way to differentiate the 2 is with an EKG and
bloodwork (cardiac enzymes).

Fear is distinguishable from anxiety in that anxiety is the response to an imagined

threat, and fear is the response to a real threat.
The factor most likely to play a role in whether a person develops dental anxiety is
whether he/she has previously had a specific frightening or painful experience in a
dental or medical setting.
Dental patients who are anxious or fearful have a tendency to put off making dental
appointments.

12

Most dentists say that they become anxious themselves when working with an
anxious patient. This fact is why the Dental Decks refer to the anxious patient as the
most difficult type of dental patient.

Assessment of Dental Anxiety

Corah Dental Anxiety Scale
Subjective evaluation by patient: Ask the patient, On a scale of 1 to 10, how anxious
are you right now?
Ways to Reduce Dental Anxiety
Prevention - good oral health, safe environment
Drugs
Behavioral methods
Behavioral Methods of Reducing Dental Anxiety
Active Listening use feedback to make sure you understand what the patient is
telling you.
Modeling if anxious patients see other patients having a good dental experience
they will expect to have a good experience, too.
Reducing uncertainty explain procedures before doing them; use Tell-ShowDo with children AND adults. Forewarn the patient about the possibility of pain.
Give patient some control over procedures and pain (Example: Tell the patient,
Raise your left hand if anything hurts you.)
Emotional support
Relaxation
Imagery
Hypnosis affects both voluntary and involuntary muscles.
Distraction anything that takes the patients mind off dental treatment a radio
set to his/her favorite station, a TV, magazines, relaxation tapes, small talk, etc.
etc.
Cognitive (thought) restructuring - focus on the positive aspects of treatment
(your smile will be beautiful, you will have fresh breath, etc.)
Build trust between you and the patient.
Note: Watching a patients eyes or eyebrows will give a good indication of whether a
patient is feeling pain during dental treatment.
PAIN pain and anxiety are interdependent. Being in pain increases your anxiety
AND if you are anxious your pain will be worse.
There are many indications that pain may be controlled psychologically (people walk
on fire, people get tattooed.)
Four factors can be used to alter the amount of sensitivity to pain in people with
normal pain responses.
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1. ANXIETY
The sensory message of pain can be separated from the emotional reaction to it.
Increased anxiety increases the emotional reaction to the pain.
1. CONTROL
Loss of control seems to increase pain by increasing anxiety and emotional
distress. The most upsetting pain is that over which you have no control.

1. DISTRACTION
Pain can be selectively tuned out if people are distracted (stereo
headphones, virtual reality goggles) or if they focus on an external object
(meditation).
This is the reason pain is worse at night - there are no distractions so people
focus on the pain.
1. INTERPRETATON
The meaning given a painful stimulus also affects pain. (If the patient feels
that having all his teeth removed to get dentures will mean that he is over the
hill, it will be more painful.)

STRESS
This definition is from the Decks: stress is a term used to describe a general
disturbance in psycho-physiological adaptation.
This definition is from Dr. Franklin: Stress is our bodys response to any
demand made upon itit is what you experience internally in response to a
situation you find hard to deal with.
This is the classic definition of stress: Stress is the absence of coping.

Stress is a normal part of life and impossible to avoid.

How you perceive the event can change the amount of stress you feel.
Your body responds to stress in many ways, both physical and emotional
o Physical: hormones surge, heartbeat and BP increase, blood sugar rises,
pupils dilate, muscles tense.
o Emotional: you may feel tired, depressed, anxious, irritable, rageful,
experience changes in eating or sleeping habits.
Anxiety is a signal that we are not coping well with stress.
Your body cant tell the difference between stress from positive event
(ex: wedding) or stress from a negative event (ex: car accident, major exam).
Your mind and body are connected.
Stress can be a killer if you dont pay attention to it. This is the way the Dental
Decks say the same thing: If a person is stressed, it implies that that person is being
maladaptively influenced by more than one negative or aversive factor.
Translation: if a person is stressed, all the things that are stressing him/her are
negatively affecting that person. These negative effects can take many forms,
including anxiety, raising blood pressure, decreased productivity on the job, trouble
in relationships, etc. etc.

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2 types of stress: acute and chronic. Studies have shown that prolonged stress
(chronic stress) can cause physical symptoms, including: arrhythmias and heart
attacks, high blood pressure and stroke, susceptibility to infections, GI problems,
weight problems, insulin-resistance, pain, sleep disturbances, disturbances in
memory, concentration and learning, depression, and allergy-like reactions.

COPING
The opposite of stress is coping. Coping is what we do to handle our stress.
Coping must be congruent with the stressor, which means that the type of coping
mechanism we use must match the stressor if the coping mechanism is going to work.
(Example: if you are stressed because you dont have enough money to pay your
rent, a massage might make you feel better temporarily but it wont address the
source of your stress.)
BEHAVIOR AND BEHAVIOR MANAGEMENT
***Note: Everything on this page is from the Dental Decks***

Definition of behavior from the Decks: a determined, purposeful unit of activity.

Determined the assumption that behavior is lawful and has determinants.
Purposeful the assumption that behavior is goal-oriented, that it seeks to achieve positive
and reduce negative need or motivated states.
Unit of activity what a person does that can be reported or described as discrete elements.
Example: Teeth do not behave, people do. Observing that a pulpal or periodontal problem
exists is s common behavior for the dentist. Avoiding the dentist even though an objective
need exists and the patient requires treatment, is a common behavior for patients. Both meet
the criteria of being determined, purposeful units of human activity.
Behavior is strongly affected by the following psychosocial factors:
Attitudes
Values
Society
Education
Beliefs
Family
Culture
BEHAVIOR 4 major fields
1. Personal-Social: usually a function of environment, work, play and society.
2. Motor starting point to access maturity.
3. Language vocalization, words, sentences, facial and hand movements.
4. Adaptive use of motor capacity and solutions to practical behavior.

Behavioral Development any observable response which is mediated through the

neuoromotor system.
To understand the development of human behavior you must understand the
concepts of maturation and learning.
o Maturation means growing more sophisticated in function. Maturity modifies
expectations of a childs behavior in that a child can not be expected to learn a
mode of behavior until he/she has matured to a stage at which he is ready for
such learning.
o The process of learning is continual and multiple. Learning occurs as a person
attempts to satisfy his needs. Motivation is a fundamental part of every learning
situation (more about motivation later).

Behavior Management is the means by which the dental team effectively and efficiently
performs treatment for the patient and at the same time instills a positive attitude.

15

Note: Most researchers believe that changes in behavior are a prerequisite to changes in
attitude.
Types of Interaction between Dentist and Patient
Aversive (Bad)
Non-Aversive (Good)
>Psychophysiological reactions
>Communication gathering information,
>Stress, anxiety and fear
identifying problems, giving information
>Pain
(as in case presentations)
>Preventive oral health behavior
>Management of physically or emotionally
challenged patients gradually expose them
to the dental office

Try to MIMIMIZE these

Try to MAXIMIZE these
Behavior Modification = Behavior Therapy
Definition: A kind of psychotherapy that attempts to modify observable, maladjusted
patterns of behavior by the substitution of a new response or set of responses to a given
stimulus.
Techniques of Behavior Modification - have been developed using the principles of
learning theory. The more closely the technique adheres to learning theory, the better the
technique will work.
The following are techniques of behavior modification:
1. Classical conditioning (Pavlovs dogs) a form of learning in which a previously
neutral stimulus comes to elicit a given response through associative training. Basic
Principle: A stimulus leads to a response. Example: If people with white coats on are
the ones who give the painful injections that make the patient cry, just the sight of a white
coat (stimulus) might make the patient cry (response).
2. Operant conditioning (BF Skinner) all behavior (except fear of falling and fear of
loud noises) is learned. Basic principle: the consequence of a behavior is a
stimulus that can affect future behavior. The consequence that follows a response
will alter the probability of that response occurring again in a similar situation. In
other words, if we want a behavior to happen over and over again, what follows the
behavior (the consequence of the behavior) is more important than what comes before
the behavior.
There are 4 basic types of operant conditioning, distinguished by the nature of the
consequence. They are:
Positive reinforcement
Omission
(more about these later)
Negative reinforcementPunishment
3. Aversion conditioning a technique in which punishment or unpleasant or painful
stimuli are used in the suppression of undesirable behavior. Example in dentistry:
Hand-Over-Mouth Technique.
4. Modeling (observational learning) a technique in which the person learns a
desired response by observing it being performed by others. Always occurs in a
social context (other people must be present for you to learn by watching them.)
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Example: if the dentist has an open office design, children can watch other children
be cooperative and then (hopefully) they will be cooperative, too.
5. Systematic desensitization a technique used for eliminating anxiety associated with
phobias (phobia = an irrational fear of something, such as fear of dental treatment).
The procedure involves the construction by the patient of a hierarchy of anxietyproducing stimuli.

Systematic desensitization, continued.

Example: Hierarchy of patients fears from least anxiety-producing (#1) to most
anxiety-producing (#10) situations related to dental treatment.
1. Calling for an appointment with the dentist.
2. Getting in my car to go to the dentist.
3. Sitting in the waiting room of the dentists office.
4. Getting in the dentists chair.
5. Seeing the dental instruments.
6. Having an explorer placed on the top of my tooth.
7. Having an explorer placed in a cavity.
8. Getting an injection in my gums on one side.
9. Having my teeth drilled and worrying that the anesthetic will wear off.
10.
Getting two injections, one on each side.

After the patient prepares the list, the therapist will ask the patient to imagine
himself/herself in each of the anxiety-producing situations in the list, starting
with the least anxiety-producing item (#1), advancing to the next most anxietyproducing item (#2) when he/she is ready, until finally the patient has imagined
himself/herself in all of the items in the list and the dental anxiety is gone. The
patient should begin dental treatment immediately upon completion of systematic
desensitization.
6. in vivo (real life) desensitization
The patient faces his/her fears (the dental office) without being relaxed first (by
hypnosis or imagery.) This is different than systematic desensitization (SD)
because in SD the patient imagines the anxiety-producing situation, in in vivo
desensitization the patient actually encounters the anxiety-producing situation in
real life, and thats why it is called in vivo.
Can be done in graduated exposures or can be confrontive. If you bring the
patient into the operatory for longer and longer amounts of time until he/she
is comfortable, that is an example of graduated in vivo desensitization.

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When you do in vivo desensitization in a confrontive manner it is called

flooding. Flooding is the behavioral equivalent of getting over your fear of
water by jumping in to the deep end of the swimming pool. If a patient is afraid
of spiders you make him stick his hand in a box of spiders. If a patient is anxious
about dental treatment you bring him in and do a procedure on him. Flooding is
NOT recommended to treat dental anxiety.

The area of operant conditioning has a unique vocabulary. Following are definitions of
some of the terms:
REINFORCER
Anything that will increase the future likelihood of a response if it has immediately
followed that response.
There are 2 types of reinforcers:
1) Primary (unconditioned) - food, water, sex. Do not use in the dental office.
2) Secondary (conditioned) - praise, attention, money. You will use secondary
reinforcement in the dental office, especially praise. Praise and smiling are
also referred to as social reinforcers.
Reinforcers are used in the 2 types of reinforcement: positive reinforcement and negative
reinforcement.
AVERSIVE CONDITION
One we tend to minimize contact with; one we dont like (being yelled at, being hit, etc.)
Aversion therapy procedures involving the use of painful or unpleasant stimuli to help
patients reduce unwanted but persistent behaviors. NOT recommended for dentistry.

REINFORCEMENT - causing behavior to increase. Can be positive or negative.

BOTH positive AND negative reinforcement cause an increase in a specific behavior.
The difference is in the WAY the behavior is reinforced .
POSITIVE REINFORCEMENT
A response becomes more likely in the future if a reinforcer (a reinforcer is a
positive thing see above) or an increase in a reinforcer has immediately followed
it in the past. In other words, if you want a behavior to increase you give the patient
something positive (praise, smile, etc.) every time he/she does the behavior. Then he/she will
do that behavior again because he/she wants to get that positive reinforcer again.

NEGATIVE REINFORCEMENT
A response becomes more likely to occur in the future if the removal or reduction
of an aversive condition has immediately followed it in the past.
Both positive and negative reinforcement make behavior more likely to occur in the
future.
Negative reinforcement is NOT the opposite of positive reinforcement.

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Negative reinforcement is NOT reinforcing someone in a negative way - that is

called PUNISHMENT.

OMISSION
Removal of a pleasant stimulus.
PUNISHMENT
A response becomes less likely in the future is an aversive condition or an increase in
an aversive condition has immediately followed it in the past.
Punishment is NOT recommended in the dental office.
EXTINCTION (or EXTINGUISHING a behavior)
Causing behavior to decrease by not reinforcing it any more.
SUMMARY:
Type of Reinforcement
Positive Reinforcement
Negative Reinforcement
Punishment

How it Works
Effect on Behavior
A positive condition (a reinforcer)
Behavior
is GIVEN
increases
A negative (or aversive)
Behavior
condition is TAKEN AWAY
increases
A negative (or aversive)
Behavior
condition is GIVEN
decreases

The Hand-Over-Mouth technique can be used to illustrate both punishment and negative
reinforcement. If you put your hand over a childs mouth because he is misbehaving, that
is punishment (imposition of an aversive condition). Once your hand is over the childs
mouth, if he sits still and you tell him you will remove your hand if he continues to sit
still that is negative reinforcement (removal of an aversive condition to reinforce the
desired response (sitting still).
SHAPING
A technique of operant conditioning used in behavior therapy.
The method of successive approximations; new behavior is produced by providing
reinforcement for progressively closer approximations to the final desired behavior.
The patient is led through the procedure step by step. When you want a patient to
learn a difficult, complex behavior (such as flossing), break it down into small,
sequential, manageable steps.

COMMUNICATION - VERBAL
Dos and Donts in Effectively Communicating with Patients
DO
DONT
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Describe
Be specific
Be responsive
Time appropriately
Pay attention

Evaluate
Be general
Be evasive
Be premature or too deep
Be inattentive or wander

Use EMPATHY in communicating with patients

What is empathy? It is trying to understand what another person is feeling, trying to
put yourself in his/her place. This does not mean you have to agree with the person,
only that you try to understand his/her point-of-view.
Empathy is NOT the same thing as sympathy.
Nonverbal communication (facial expressions that indicate that you are concerned
about the patient) is very important in expressing empathy.
Active Listening
Active listening is using feedback to understand others.
Feedback = stating your reactions or thoughts to what was said. Feedback must
be immediate, honest and supportive (positive).
Active Listening is a two-part skill: 1) First you understand, 2) Then you
communicate your understanding.

REFLECTION

Reflection can be defined as accurate empathic understanding.

Reflection is a part of active listening.
Reflection should reflect more than just content of the words; it is not simply
objective knowledge (I understand what your problem is.)
You use reflection to communicate to the patient that you understand his/her
thoughts and feelings (not just his words). There are 2 techniques you can use to
reflect a patients thoughts and feelings:
1) paraphrasing what the person said to you - stating it in your own words.
You can use phrases such as What I hear you saying is or Let me see
if I understand you Dont just repeat what the patient says this is
called parroting, and people can take offense at this.
2) clarifying - asking questions until you understand.

The best way to show a patient that you care about what he/she is telling you is to use eye
contact. Eye contact is the principle nonverbal cue that people can use to regulate
verbal communication.
VERBAL COMMUNICATION - TYPES of QUESTIONS
1. Open-Ended Questions those that cannot be answered with a simple yes or
no.
The most effective type of question in helping patients to express their
understanding of the proposed treatment plan.

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Open-ended questions request information in the patients own words

about a general content area.
Open-ended questions draw more information from the patient than any
other type of question.
Open-ended questions are the best type of question to ask to gather
information from the patient.
Example: How are you doing with your brushing and flossing?
Tell me about the pain you are having.
2. Closed-Ended Questions can be answered with a yes or no. Avoid these.
Example: Does your tooth hurt?
3. Facilitating Questions encourage the patient to say more, without specifying an
area or topic.
Example: Tell me more about that.
4. Direct Questions questions that ask the patient for a specific bit of information.
Example: Is it easier to hold the brush this way?
5. Probing Questions ask for more specific information that the patient offers
spontaneously.
Example: What else did you notice about your gums?
6. Laundry List Questions ask the patient to respond from among a list of
alternative adjectives or descriptions provided by the dentist.
Example: Is the pain throbbing, aching, dull or sharp?
7. Leading Questions the way you ask the question suggests the answer you want
from the patient. Not a good type of question to use.
Example: Youre not afraid of needles, are you?

COMMUNICATION NONVERBAL
(Nonverbal communication is the same thing as body language.)

Types of Nonverbal Communication

Voice inflection, tone & volume
(its not what you say, but how you
say it)
Gestures & postures
Touch
Dress & grooming
Physical distance
Facial expression
Skin color (pale, blushing)

Environment

Acceptable Nonverbal
Communication Varies with:
Age
Gender
Ethnic Background
Geographical Region
Culture
Situation

Characteristics of Nonverbal Communication

Nonverbal communication exists.
You cant NOT communicate.

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Remember this: Attitudes, emotions and feelings are expressed better

nonverbally; words are better for expressing thoughts.
Double messages - people often simultaneously express different and even
contradictory messages in their verbal and nonverbal behaviors, commonly to cover
nervousness, to make you think they are less sick or less in pain than they actually
are.
The face and eyes are the most noticed parts of the body. Different emotions show
most clearly in different parts of the face:
happiness, surprise - eyes and lower face.
anger - lower face, brows, forehead.
fear and sadness - eyes.

THE HEALTH BELIEF MODEL

Is a conceptual framework that describes a persons health behavior as an
expression of his/her beliefs about health.
Was designed to predict a persons health behavior, including the use of
health services, and to justify intervention to alter maladaptive health
behavior.
This model suggests that people will take action to prevent a disease only
when they believe they are susceptible to it.
Components of the Health Belief Model
1. The persons own perception of his/her susceptibility to a disease or condition.
(Im a health care worker. I might get AIDS from a patient.
2. The likelihood of contracting that disease or condition. (I wont get AIDS
unless I stick myself with a needle from a person with AIDS.)
3. The persons perception of the severity of the consequences of contracting the
condition or the disease. (If I get AIDS I will die.)
4. The perceived benefits of care and barriers to preventive behavior. (If I DO
stick myself with a needle from an AIDS patient, beginning the drug regimen
immediately will be beneficial to my health.)
5. The internal or external stimuli that result in appropriate health behavior by the
person. (Internal: I want to live a long life and raise my kids so Ill use
universal precautions. External: If my office gets a surprise OSHA visit we
better be using universal precautions.)
7 STEPS in the EDUCATIONAL PROCESS
STEP 1: RECOGNIZING NEEDS the dentist recognizes educational needs as he/she
checks for treatment needs. Then the dentist helps the patient to recognize his/her own
needs.
STEP 2: EXPRESSING NEEDS the dentist records educational needs and helps the
patient to state his/her own needs.

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STEP 3: STIMULATING MOTIVATION motivation arouses and maintains interest.

The dentist may appeal to inner needs or use artificial stimuli to motivate patients.
STEP 4: SETTING GOALS these may be short-term goals or long-term goals. Goals
guide a persons activity. Goals must be meaningful to the person, attractive and
attainable.
STEP 5: ACTING TO ACHIEVE GOALS activity is necessary to learning. The
activity should be directed toward specific goals.
STEP 6: REINFORCING LEARNING review and repetition aid in retention of what
is learned.
STEP 7: EVALUATING RESULTS this aids in judging what the patient has learned
and how effective the dentists teaching has been. This can help clarify or redefine the
goals.
Note: ALL learning situations wont follow these steps in exact sequence, but most
situations will include all of the steps in some form.
THE RELATIONSHIP BETWEEN NEEDS AND LEARNING
Needs are driving forces that prompt a person to act.
The process of learning is continual and multiple.
Learning occurs as a person attempts to satisfy his needs.
Telling a person what he needs may convince him that a behavior change is
desirable.
Expressing needs helps to pinpoint them for the dentist and patient.
Recording educational needs can be as important as recording treatment needs.
MOTIVATION
Definition
The internal and external driving forces that prompt a person to act; the drive that
pushes a person to satisfy a need.
Influences the way a person thinks, feels and responds.
Motivation is a fundamental part of every LEARNING situation.
Needs and goals may provide motivation.
o Short-range goals are less remote and more easily attained.
o Goals should be attractive and attainable in order to be meaningful.
o Goal-directed activity is necessary for learning.
Patients rarely learn without some kind of motivation.
Types of Motivation.
1) Intrinsic Motivation
Originates from strong drives within
the individual, such as hunger,
thirst, anxiety.
More likely to induce long-term
changes in attitudes & behaviors.

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People who are intrinsically

motivated are more likely to
continue toward a goal
regardless of what other people
say or do.

Behaviors leading to selfimprovement are generally

motivated by intrinsic rewards.

2) Extrinsic Motivation (Incentives)

Exist outside of the patient.

Examples: praise, encouragement,
material rewards, punishment
or removal of rewards, fear or threats

Motivation 4 Basic Factors (Ex: Well use the situation of a patient with halitosis,
bleeding gums, and a bad taste in his mouth)
1. Driving force desire to eliminate odor.
2. Action by the individual makes an appt.
3. Need or goal to be achieved prophy and fluoride.
4. Some form of satisfaction of a persons needs fresh breath.
Humanistic Theory of Motivation - Maslows Hierarchy of Needs
Theory states that lower level needs must be met before higher level needs can be met
1. Physiologic Needs food, water, oxygen, sleep. (LOWEST level of needs)
2. Safety Needs protection from physical threat or harm.
3. Social/Identity Needs a sense of belonging, giving/ receiving affection, desire for
identity & social recognition, expression of love.
4. Esteem Needs desire to be successful, self-confident and respected.
5. Self-Actualizationcomplete maturation, be all you can be (HIGHEST level of needs)
When a high value is placed on dental health, motivation increases the chance that
the individual will not only improve his dental health practices but will be
committed to them over a long period of time despite any external barriers (lack of
finances, lack of transportation).
COMPLIANCE
Definition: the extent to which a persons behavior coincides with medical or
health advice.
Other terms that mean the same thing: adherence, therapeutic alliance.
Few patients comply completely with professional suggestions in dentistry or
medicine. This is especially true if the disease is chronic and not perceived as lifethreatening.
Compliance Depends On
Age
SES
Culture

Psychosocial
problems
Duration and cost of
therapy

Factors that Decrease Compliance

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Treatment time.

Side effects of
therapeutic agents

Complexity of the required

behavioral changes.
Problem is chronic.
Problem is only mildly threatening.
Stressful life events.

Factors that Increase Compliance

Methods to Improve Compliance

Problem is immediate.
Threat is severe.
Patients are informed.
Patients receive positive
reinforcement.
Barriers to treatment are reduced.

Successful communication with the patient, repeated as necessary.

Inform in writing.
Simplify.
Accommodate suggestions fit the patients skills and needs.
Positive reinforcement.
Keep records of compliance.
Remind patients of appointments.
Identify potential noncompliers and discuss problems noncompliance may cause.

PRINCIPLES OF ETHICS - Definitions

Justice - be fair. Do for one what you do for the other. Requires health professionals to
inform their patients about treatment and to protect their confidentiality.
Autonomy - consider what the patient wants.
Beneficence - do good, youre a member of a helping profession.
Nonmaleficence - do no wrong.
Fidelity - keep your word.
CULTURAL DIVERSITY

In treatment planning, the dentist should consider a patients ethnic identity and
heritage because the patients cultural background influences the formation of his
health-related beliefs and attitudes.
The facial expressions for fear and anger are the same in all cultures.

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