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AVERSIVE CONDITIONING-HAND OVER MOUTH - EXERCISE (HOME)        

 

Pulp therapy, restorative procedures, space maintenance and education in prevention are the basic services provided to children. It takes more than diagnostic acumen and knowledge to deliver quality dental care to children. The “X” factor is cooperation of the child. Technical skills alone are useless if the child cannot cooperate and the dentist cannot place the filling or treat the pulp or is not able to persuade the child to accept the appliance.

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Fortunately, most children prove to be fine patients. For those, however, who find it difficult to accept a strange environment, and pose a real or imagined threat to the body, who do not comprehend orders or the child definitely demonstrating a temper tantrum, the dentist must demonstrate his authority and mastery of the situation and should gain the child’s attention. The key is aversive conditioning method, to gain the attention of the child so that he can listen to what is being said and receive the dental care by finding a way to overcome anxieties so that his or her dental needs may be met.

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There are several options available to the dentist who finds himself in company with a child who is uncooperative, vocal and to a degree violent. This paper is about children who are normal and who, by virtue of age and maturation, can be reasoned with and are able to understand simple verbal commands.
 
The aversive conditioning method of behavior modification is often referred to as HOM technique, stands for Hand Over Mouth technique.  In 1929,Dr.Evangeline Jordan wrote,”If a normal child will not listen but continues to cry and struggle ….hold a folded napkin over the child’s mouth ….and gently but firmly hold his mouth shut .
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His screams increase his condition of hysteria, but if the mouth is held closed, there is little sound, and he soon begins to reason.” Levitas (1974) called it as HOME, Hand Over Mouth Exercise, exercise because use of this technique is an exercise in judgements:on whom? When? How?  Kramer (1973) called it as aversion. Lencher and Wright (1975) termed it as aversive conditioning. Lampshire has referred HOM as emotional surprise therapy as the sudden and firm approach comes as a surprise to the child, and an immediate attitude change occurs.

 

HOME should be employed for the so-called normal, healthy child, who is three years of age or older, on the assumption that one can reason with the children. It is important to stress that HOME is not used routinely but as a method of last resort. Levitas (1974) makes his point by describing his effort to secure a child’s attention: I cajole, I plead, I beg, I urge, I order the child to listen to me.

 

The first step that must be taken with this difficult child is to get him to listen to what the dentist has to say. Repeated orders in a voice with increasing authority will cause the child to pause and listen. Infact this firm positive approach is effective enough to cope with all but the few most difficult children. Every dentist who treat children will have some cases where other behavioral techniques won’t work as the child approaches hysteria, it is then the physical means must be resorted to in order to calm the patient sufficiently to listen to what you have to say. No doubt all who employ this technique would agree that this technique is not for the very young, immature, serious physical handicaps, or for those who are mentally or emotionally afflicted. This is not used as a punishment but only as a means of getting an attention of the child so that a dialogue may be established.

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The technique can be summarized as:
  The child is placed firmly on the dental chair as the dentist becomes seated on the stool.
  • If the child strikes out or flails about, both the chair side dental assistant and the dentist may restrain the patient. The child is restrained to prevent self-harm, to protect the dental staff and also to avoid damage to the dental equipment.
  • If the child continues the physical resistance, screaming or crying little communication is taking place. The dentist then places the hand over the child’s mouth to stifle the noise .At the same time, in close proximity to the patient the dentist says calmly but firmly.
  • Once the patient discontinues resistance, the dentist should remove the hand and reinforced the improved behavior.
  • If a child resumes the unacceptable behavior when the hand is removed; another attempt or two may be made to modify the behavior by again placing the hand over the mouth to stifle the noise and establish communication.
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Example:
 

The dentist places the hand over the child’s mouth to muffle the noise and brings face close to his & talks directly into his ear. “If you want me to take my hand away, you must stop screaming & listen to me. I only want to talk to you & look at your teeth.” After a few seconds, this is repeated, “Are you ready to remove my hand”? Almost invariably there is nodding of the head. With a final word of caution to be quiet, the hand is removed.

As it leaves the face, there may be another request, “I want my mommy.” Immediately the hand is replaced. The admonition to stop screaming is repeated, & the dentist adds, “You want your mommy”? Once again the head bobs. And then, “All right, but you must be quiet, and I will bring her in as soon as I am finished. O.K.”? Again, the nod – and the hand is slowly lowered. The assistant is always present during HOME to help restrain flailing arms and legs so that no one is physically injured. By restraining the child he can be made aware of the fact that his undesirable coping strategies are not necessary or useful.

 

While the child is composing himself, the dentist begins to talk – about his clothes, about his freckles, about his pets, about almost anything, and no reference is made to what has gone before. Most of the times that is done & over. If there is an attempt on the part of the child to start again, a gentle but firm reminder that the hand will be replaced is usually enough to make him reconsider.

 

It is highly important to communicate with parents before and after treatment when this technique is employed. Whenever possible parents should be notified in advance and their permission obtained before employing this technique. HOME must never be used in anger. Prudent usage implies that the dentist is in complete control of his/her emotions. The dentist must learn to control under all circumstances even though he may feel anger as any person might. If unable to remain calm and control personal behavior, the clinician should shift to some other management techniques.

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It may take longer initially to use HOME, but a cooperative healthy patient will be the happy result. The child will lose his fear of dentistry. The immediate effect of gases and drugs may be obvious more quickly than that of HOME. But the long term benefits from HOME of rapport, confidence and learning are indispensable.

The Hand Over Mouth Exercise may be the purest expression of understanding, concern, and love a dentist can show a child whose fears of dental treatment are boundless yet unfounded. For, afterall, HOME is where the heart is.

   
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