Kiểm soát hành vi trẻ em trong điều trị nha khoa bằng phương pháp không dùng thuốc

Tap chi THONG TIN Y DlfOC

So 5 ndm 2012

KIBIA SOAT HANH VI TRE EM TRONG DIED TR) NHA KHOA DANG PHUONG PHAP
KHONG DUNG THUOC
Vd TruVng Nhu" Ngpc
Mot trong nhuhg van de quan trong nhat trong dieu trj cho t)enh nhan (BN) tre em do la
kiem soat hanh vl. Niu khong co si/ hdp tac cua tre thi dieu tri trong nha khoa rat kho thut
hien. Hau hit cac tre khi tdi phong kham nha deu cd mot vai cam xuc lo lang hoae sd hai do
hoc dddc tCfbo me, nhuhg ngudi than, ban be hoae ehi ddn glan la do tudng titdng. Do vay,
eae nha sy can phai ed nhutig klin thut chuyen sau ve tam ly tre em died nhOhg bien phap
tlip can tre phu hcfp.
I . CAT VAN DE
Hlnh vi nha khoa tre em dupe djnh nghia
la nhihig phan xa hinh thanh tif cac yeu td
tam li, xa hdi, kinh nghiem thu dupe sau khi
mic loi khi tre edn nhd ho3e tudi thieu nien cd
lien quan tdi eae tinh hudng trong nha khoa
[2,3]. Do vay, viec chan doin loai hanh vi eiia
tre rat phifc tap va eung la van de can thiet
trUde khi lus chpn ky thuat tiep can tre.
Kiem soat hanh vi cd the la khach quan
nhU: tao mdi trudng giao tiep hieu qui vdi tre
va cha me chung, tao dupe Idng tin vdi ca tre
va cha me de hp chap nhan dUpc thu thuat
nha khoa, tuyen truyen cho tre va cha me mat
tich cUc ciia dU phdng sii'c khde rang mieng,
tao mdi trUdng thU gian, thoal mai eho dpi ngu
nhan vien lam viec hieu qua.
I I . TRE LAN OAU DEN PHONG NHA

Nen dua tre di tdi phdng kham rSng
khoang tir 3-4 tudi [1]. Mii'c dp bleu hien sU
hdp tac cua tre miu giao rat cao d lan gap dau
tien. SU lo ling eiia me ddng vai trd quan
trpng trong phan ifhg ciia tre d phdng kham.
Co nhieu nhan td khac nhau anh hUdng tdi
hlnh vi ciia tre d lan gap dau tien. Lan dau tdi
thudng chi khim, dlnh gii X-quang v l neu
can du phdng thi bdi fluoride trif phi tre cd cic
benh qua cap b'nh.
Tre cang nhd tudi cang de sp hai nen cd
the giy ra lo sp trong khi ehup X-quang, dan
tdi hanh vi khdng hpp tae eua tre. Cha me nen
giu" may ehup trong mieng tre de chiing elm
thay an toin hdn. Tre nhd tudi khdng nen tach
rdi khdl tid me ho3e phai nam tren ghe rang
mdt minh. Khdng nen thut hien bat ki thii
thuat nha khoa nao ngay tir lan dau tien cho
dil tre rat hdp tic tru" tnrdng hdp cap eifU.
I I I . KIEM SOAT HANH V I
Kiem soat hanh vi ciia tre la van de rat
phut tap ddi hdi su" phdi hpp ciia ea cha me.
"TS., Vien Oao tao RSng Ham M3t - Tnrdng Dai hoc Y Ha Npi

nhan vien nha khoa va tham chi ca thay cd
giao. Cd the kiem soit hlnh vi bing hai each
cd bin: each khdng diing thuoc va each diing
thude. Cach khdng diing thude ed nhieu kl
thuat khac nhau nhU:
- Hinh thanh hanh vi trUde khi tdi khim benh.

- Giao tiep.
- Hinh thanh hanh vi: ky thuat Ndi - Diln Lam, gay cam iitig, lay tam gUdng cho tre hoc
theo, ludng trUdc tinh hudng bat ngd.
1. Hinh thanh hanh vi tntdc khi tdi
khambenh
Cach nay cd mue dich chuan bj tam li cho tre
trUdc khi di kham bing nhieu each nhu nghe
nhin, viet thU, xem phim, xem eae doan video.
Giai thich cho tre hieu 6\i(ic tam quan trpng ciia
viec gID' gin sifc khde rang mieng. NhChig doan
video ve cic tre khac da tutig dieu trj r3ng mieng
nhu the nao tao cho tre ed cam xiic va hanh vi
tUdng tu nhu the. Oieu ehinh hlnh vi cho tre
trUdc budi hen od the tien hlnh bing cich eho
tre gap gd vdi nhihig BN kieu miu nhu anh chj,
ban eung liila hoae chinh cha me nhutig ngUdi da
tifng trii qua van de rang mieng.
Nen gifi thU ndi ngan gpn ve nhutig thu
thuat se lam cho tre biet. Cich nay gpi la
phUdng phip chuan bi bang thU tin. Cha me
cung nen dUa cho tre nhihig Idi khuyen de
chiing chuan bi t i m li trUdc khi tdi dieu trj.
2. Giao dep
Dau hieu xac nhan nha sT thanh odng trong
kiem soat hlnh vi cua BN nhi do la khi ning
giao tiep va ehinh phue dupt sU tin tUdng eiia
tiB. SU sp hai va tinh hieu ki bam sinh ciia tre
giiip ehung ta biet tn/dc la phai giai thfeh rat tdt
cho chiing t n j & khi tien hanh mpt kf tiiuat mdi
hoae khac Sir giao tiep dupc tao ra tir nhfhig

diem ttiiet yeu eua ki tiiuat Ndi - Dien - Lam.
Tinh khich quan ciia giao tiep:


Tap chi THdNG TIN Y DlfOC
2.1. Hinh thanh si/giao dip:
Ndi chuyen giiip nha sT tim hieu rat nhieu
dieu ve fre va lam chung thay thoai mai, thu
glan nhUng khdng nen di qui gidi han. Mdt vai
tre nhan ra ring bing cicli kiem soat cudc ddi
thoai chung cd the cd ging tao ra nhutig anh
hudng dang ke len mdi trudng (Lim bic sT
phai theo tre nhieu hdn).
2.2. Hinh thanh ngudi trao thong tin:
NgUdi tiuyen dat od tiie la bat ki al tai phdng
kham neu biet ttidng tin. SU giao tiep dau tien
chi'nh la khi l l tan tiep ddn tre va cha me chung
vdi net m3t vul ve. Cude trd chuyen nay rat quan
trpng vi nd xay dutig ttiai dp va niem tin ciia BN
vdi nhan vien y te. Trp thii nen ndi chuyen vdi tre
tren dudng tij" phdng tiep ddn tdi khu dieu tri va
trong khi chuan bj tie len ghe r3ng. Khi nha sT tdi,
vai trd giao tiep ciia trp thii bj md nhat, khi dd tre
od tiie ling nghe mdt ngUdi tal mdt thdi diem.
2.3. Thong dlep ro rang:
Bao gdm ca nhihig Idi chao hdi, viec giai
thfeh vdi BN eho tdi Idi elm dn. NhChig cau ndi
vdi trd nen ddn glan va de hieu. Cd the diing
cich ndi lai. Khi ndi chuyen vdi tre nen ghi nhd
mdt vai diem quan trpng sau:

- Tre em khdng the phin ifng lai ngay vdi
cac cau hdi, chung can nhieu thdi glan de thau
hieu chung hdn ngUdi Idn.
Nen dUa ra nhihig yeu cau ddn gian va
trong khi n3ng thuc hien ciia tre.
- T i t ca nhu'ng yeu cau nen dUde dUa ra
bing ngdn ngC? tfch cUc vi each tiep can tieu
cUc cd the khien tre sp hai. Vf du: nen trinh
ndi "Nim yen" ma nen thay bing "Chu
khdng the chu'a rang eho chiu tdi khi chau
ngdl yen vj trf".
Nen gpi ten tre bing ten than mat hay
dupc sir dung d nha.
3. Hinh thanh hanh vl
Hinh thanh hlnh vl dim tren tren thuyet
kfch thfch - phin ifng v l ngudn gdc eiia nhan
thifc xa hdl, tre dUpe day each img xif nhU the
nao. Cae ki thuat cd the sir dung de hinh
thanh hlnh vi eho tre bao gdm:
- Ki thuat Ndi - Diln - Lam.
- Giy d m ifng bing dch kfchttifehdau nhe.
- Lay tam gUdng eho fre hpe theo.
- LUdng bT/dc tinh hudng bat ngd.
Nguyen tic ciia kiem soat hlnh vi bao gom:
bit dau vdi nhihig yeu d u ddn gian d l ttiut
hien, giai thfch nhChig quy trinh d n ttiiet cho tre
hieu va phdi hpp, giai thfch eho tiftig phan cu
ttie, giai ttifeh that d l hieu cho tie, giup tie ttie
hien nhutig hlnh vi tdt cho dieu trj.

So 5 nam 2012
3.1. KI thuat Ndi - Dien - Lam:
KT thuat nay dUpe Addleston tim ra nam
1959. Trong do, tre se diitic ndi qua ve d e thao
tac dieu trj, dUpc tiep xiic vdi dung cu de biet
chung se lam nhChig gi va sau dd tien hanh lam
ttiu ttiuat Khi dd diici tre se dude ndi la rang ciia
chung d n dUpc chai viia hoae lam sach. Tre se
nhin thay tay khoan, xem ehung quay trdn nhU
the nao va se dupe gidi thieu mdt kT thuat danh
rang dae biet, rang dUpc lam sach vdi nUdc. Viec
nen lam tiep ngay sau ki thuat nay la khen ngpl
tre de tang eUdng nhuhg hanh vi tdt ciia chiing.
Khi duS tre di ehup phim X-quang, nen gidi
ttiieu cho chiing biet do la mdt may anh de ehup
rang va de tre tin chic chan ring may dd se
khdng lam dau ma chi di gan tdi ma eiia tre thdi.
Phdng ehup nen cd d c thij nhoi bdng hoae cac
dd chdi ma tre thfeh de giam d m giic sp hai.
KT thuat nay nen dUpc lam trUde moi lan cd
dung CU mdi tiep xuc vdi tre. ICi thuat Ndi Diln - Lam can dupe sifa ddi khi ap dung eho
tre cd thj lUc kem. Khi do se diing kT thuat Ndi
- Sd - Lam ho3c Ndi - Ngifi - Lam. Tre se dUpe
cham, ngin, cam giac dupe vat lieu hoae dung
eu (trir vat sic nhpn).
3.2. ky thuat gay cam uhg:
Ky thuat nay cdn dupe gpi la ky thuat ifc
che tUdng tac. Dd la qua trinh tap luyen hoae
thUc hien eae bUdc lam giam nhay d m ciia BN
vdi nhutig lo lang xuat hien do d c vat the

hoae trong nhu'ng hoan canh dac biet Vdi moi
tinh hudng hoae vat the se dupc gidi thieu vdi
dp gay sp hai tang dan bit dau tif mifc thap
nhat de tao ra nhieu mifc gay lo sp.
KT thuat nay gdm ba giai doan:
- HUdng dan BN thU gian.
- Xay dutig cac mifc dp sp hai tang dan de
tao ra nhihig kfch thfch cd lien quan tdi noi sp
chfnh eiia BN.
- Cho BN thay d c mifc dp lo sp eac kfch thfch
dx) hS khi BN thay de chju, bit dau vdi ddng tac
gay ra sU lo sp tiiap nhat eho BN. Chi bit dau
thut hien dpng tae tiep tiieo khi BN thay khdng
con k) sp nuci. Vi du: neu diiS tre sp tiam rang,
phudng phip giy d m utig od tiie ttiut hien thanh
odng bao gdm d e yeu td la khautiepddn, nha s,
ghe rang, kham lim sang, dch phdng benh rang
mieng, trim phuc hoi bat ki cho nao d n thiel, ki
thuat nay yeu d u d n hen kham lai nhieu Sn.
3.3. Lay tam gudng eho tre hgc theo:
PhUdng phap nay keo theo viec cho phep tre
quan sat mdt hoae mdt vai ngUdi (tam gUdng),
nhihig ngUdi se the hien d c hanh vi thfch hpp
trong dch tinh hudng die biet. BN se thudng


Tap chi THONG TIN YDlfOC
xuyen bat chude nhutig hanh vi kieu miu dd
trong d c tinh hudng tUdng tU. Hinh mau dd cd
the la ngUdI that (la nhChra tre khac cung cd mat

tai phdng khim). Hinh mau eung ed the la phim
anh (ed tinh chat tUpng frutig hoae thay the).
Hinh miu od ttie diing nhan vat khdng cd that Vi
du nhu anh hoae doan video quay dnh chupt
Mickey dang dieu fri rang d phdng kham.
Cac budc d n thut hien khi diing dch lay
hinh mau cho tre hpe theo:
- Gay dupe sU chu y ciia tre.
- Hanh vi mono mudn lam miu dUpc.
- Can hudng dan nhutig ddng tae eiia hanh vi
nha sl mong mudn liic dau tien tre bit ehudc
- Ciing ed dch hanh vi d n thue hien.
Hinh miu la phUdng phap dem lai Ipi fch
dang ke trong khi cdng sii'c bd ra rat it. Thay vi
trong thdi gian chd dpi tre cd the bj anh hUdng
xau bdi tam ly lo ling ciia ngUdi me thi tdt hdn
chung ta nen dua tre vao phdng dieu trj ngay
neu d do cung ed nhutig tam gUdng cho tre
hpe theo dang 6\i(ic dieu trj. Khi anh chj ciia
tre cd the lam hinh miu 6\iiic, ehung ta nen
lUa chpn de cho tre thafy ring khdng ed gi phai
sp d va "Em cung lam dupe ma".
3.4. Kiim soat dnh huong bat ngd:
SU mat di nhutig hanh vi da 6\Jl(ic thiet lap
ho3c xuat hien nhChig yeu td lam thay ddi hanh
vi ciia tre d n dUde han die bang deh kiem soit
d e tinh hudng xay ra khd ludng tn/dc. SU ciing
ed bing deh nhae lai ludn lam tSng tfnh thanh
thuc CLia hanh vi. Chung dUpc phan thanh hai
loai: cung cd dUdng tinh va ciing ed am tinh.

Ciing ed dUdng tinh la su eiing cd cua nhutig
hlnh vi xuat hien bat ngd se lam tang tinh tiiuan
thyc ciia hanh vi. Cung cd am tinh la sU ciing cd
cua nhutig hanh vi da bj lu md cung lam tang
ti'nh thuan thuc ciia hanh vi. Cung cd qua nhutig
vat the, xa hdl va d c hoat ddng. NhChig BN sp
hai od the d n dutfc cung cd hanh vi nhieu lan.
Ciing cd xa hpi nen dutfc thut hien mdt deh
chan thanh sau mdi lan tdi kham theo ljch hen
de BN cd nhihig hanh vi thfch hdp tUdng ifhg vdi
yeu d u khi bic si thao tic lim viec.
4. Cac ky thuat kiem soat hanh vikhac
4.1. Diing am nhae diglam dau:
Hay edn dUde gpi l l "nhilu trang" - dd la
loai am thanh hon hpp lim BN rat khd de chu
y vao bat ki d i gi. Cd hieu utig niy II do BN bj
xao lang, phan tan ehu y va cd d m giac hUng
phan trong qua trinh dieu trj ciia nha si.
4.2. Kiim soat am ludng:
Khi sU truyen dat va dien ta that bai, kiem
soit I m lupng la yeu td ehu ehdt de cd the dat

So 5 ndm 2012
dupc sU chap thuan eiia tre. SU thay ddi
nhanh ve gipng dieu va d c h dien dat la mdt
bien phap hieu qua de kiem soat nhutig hanh
vi tieu cut ciia tre. Kiem soat am lupng ehIng
han nhu dot nhien ra lenh "ni'n ngay va tap
trung vio day" bao gid eung cd ket qua hdn la
ed phdi hpp nhieu deh truyen dat khac.

4.3. Giao tlip bang nhieu glae quan:
NhChig thdng diep khdng diing Idi ndi nhu
ngdn ngu" hinh the cung od ttie tao ra dupe nhChig
hanh vi tfch cut ctio tne. Cach dat tay len vai tre
khi ndi cung lam cho tre d m giac than thien, am
ap. Giao tiep bing anh mat cung quan ttpng
khdng kem. Ling nghett'ehcut eung quan trong
dae biet vdi tre d tudi ttiieu nien. Do do hay lam
sao de hieu dude d m xuc ciia tte.
4.4. Tholmien trong nha khoa:
Thdi mien &\iriz djnh nghia la mdt trang
thai dac biet cua tinh than d mpt ngUdi do
ngUdi khic tao ra. Mdt tinh trang ciia tinh than
gpi y ra rang anh ta khdng chi d l chap nhan
lam theo hPn luc tinh tao ma edn hanh ddng
rat manh me hdn cd the lam khi binh thudng.
Jame Braid (Anh) la ngUdi dau tien sif dung
thuat ngii' thdi mien va md ta hien tUpng bf an
dd la trang thai thdi mien than kinh. Bdn dSc
diem eiia trang thai thdi mien dd la:
- Khdng ndi tiep vdi cudc sdng thUe nhutig
khac vdi viec ngii.
Bj bit budc phai lam theo nhihig gi ma
ngUdi thdi mien yeu cau trong va sau trang
thii thdi mien.
- Cd tiem n3ng de thut hien sU viec hdn la
vdi thUc tai khach quan khi ed nhu'ng bien ddi
ve nhan thifc, tri nhd, d m xuc dUa tren nhihig
Idi gdi y cua nha thdi mien.
- Cd kha n3ng chju dutig nhutig mau thuin

ma binh thudng thi bj rdi loan.
4.5. Doi dau:
BN khdng diap thuan khdng nhuhgtiJ"nhan
thiit v l phan litig lai vdi cdn dau ml cdn do dch
hp giai quyet va ddi mat vdi nhihig sbess do dc
cdn dau tnTct day giy ra. Cic kltiiuatddi dau la:
- Lam xao nhang hoae chuyen ddi sU chu y
vao cii de dpa II y tUdng chii dao ciia phUdng
phip ddi dau. Chung ta cd the lam dupe bing
deh ndi chuyen thudng xuyen va dat nhutig
d u hdi thu vj vdi tre.
- Cho phep tre ndi ra noi lo sp vdi nha si de
tao eho tre d m giic an toan hdn.
- Cho phep bd me tre d trong phdng dieu
trj de tre thay an toan hdn.


Tap chi THdNG TIN Y DlfOC
4.6. Tht/glan:
PhUdng phap tiiu gian thudng bao gom mdt
chuoi d c bai tap phai hpe va yeu d u BN phai tap
luyen thudng xuyen d nha it nhat 15 phiit moi
ngay. Muc dich ciia d c bai tap nay giup giam
dng tiling va phat huy tiem nang chdng lai dau.
4.7. ue ehi hanh vl:
LTC ehe hanh vi cd ba each:
- Bjt mieng tre.
- Han che cif ddng eiia tre.
- Kiem soit am lupng.
LTC che hlnh vi thUdng dupe lUa chpn cudi

ciing cho nhutig fre qua nhd tudi, bj tat nguyen
ho3c nhutig tre od van d i khdng binh thudng ve
d m xuc va than kinh. Mdt vai nha sT diing dch
nay nhU mdt bien phap de dpa nat tre va mdt sd
cha me khdng tan thanh vdi deh lam nay va
cung d n sU thdng qua ciia luat phip. Ngay nay
viec giam dau y thifc cd the giup han che d e
trUdng hpp phai ifc ehe hanh vi hdn.

5. Til lap hinh vi
Ap dung cho nhutig tre the hien dang ve lo
ngai, run sd hoSc nhChig hanh vi gay can trd.
SU xuat hien nhihig hanh vi nay cd the la do
du am ciia lan th3m kham nha khoa trUdc day,
anh hudng hlnh vi khdng thich hpp tif bd me
ho3c mdi trUdng sdng. Trong sudt qua trinh tai
lap lai, muc tieu la xay dung mdt chuoi nhChig
lien ket trong trf nao tre. Neu tre da cd nhChig

So 5 nam 2012
an tupng khdng tdt ve phdng khim nha trUdc
day va dUde dUa tdi mdt phdng kham nha
khac thi nhin chung tre vin cd xu hUdng ap
dat suy nghl nhCitig dieu tdi te tUdng tU se xay
ra d phdng kham mdi. Hinh thifc tam If nay gpi
la "khai quat kfch thfeh". £)e loal bd dieu nay,
dpi ngu nhan vien nha khoa d n phai tao ra sU
khac biet va tao nen nhu'ng tic ddng mdi lam
hai Idng va thay the cai eu.
IV. KET LUAN

Kiem soat hanh vl eiia tre ttong can tiilep nha
khoa hang ngay la dieu khdng ttie thieu de dam
bao ca dieu tri thanh edng. Kiem soat hanh vi
bing dch khdng diing thude la phUdng phap
dupc lu^ chpn dau tien. PhUdng phap nay cd
nhieu kl thuat khac nhau nhU: hinh thanh hanh
vl trUdc khi tdi kham benh, giao tiep, hinh ttianh
hanh vi,... Tiiy theo tijtig ddi tUdng ml chung ta
nen luS chpn ky tiiuat hpp ly. Thdi mien trong
nha khoa la mdt khai niem tUdng ddi mdi trong
nha khoa tre em nhuhg cung la mdt ky ttiuat cd
the cho la ddn glan va hieu qua.
TAI LIEU THAM KHAO
1. Courson P.: Odontologie pediatrique au quotidien.
Deuxieme edition, 2005.
2. McDonald E.R.: Dentistry for child and
Adolescent. 2004.
3. Rao A.: Behavior management in dental practices.
Principles and practice of pedodondcs, 2008,
Jaypee, pp.91-121.iS'

UC CHE CALCINEURIN (TACROUMUS) - MOT DOOC TIEN MOI TRONG DIBJ TR|
VIEM DA 0! UNG
Nguyen Thi Van", Cat Van Anh"
Nhihig nSm gan day, nhitng din bo trong qua trinh nghien euV ve dieu tn eae benh ly da da
dan din si/ehap nhan cae san pham mdi trong dieu tri. Nhuhg san pham mdi nay dddc thifa
hudng nhuhg din bo mdi trong nghien euV ve mien dich benh ly. Mgt trong nhuhg din t>g dd
la diing de ehi calelneurin (tacrolimus) brong dieu tri viem da di dhg.
I . DAT VAN DE
Dieu til viem da dj irhg da dUdc dlnh dau

bing mdt bUdc ngoSt vio n3m 2001 bdi sU ra
ddi aJa d c thude dieu hda miln djch dieu trj tai
eho va toan thin. Mdt ttong nhuhg sin pham dd
la tacrolimus (Protopic) va picrollmus (Elidel).
Dly la nhihig hoat chat cd cd ehe tac dpng nhU
dcrosporin: ut ehe d c ealdneurin lam kim ham
qui trinh sin xuat d e cytokin. NhChig chi dinh
dill yeu eiia nd trong dieu tri tai dio la d c benh
"PGS.TS., 0?i hpe Y Ha Npi; "ThS., Benh vien M3t Tmng uHng

ly viem da v l dac biet trong viem da dj utig.
NgUpc lai vdi cortieoid, nd khdng gay teo da,
thim da. Cung sau nhieu cdng trinh nghien cuU
tuWng ti/ nhu vdi Protopic, ngUdi ta da duS ra ttij
trUdng san pham Aldara cd vai trd kfch thi'di dip
utig mien djch qua tmng glan thymus-1. Trong
dd vai trd ciia lympho T (LT) ddng vj tri quan
trpng trong cd die benh sinh d c bdnh ly da ke
d ton tiiUdng vay nen. LTc che hoat hda d c te
bao LT hoSe d e cytokin S\i(ic giai phdng ra tij"