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Behavior Guidance for the Pediatric Dental Patient
Latest Revision
2024
Abbreviations
AAPD: American Academy of Pediatric Dentistry.
AAT: Animal-assisted therapy.
ITR: Interim therapeutic restoration.
PECS: Picture exchange communication system.
SADE: Sensory-adapted dental environment.
SDF: Silver diamine fluoride.
SHCN: Special health-care needs.
Abstract
This best practice provides health care personnel, parents, and others with information for predicting and
guiding behavior in children during dental procedures. Successful treatment of pediatric dental patients depends
on effective communication and developing customized behavior guidance plans dependent on the patient’s
treatment needs and the skills of the dentist. Behavior guidance is a continual process from basic to advanced
techniques, using nonpharmacological and pharmacological options. When considering behavior guidance
options, the following factor should be included and documented: medical history, temperament, informed
consent (including risks, benefits, and alternatives), pain assessment, acuity of treatment needs, previous
behavior during treatment, previous behavior guidance techniques used, and any alternative treatment options
including no treatment or deferred care. Basic behavior guidance includes communication guidance, positive
pre-visit imagery, direct observation, tell-show-do, ask-tell-ask, voice control, non-verbal communication,
positive reinforcement and descriptive praise, distraction, and desensitization. For anxious patients and those
with special health care needs, additional behavior guidance options include sensory-adapted dental
environments, animal assisted therapy, picture exchange communication systems, mind-body therapies such as
biofeedback and breathing exercises, and nitrous oxide-oxygen inhalation. Advanced behavior guidance includes
protective stabilization, sedation, and general anesthesia. Each option requires an evaluation of objectives,
indications, contraindications, and precautions. Knowledge of these options will aid healthcare professionals in
providing patient-specific and family-centered behavior guidance for infants, children, adolescents, and persons
with special health care needs.
This document was developed through a collaborative effort of the American Academy of Pediatric Dentistry
Councils on Clinical Affairs and Scientific Affairs to offer updated information and recommendations to inform
health care providers, parents and others about the behavior guidance techniques used and behavioral influences
impacting contemporary pediatric dental care.
KEYWORDS: ANESTHESIA, GENERAL; SEDATION; BEHAVIOR THERAPY; NITROUS OXIDE; DENTAL
ANXIETY; PEDIATRIC DENTISTRY
Purpose
The American Academy of Pediatric Dentistry (AAPD) recognizes that dental care is medically necessary for
the purpose of preventing and eliminating orofacial disease, infection, and pain, restoring the form and function
of the dentition, and correcting facial disfiguration or dysfunction.
1
Behavior guidance techniques, both
nonpharmacological and pharmacological, are used to alleviate anxiety, nurture a positive dental attitude, and
perform quality oral health care safely and efficiently for infants, children, adolescents, and persons with special
health care needs (SHCN). Tailoring techniques to the needs of the individual patient and the skills of the
practitioner can allow for improved clinical outcomes. The AAPD offers these recommendations to inform health
care providers, parents, and other interested parties about influences on the behavior of pediatric dental patients
and the many behavior guidance techniques used in contemporary pediatric dentistry. Information regarding pain
management, protective stabilization, and pharmacological behavior management for pediatric dental patients is
provided in greater detail in additional AAPD best practices documents.
2-6
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Methods
Recommendations on behavior guidance were developed by the Clinical Affairs Committee, Behavior
Management Subcommittee and adopted in 1990.
7
This document by the Council of Clinical Affairs is a revision
of the previous version, last revised in 2020.
8
This update reflects a review of proceedings from the most recent
AAPD conferences on behavior guidance
9,10
, other dental and medical literature related to behavior guidance of
the pediatric patient, and sources of recognized professional expertise and stature including both the academic
and practicing pediatric dental communities and the standards of the Commission on Dental Accreditation.
11(pg25-
26)
In addition, a search of the PubMed
®
/MEDLINE electronic database was performed (see Appendix 1). Articles
were screened by viewing titles and abstracts. A narrative review was performed to extract the data and used to
summarize research on behavior guidance for infants and children through adolescents, including those with
special healthcare needs. An additional 50 articles on mind-body therapies were hand-searched, and a proportion
of them were reviewed by the workgroup for inclusion in this document. The information presented in this best
practice document aligns with the recent AAPD clinical practice guideline Nonpharmacological Behavior
Guidance for the Pediatric Dental Patient
12
which offers evidence for the efficacy of various nonpharmacological
behavior guidance techniques. This document extends the discussion of behavior guidance to include objectives,
indications, and contraindications of both nonpharmacological and pharmacological techniques. When data did
not appear sufficient or were inconclusive, recommendations were based upon expert and/or consensus opinion
by experienced researchers and clinicians.
Background
Dental practitioners are expected to recognize and effectively treat childhood dental diseases that are within the
scope of knowledge and skills acquired during their professional education. Safe and effective treatment of these
diseases requires an understanding of modifying the child’s and family’s response to care and an ability to modify
treatment approaches accordingly. Behavior guidance is a continuum of interaction involving the dental team
(i.e., dentist and staff), the patient, and parent directed toward communication and education before and during
the delivery of care. Goals of behavior guidance are to: 1) establish communication, 2) alleviate the child’s dental
fear and anxiety, 3) promote patient’s and parents’ awareness of the need for good oral health and the process by
which it is achieved, 4) promote the child’s positive attitude toward oral health care, 5) build a trusting
relationship between the dental team and the child/parent, and 6) provide quality oral health care in a comfortable,
minimally-restrictive, safe, and effective manner. Behavior guidance techniques range from establishing or
maintaining communication to stopping unwanted or unsafe behaviors.
13
Knowledge of the scientific basis of
behavior guidance and skills in communication, empathy, tolerance, cultural sensitivity, and flexibility are
requisite to proper implementation. Behavior guidance is never meant to be punishment for misbehavior, power
assertion, or any strategy that hurts, shames, or belittles a patient. General considerations for use of any behavior
guidance technique include alternative behavior guidance modalities, the oral health needs of the patient, the
effect on the quality of dental care and the patient’s well-being, the patient’s emotional and cognitive
development, medical and physical status, and the safety of the patient, parent, and dental team.
Predictors of child behaviors
Patient attributes
The ability to assess the child’s developmental level, dental attitudes, and temperament allows a provider to
anticipate the child’s reaction to care. The response to the demands of oral health care is complex and determined
by many factors. Factors that may contribute to noncompliance during the dental appointment include fears,
general or situational anxiety, a previous unpleasant and/or painful dental/medical experience, pain, inadequate
preparation for the encounter, and parenting practices.
13-18
In addition, cognitive age, developmental delay,
inadequate coping skills, general behavioral considerations, negative emotionality, maladaptive behaviors,
physical/mental disability, and acute illness or chronic disease are potential reasons for noncompliance during
the dental appointment.
13-18
Behavioral challenges often are more readily recognized than dental fear/anxiety due to associations with general
behavioral considerations (e.g., activity, impulsivity) versus temperamental traits (e.g., shyness, negative
emotionality).
19(pg345)
Only a minority of children with uncooperative behavior have dental fears, and not all
fearful children present with disruptive behavior in the dental setting.
14,20,21
Dental anxiety in children is an
expected occurrence due to unfamiliar environment and expectations. Apprehension to dental care may range
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from a true dental phobia to mild situational anxiety. Although anxiety may wane as patients mature, about fifteen
percent of pediatric patients have persistent anxiety or develop dental anxiety as adults.
22
Prevention of dental
anxiety through thoughtful behavior guidance practices aids in the development of patients with diminished fear
and apprehension.
22
Fears may occur when there is a perceived lack of control or potential for pain, especially
when a child is aware of a dental problem or has had a painful healthcare experience. If the level of fear is
incongruent with the circumstances and the patient is not able to control impulses, disruptive behavior is likely
to occur.
19(pg345)
Cultural and linguistic factors also may play a role in patient cooperation and selection of behavior guidance
techniques.
23-25
Since every culture has its own beliefs, values, and practices, understanding different cultures
will help providers to communicate better with patients and promotes a sense of genuine caring. Availability of
translation services is essential for those families who have limited English proficiency.
26,27
A federal mandate
requires translation services for non-English speaking families be available at no cost to the family in healthcare
facilities that receive federal funding for services.
28
As is true for all patients/families, active listening helps the
dental team address the patient’s/parents’ concerns in a sensitive and respectful manner.
25
Parental influences
Parents influence their child’s behavior at the dental office in several ways. Positive attitudes toward oral health
care may lead to the early establishment of a dental home. Early preventive care leads to less dental disease,
decreased treatment needs, and fewer opportunities for negative experiences.
29,30
Parents who have had negative
dental experiences as a patient may transmit their own dental anxiety or fear to the child thereby adversely
affecting the child’s attitude and response to care.
14,17,31,32
Additionally, past and current stressors experienced by
parents can negatively impact child behavior. Parental adverse childhood events can be associated with increased
negative behaviors in children, including increased hyperactivity and aggression.
33
Long term economic hardship
can result in parental depression, anxiety, irritability, substance abuse, and violence, which in turn can affect a
child’s behavior.
25
Parental depression may result in parenting changes, including decreased supervision,
caregiving, and discipline for the child, thereby placing the child at risk for a wide variety of adjustment issues
including emotional and behavior problems.
25
Through provision of compassionate care, dentists can promote
parental resilience and aid families in finding additional supports where needed.
33
Parenting styles vary across families and cultures and may influence the behavior of children during dental
visits.
16
As establishment of a dental home by 12 months of age continues to grow in acceptance, parents will
expect to be with their infants and young children during examinations as well as during treatment. Parental
involvement, especially in their children’s health care, has changed dramatically in recent years.
30,34
Frequently,
parental expectations for the child’s response to care (e.g., no tears) are unrealistic, while expectations for the
dentist who guides their behavior are great.
18
Parents’ desire to be present during their child’s treatment does not
mean they intellectually distrust the dentist; it might mean they are uncomfortable if they visually cannot verify
their child’s safety. Understanding the changing emotional needs of parents is important because of the growth
of a latent but natural sense to be protective of their children.
35,36
Encouraging parents’ questions, honoring
parents’ wishes, and maintaining openness while setting realistic expectations will build confidence and trust
between the provider and parent.
18,30,36-39
Orientation to dental environment
The nonclinical office staff plays an important role in behavior guidance. The parent’s initial contact with the
dental practice allows both parties to determine whether the practice is likely to be able to address the child’s
primary oral health needs.
40
The scheduling coordinator or receptionist often will be the first point of contact with
a prospective patient and family, either through the internet or a telephone conversation, and welcoming language
can foster helpful communication. Determining the chief complaint and any special health care or
cultural/linguistic needs can provide insight into patient or family anxiety or stress. Consideration of appointment
scheduling will benefit the parent/patient and practitioner by building a trusting relationship that promotes the
patient’s positive attitude toward oral health care. Appointment scheduling can be tailored to the needs of the
individual patient’s circumstances and the skills of the practitioner. Having established policies on scheduling
rather than leaving scheduling to chance can facilitate purposeful and efficient visits. Schedulers can help set
expectations for the initial visit by providing relevant information and may suggest a pre-appointment visit to the
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office to meet the dental team and tour the facility.
19(pp348-349)
Schedulers also can confirm the office’s location,
offer directions, and ask if there are any further questions. These initial encounters with the practice can help to
allay fears and better prepare the family and patient for the first visit.
From a behavioral standpoint, many factors are important when appointment times are determined.
19(pg353)
Appointment-related concerns include patient age, presence of a special health care need, the need for sedation,
distance the parent/patient travels, length of appointment, additional staffing requirements, parent’s work
schedule, and time of day.
19(pg353)
Urgent treatment is a priority, however, and may supersede these factors when
acute needs necessitate timely care.
41
Prolonging the duration of an appointment beyond a patient’s tolerance
level solely for the practitioner’s convenience can negatively affect a child’s behavior.
19(pg353)
Reception staff are usually the first team members the patient meets upon arrival at the office. The caring and
assuring manner in which the child is welcomed into the practice at the first and subsequent visits sets the tone
for each appointment.
18,42
A child-friendly reception area (e.g., age-appropriate toys and games) can provide a
distraction for young patients. These first impressions may influence future behaviors.
Patient assessment
An evaluation of the child’s cooperative potential is essential for treatment planning. No single assessment
method or tool is completely accurate in predicting a patient’s behavior, but awareness of the multiple influences
on a child’s response to care can aid in treatment planning.
43
Initially, information can be gathered from the parent
through questions regarding the child’s cognitive level, temperament/personality characteristics,
20,44-48
anxiety
and fear,
14,20,49,50
reaction to strangers,
51
and behavior at previous medical/dental visits, as well as how the parent
anticipates the child will respond to future dental treatment. Later, the dentist can evaluate cooperative potential
by observation of and interaction with the patient. Whether the child is approachable, somewhat shy, or definitely
shy and/or withdrawn may influence the success of various communicative techniques. Assessing the child’s
development, past experiences, and current emotional state allows the dentist to develop a behavior guidance
plan to accomplish the necessary oral health care.
19(pp346,347)
During delivery of care, attention to physical and/or
emotional indicators of stress allows for alterations of the behavioral treatment plan as needed.
23-26,52
Childhood adverse events such as bullying, domestic violence, neglect, family separation, and racism may have
a negative effect on patient behavior in a dental setting.
23,24,53,54
Adverse childhood events can impact function
and behavior, including changes in auditory processing, misinterpretation of facial expressions, and inability to
express emotions, and may lead to a heightened sense of danger.
55
Poor conduct, stimulated by certain sounds or
smells, sensations, or emotional states, may lead to maladaptive behaviors.
55
Trauma-informed care can be
described as “a framework that involves understanding, recognizing, and responding to the effects of all types of
trauma and seeking to employ practices that do not traumatize or re-traumatize.”
56
Employing a trauma-informed
care approach when assessing patient behavior, engaging and empowering families, promoting resilience, making
referrals, and choosing purposeful behavior guidance modalities will help to ensure the physical and emotional
safety of the child.
57,58
Dentist/dental team behaviors
The behaviors of the dental team are the primary tools used to guide the behavior of the pediatric patient. The
dental team’s attitudes and communication skills are critical to creating a positive dental visit for the child and to
gain trust from the child and parent.
30
Attentiveness to communication styles throughout interactions with patient
and families is important.
59
Communication (i.e., imparting or interchange of thoughts, opinions, or information)
may occur by a number of means but, in the dental setting, it is accomplished primarily through dialogue, tone
of voice, facial expression, and body language.
60-62
Communicating with empathy, offering reassurance, and
giving clear and specific instructions can help reduce anxiety and encourage patient cooperation.
63
Communicating with children poses special challenges for the dentist and the dental team. A child’s cognitive
development will dictate the level and amount of information interchange that can take place. With a basic
understanding of the cognitive development of children, the dental team can use appropriate vocabulary and
body language consistent with the patient’s intellectual development.
60-62
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Communication may be impaired when the dental team’s expressions and body language are inconsistent with
the intent of the message being conveyed. When body language conveys uncertainty, anxiety, or urgency, the
dentist cannot effectively communicate confidence or a calm demeanor.
60-62
In addition, the operatory may
contain distractions (e.g., another child crying) that, for the patient, produce anxiety and interfere with
communication. Dentists and other members of the dental team may find it advantageous to discuss certain
information (e.g., postoperative instructions, preventive counseling) away from the operatory and its many
distractions.
18
The communicative behavior of dentists is a major factor in patient satisfaction.
60,64
Dentist actions that are
reported to correlate with low parent satisfaction include rushing through appointments, not taking time to explain
procedures, barring parents from the examination room, and generally being impatient.
63
However, when a
provider offers compassion, empathy, and genuine concern, acceptance of care may be better.
63
While some
patients may express a preference for a provider of a specific gender, female and male practitioners have been
found to treat patients and parents in a similar manner.
65
The clinical staff is an extension of the dentist in behavior guidance. A collaborative approach helps assure that
both the patient and parent have a positive dental experience. All dental team members are encouraged to expand
their skills and knowledge through dental literature, video presentations, and/ or continuing education courses.
66
Informed consent
A purposeful behavior guidance decision includes a review of the patient’s medical, dental, and social history
followed by an evaluation of current behavior. Decisions regarding the use of behavior guidance techniques other
than communicative management cannot be made solely by the dental team and include the parent, as well as the
child when possible. They must involve a parent and, if appropriate, the child. The practitioner, as the expert on
dental care (i.e., the timing and techniques by which treatment can be delivered), is obligated to effectively
communicate behavior and treatment options, including potential benefits and risks, and help the parent decide
what is in the child’s best interest.
30
Successful completion of diagnostic and therapeutic services is viewed as a
partnership of dentist, parent, and child.
30,67,68
The conversation allows questions from the parent and patient in
order to clarify issues and to verify the parents’ and child’s comprehension. Communication in the family’s
preferred language, with assistance of a trained interpreter if needed is critical to verify their comprehension of
the proposed treatment and ability to provide informed consent.
13,28,69
Communicative behavior guidance, by virtue of being a basic element of communication, requires no specific
consent. All other behavior guidance techniques require informed consent consistent with AAPD’s Informed
Consent
69
and applicable state laws. A signature on the consent form does not necessarily constitute informed
consent. Informed consent implies information was provided to the parent, risks/benefits and alternatives were
discussed, questions were answered, and permission was obtained prior to administration of treatment.
13
If the
parent refuses treatment after discussions of the risks/benefits and alternatives of the proposed treatment and
behavior guidance techniques, obtaining an informed refusal form that is signed by the parent and retained in the
patient’s record is prudent.
70
If the dentist believes the informed refusal violates proper standard of care, he can
recommend the patient seek another opinion and/or dismiss the patient from the practice.
69
In the event of an unanticipated behavioral reaction to dental treatment, protecting the patient and staff from harm
is incumbent on the practitioner. Following immediate intervention to assure safety, if a new behavior guidance
plan is developed to complete care, a new informed consent for the alternative methods is indicated.
69,71,72
Pain assessment and management during treatment
Pain has a direct influence on behavior and can be assessed and managed throughout treatment.
73
Anxiety may
be a predictor of increased pain perception.
74
Findings of pain or a painful past health care visit are important
considerations in the patient’s medical/dental history that will help the dentist anticipate possible behavior
concerns.
2,73
Prevention or reduction of pain during treatment can nurture the relationship between the dentist
and the patient, build trust, allay fear and anxiety, and enhance positive dental attitudes for future visits.
75-79
Pain
can be assessed using self-report, behavioral, and biological measures. In addition, several pain assessment
instruments are available to use with dental patients.
2
The subjective nature of pain perception, varying patient
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responses to painful stimuli, and lack of objective pain assessment tools may hinder the dentist’s attempts to
diagnose and intervene during procedures.
31,78-82
Observations of changes in patient behavior (e.g., facial
expressions, crying, complaining, body movement during treatment) as well as monitoring of biologic measures
(e.g., heart rate, sweating) will help providers to evaluate pain.
2,75,78
The child’s self-described pain is a critical
component of pain assessment, and the parent’s observations of their child’s pain are supplementary.
31,79-81,83
Listening to the child at the first sign of distress will facilitate assessment and any needed procedural
modifications.
79
Misinterpreted or ignored changes in behavior due to painful stimuli can cause sensitization for
future appointments as well as psychological trauma.
84
Documentation of patient behaviors
Recording the child’s behavior serves as an aid for future appointments.
80
A commonly used behavior rating
systems in both clinical dentistry and research is the Frankl Scale
85
. This scale (see Appendix 2) separates
observed behaviors into four categories ranging from definitely negative to definitely positive.
85
In addition to
the rating scale, an accompanying descriptor (e.g., “+, non-verbal”) can help practitioners better plan for
subsequent visits.
Treatment deferral
Dental disease usually is not life-threatening, and the type and timing of dental treatment can be deferred in
certain circumstances. When a child’s cognitive abilities or behavior prevents routine delivery of oral health care
using communicative guidance techniques, the urgency of dental needs influences a prioritized plan of
treatment.
71,72
In some cases, treatment deferral may be considered as an alternative to treating the patient under
sedation or general anesthesia. However, rapidly advancing disease, trauma, pain, or infection usually dictates
prompt treatment. Deferring some or all treatment or employing therapeutic interventions (e.g., silver diamine
fluoride [SDF],
86,87
interim therapeutic restoration [ITR],
88,89
Hall technique crowns
88
, fluoride varnish) until
the child is able to cooperate may be appropriate when based upon an individualized assessment of the risks
and benefits of that option. In select cases where ITR or SDF is employed, regular reevaluations have been
recommended
86,87
and retreatment may be needed.
90,91
Treatment deferral also may be considered in cases when nonurgent treatment is in progress and the patient’s
behavior becomes hysterical or uncontrollable. Under such circumstances, a brief suspension of the procedure
would permit the practitioner to discuss alternative approaches with the patient/parent. If treatment deferral is
reasonable and preferred, steps to bring the incomplete procedure to a safe and prompt conclusion would be
initiated.
72
Behavior guidance techniques
Since children exhibit a broad range of physical, intellectual, emotional, and social development and a diversity
of attitudes and temperament, having a wide range of behavior guidance techniques to meet the needs of the
individual child and being tolerant and flexible in their implementation is essential.
16,24
Behavior guidance is not
an application of individual techniques created to deal with children, but rather a comprehensive, continuous
method meant to develop and nurture the relationship between the patient and dental team, which ultimately
builds trust and allays fear and anxiety. Some of the behavior guidance techniques in this document are intended
to maintain communication, while others are intended to modify inappropriate behavior and establish
communication. As such, these techniques cannot be evaluated on an individual basis as to validity but ideally
are assessed within the context of the child’s total dental experience. Techniques must be integrated into an
overall behavior guidance approach individualized for each child. Consequently, behavior guidance is as much
an art as it is a science.
Recommendations
Basic behavior guidance
Communication and communicative guidance
Communicative management and appropriate use of commands are applied universally in pediatric dentistry with
both the cooperative and uncooperative child. At the beginning of a dental appointment, asking questions and
active/reflective listening can help establish rapport and trust.
38,62
The dentist may establish teacher/student roles
in order to educate the patient and deliver quality dental treatment safely.
19(pp352),30
Once a procedure begins, bi-
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directional communication should be maintained, and the dentist should consider the child as an active participant
in the care provided.
92
With this two-way interchange of information, the dentist also can provide one-way
guidance of behavior through directives. Use of self-disclosing assertiveness techniques (e.g., “I need you to open
your mouth so I can check your teeth”, “I need you to sit still so we can take an X-ray”) tells the child exactly
what is required to be cooperative.
62
The dentist can ask the child ‘yes’ or ‘no’ questions where the child can
answer with a ‘thumbs up’ or ‘thumbs down’ response. Also, observation of the child’s body language is
necessary to confirm that the patient understands and so that comfort and pain level can be assessed.
62,77,78
Communicative guidance comprises a host of specific techniques that, when integrated, enhance the level of
cooperation of the patient. Rather than being a collection of singular techniques, communicative guidance is an
ongoing subjective process that becomes an extension of the personality of the dentist. Associated with this
process are the specific techniques of pre-visit imagery
93
, direct observation
94,95
, tell-show-do
38
, ask-tell-ask
26
,
voice control
19(p352),30,41(pp359,360),42
, nonverbal communication
38,41(pp358,359),67
, positive reinforcement
19(p359)
,
41(pp359),60-62
, distraction (e.g., audiovisual, imagination, clinic design), memory restructuring
96,97
, desensitization
98
,
parental presence/absence
36,38,39
, enhanced control
99-101
, sensory-adapted dental environment
98,102,103
, animal-
assisted therapy
104
, picture-exchange communication system
105,106
, cognitive behavior therapy
100,107-110
, and
nitrous oxide/oxygen inhalation
4,38
The dentist should consider the cognitive and psychological development of
the patient, as well as the presence of other communication deficits (e.g., hearing disorder), when choosing
specific communicative guidance techniques.
Positive pre-visit imagery
• Description: Patients preview positive photographs or images of dentistry and dental treatment before the
dental appointment.
93
• Objectives: The objectives of positive pre-visit imagery are to:
— provide children and parents with visual information on what to expect during the dental visit; and
— provide children with context to be able to ask providers relevant questions before dental procedures
commence.
• Indications: Use with any patient.
• Contraindication: None.
Direct observation
• Description: Patients are shown a video or are permitted to directly observe a young cooperative patient
undergoing dental treatment.
93-95
• Objectives: The objectives of direct observation are to:
— familiarize the patient with the dental setting and specific steps involved in a dental procedure; and
— provide an opportunity for the patient and parent to ask questions about the dental procedure in a
safe environment.
• Indications: Use with any patient.
• Contraindications: None
Tell-show-do
• Description: The technique involves explanations of procedures in phrases appropriate to the developmental
level of the patient (tell); demonstrations for the patient of the visual, auditory, olfactory, and tactile aspects
of the procedure in a carefully defined, nonthreatening setting (show); and then, without deviating from the
explanation and demonstration, completion of the procedure (do). The tell-show-do technique operates with
communication skills (verbal and nonverbal) and positive reinforcement.
30,38,41(pp357,358),42
• Objectives: The objectives of tell-show-do are to:
— teach the patient important aspects of the dental visit and familiarize the patient with the dental setting
and armamentarium; and
— shape the patient’s response to procedures through desensitization and well-described expectations.
• Indications: Use with any patient.
• Contraindications: None.
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Ask-tell-ask
• Description: This technique involves inquiring about the patient’s visit and feelings toward or about any
planned procedures (ask); explaining the procedures through demonstrations and non-threatening language
appropriate to the cognitive level of the patient (tell); and again inquiring if the patient understands and how
she feels about the impending treatment (ask). If the patient continues to have concerns, the dentist can
address them, assess the situation, and modify the procedures or behavior guidance techniques if necessary.
26
• Objectives: The objectives of ask-tell-ask are to:
— assess anxiety that may lead to noncompliant behavior during treatment;
— teach the patient about the procedures and their implementation; and
— confirm the patient is comfortable with the treatment before proceeding.
• Indications: Use with any patient able to dialogue.
• Contraindications: None.
Voice control
• Description: Voice control is a deliberate alteration of voice volume, tone, or pace to influence and direct the
patient’s behavior. While a change in cadence may be readily accepted, use of an assertive voice may be
considered aversive to some parents unfamiliar with this technique. An explanation before its use may
prevent misunderstanding.
19(pg352),30,41(pp359,360),42
• Objectives: The objectives of voice control are to:
— gain the patient’s attention and compliance;
— avert negative or avoidance behavior; and
— establish appropriate adult-child roles.
• Indications: Use with any patient.
• Contraindications: Patients who are hearing impaired.
Nonverbal communication
• Description: Nonverbal communication is the reinforcement and guidance of behavior through appropriate
contact, posture, facial expression, and body language.
30,38,41(pp358,359),42,67
• Objectives: The objectives of nonverbal communication are to:
— enhance the effectiveness of other communicative guidance technique; and
— gain or maintain the patient’s attention and compliance.
• Indications: Use with any patient.
• Contraindications: None.
Positive reinforcement
• Description: In the process of establishing desirable patient behavior, constructive feedback is essential.
Positive reinforcement rewards desired behaviors thereby strengthening the likelihood of recurrence of those
behaviors. Social reinforcers include positive voice modulation, facial expression, verbal praise, and
celebratory gestures (e.g., high-five, fist bump) by all members of the dental team. Descriptive praise
emphasizes specific cooperative behaviors (e.g., “Thank you for sitting still”, “You are doing a great job
keeping your hands in your lap”) rather than a generalized praise (e.g., “Good job”).
62
Nonsocial reinforcers
include tokens and toys.
• Objective: The objective of positive reinforcement is to reinforce desired behavior.
19(pg359),38,41(pp358,359),60-62
• Indications: Use with any patient.
• Contraindications: None.
Distraction
• Description: Distraction is the technique of diverting the patient’s attention from what may be perceived as
an unpleasant procedure. Distraction may be achieved by imagination (e.g., stories), clinic design, and audio
(e.g., music) and/or visual (e.g., television, virtual reality eyeglasses) effects.
38,111
Giving the patient a short
break during a stressful procedure can be an effective use of distraction before considering more advanced
behavior guidance techniques.
60-62
• Objectives: The objectives of distraction are to:
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— decrease the perception of unpleasantness; and
— avert negative or avoidance behavior.
• Indications: Use with any patient.
• Contraindications: None.
Memory restructuring
• Description: Memory restructuring is a behavioral approach in which memories associated with a negative
or difficult event (e.g., first dental visit, local anesthesia, restorative procedure, extraction) are restructured
into positive memories using information suggested after the event has taken place.
97
This approach was
utilized with children who received local anesthesia at an initial restorative dental visit and showed a
change in local anesthesia-related fears and behaviors at subsequent treatment visits.
96,97
Restructuring
involves four components: (1) visual reminders; (2) positive reinforcement through verbalization; (3)
concrete examples to encode sensory details; and (4) sense of accomplishment. A visual reminder could be
a photograph of the child smiling at the initial visit (i.e., prior to the difficult experience). Positive
reinforcement through verbalization could be asking if the child had told her parent what a good job she had
done at the last appointment. The child is asked to role-play and to tell the dentist what she had told the
parent. Concrete examples to encoding sensory details include praising the child for specific positive behavior
such as keeping her hands on her lap or opening her mouth wide when asked. The child then is asked to
demonstrate these behaviors, which leads to a sense of accomplishment.
• Objectives: The objectives of memory restructuring are to:
— restructure difficult or negative past dental experiences; and
— improve patient behaviors at subsequent dental visits.
• Indications: Use with patients who had a negative or difficult dental visit.
• Contraindications: None.
Desensitization to dental setting and procedures
• Description: Systematic desensitization is a psychological technique that can be applied to modify behaviors
of anxious patients in the dental setting.
98
It is a process that diminishes emotional responsiveness to a
negative, aversive, or positive stimulus after progressive exposure to it. Patients are exposed gradually
through a series of sessions to components of the dental appointment that cause them anxiety. Patients may
review information regarding the dental office and environment at home with a preparation book or video or
by viewing the practice website. Parents may model actions (e.g., opening mouth and touching cheek) and
practice with the child at home using a dental mirror. Successful approximations would continue with an
office tour during nonclinical hours and another visit in the dental operatory to explore the environment.
After successful completion of each step, an appointment with the dentist and staff may be attempted.
98
• Objectives: The objective of systematic desensitization is for the patient to:
— proceed with dental care after habituation and successful progression of exposure to the environment;
— identify his fears;
— develop relaxation techniques for those fears; and
— be gradually exposed, with developed techniques, to situations that evoke his fears and diminish the
emotional responses.
41(pg361)
• Indications: Use with patients who have experienced fear-invoking stimuli, anxiety, and/or
neurodevelopmental disorders (e.g., autism spectrum disorder).
• Contraindications: None.
Enhanced control
• Description: Enhanced control is a technique used to allow the patient, especially an anxious/fearful one, to
assume an active role in the dental experience. The dentist provides the patient a signal (e.g., raising a hand)
to use if he becomes uncomfortable or needs to briefly interrupt care. The patient should practice this gesture
before treatment is initiated to emphasize it is a limited movement away from the operatory field. When the
patient employs the signal during dental procedures, the dentist should quickly respond with a pause in
treatment and acknowledge the patient’s concern. Enhancing control has been shown to be effective in
reducing intraoperative pain.
100,101
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• Objectives: The objective is to allow a patient to have some measure of control during treatment in order
to contain emotions and deter disruptive behaviors.
99,112
• Indications: Use with patients who can communicate.
• Contraindications: None, but if used prematurely, fear may increase due to an implied concern about the
impending procedure.
Communication techniques for parents (and age-appropriate patients)
Because parents are the legal guardians of minors, successful bi-directional communication between the dental
team and the parent is essential to assure effective guidance of the child’s behavior.
69
Socioeconomic status, stress
level, marital discord, dental attitudes aligned with a different cultural heritage, and linguistic skills may
present challenges to open and clear communication.
25,26,113
Communication techniques such as ask-tell-ask,
teach back, and motivational interviewing can reflect the dental team ’s caring for and engaging in a patient/
parent centered-approach.
26
These techniques are presented in Appendix 3.
Parental presence/absence
• Description: The presence or absence of the parent sometimes can be used to gain cooperation for treatment.
Parents can play a critical role in their child’s dental treatment by providing emotional support and
encouragement. In this behavior guidance technique, the parent is asked by the provider to leave the operatory
if a child does not cooperate for dental treatment. If the patient agrees to and demonstrates improved
behavior, the parent is asked to return as a positive reward for the child’s cooperation.
36
Implementation
of this strategy must be discussed beforehand and mutually agreed to by the parent and provider.
• Objectives: The objectives of parental presence/absence for parents are to:
— participate in examinations and treatment;
— offer physical and psychological support; and
— observe the reality of their child’s treatment.
• The objectives of parental presence/absence for practitioners are to:
— gain the patient’s attention and improve compliance;
— avert negative or avoidance behaviors;
— establish appropriate dentist-child roles;
— enhance effective communication among the dentist, child, and parent;
— minimize anxiety and achieve a positive dental experience; and
— facilitate rapid informed consent for changes in treatment or behavior guidance.
• Indications: Use with any patient.
• Contraindications: Parents who are unwilling or unable to extend effective support.
Additional considerations for dental patients with anxiety or special health care needs
Sensory-adapted dental environment (SADE)
• Description: The SADE intervention includes adaptions of the clinical setting (e.g., dimmed lighting, moving
projections such as fish or bubbles on the ceiling, soothing background music, application of wrap/blanket
around the child to provide deep pressure input) to produce a calming effect.
98,103
• Objectives: The objective of SADE is to enhance relaxation and avert negative or avoidance behaviors.
102
• Indications: Use with patients having autism spectrum disorder, sensory processing difficulties, other
disabilities, or dental anxiety.
114
• Contraindications: None.
Animal-assisted therapy (AAT)
• Description: AAT has been beneficial in a variety of settings including the dental environment.
115
It is a goal-
oriented intervention which utilizes a trained animal in a healthcare setting to improve interactions or
decrease a patient’s anxiety, pain, or distress. Unlike animal-assisted activities (e.g., a pet entertains patients
in the waiting area), AAT appointments are scheduled for specific time and duration to include an animal
that has undergone temperament testing, rigorous training, and certification. The animal, which is available
for companionship during the dental visit, can help break communication barriers and enable the patient to
establish a safe and comforting relationship, thereby reducing treatment-related stress. For each visit, the
goals and results of the intervention should be documented.
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• Objectives: The objectives of AAT are to:
— enhance interactions between the patient and dental team;
— calm or comfort an anxious or fearful patient;
— provide a distraction from a potentially stressful situation; and
— decrease perceived pain.
104
The health and safety of the animal and its handler need to be maintained.
104
• Indications: Use AAT as an adjunctive technique to decrease a patient’s anxiety, pain, or emotional distress.
• Contraindications:
— The contraindications for the patient:
allergy or other medical condition (e.g., asthma, compromised immune system) aggravated
by exposure to the animal; and
lack of interest in or fear of the therapy animal.
— The contraindication for the animal and handler: a situation that presents a significant risk to one’s
health or safety.
116
Picture exchange communication system (PECS)
• Description: PECS is a visual alternative and augmentive technique developed for individuals with limited
to no verbal communication abilities and may work particularly well for those with autism and complex
communication needs
106
. The individual shares a picture card with a recognizable symbol to express directly
a request or thought.
106
Because each image corresponds directly to one object, person, or concept, clarity
in the resulting communication is enhanced.
106
The patient is able to initiate communication, and no
special training is required by the recipient.
• Objectives: The objective is to allow individuals with limited to no verbal communication abilities to express
requests or thoughts using symbolic imagery.
105
A prepared picture board may be present for the dental
appointment so the dentist can communicate the steps required for completion (e.g., pictures of a dental
mirror, handpiece). The patient may have symbols (e.g., a stop sign) to request a brief interruption in the
procedure.
105
• Indications: Use as an adjunctive approach to assist individuals with limited to no verbal communication
abilities improve exchange of ideas.
98,117
• Contraindications: None.
Mind-body therapies
Description: Mind-body therapies in children, including biofeedback, breathing exercises, and hypnosis, may
help decrease pain and reduce anxiety in the clinical setting.
107,118,119
Both cognitive and behavioral therapies can
reduce physiologic responses to stress, distress, and perceived pain
100,108-110
. Biofeedback uses electric or
electromechanical processes to acquire physiologic data for an individual and then provides auditory, visual,
kinesthetic and other types of therapeutic feedback to the patient.
107
In the context of the dental setting, hypnosis
involves steering of attention toward specific ideas and images to influence cognition, emotions, and resultant
behavior.
120
Breathing exercises, such as deep inhalation and slow exhalation, can induce relaxation when done
alone
121
or as a component of meditation practice
107
.
• Objectives: The objective is to replace negative thoughts or maladaptive behaviors with more positive
attitudes, beliefs, and adaptive behaviors.
108
• Indications: Use with children who have situational anxiety and are receptive to mind-body strategies to
decrease stress during dental procedures.
• Contraindications: None.
Nitrous oxide/oxygen inhalation
• Description: Nitrous oxide/oxygen inhalation is a safe and effective technique to reduce anxiety and enhance
effective communication. Its onset of action is rapid, the effects easily are titrated and reversible, and recovery
is rapid and complete. Additionally, nitrous oxide/oxygen inhalation mediates a variable degree of anal-
gesia, amnesia, and gag reflex reduction. The need to diagnose and treat, as well as the safety of the patient
and practitioner, should be considered before the use of nitrous oxide/oxygen analgesia/anxiolysis. If
nitrous oxide/oxygen inhalation is used in concentrations greater than 50 percent or in combination with
other sedating medications (e.g., benzodiazepines, opioids), the likelihood for moderate or deep sedation
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increases.
122
In these situations, the clinician must be prepared to institute the guidelines for moderate or
deep sedation.
6
Detailed information concerning the indications, contraindications, and additional clinical
considerations appear in AAPD’s Use of Nitrous Oxide for Pediatric Dental Patients4 and Guidelines for
Monitoring and Management of Pediatric Patients Before, During and After Sedation for Diagnostic and
Therapeutic Procedures6 by the AAPD and the American Academy of Pediatrics.
• Objectives: The objectives of nitrous oxide/oxygen inhalation include to:
— reduce or eliminate fear and anxiety;
— enhance communication between the patient and dental team;
— instill a positive attitude toward dental care;
123(pg25)
— raise the pain reaction threshold;
— to reduce untoward movement;
— help control a hyperactive gag reflex that can interfere with dental care;
123(pg26),124
— decrease patient fatigue and increase operator efficiency for longer appointments;
123(pp25-26),125
and
— provide an amnesic effect
126,127
, thus creating a more positive outlook toward dental care;
Use with other agents (e.g., benzodiazepines, opioids) can potentiate their sedative effects but risks CNS
depression.
124
• Indications: Indications for use of nitrous oxide/oxygen inhalation analgesia/anxiolysis include:
— a fearful or anxious patient;
— certain patients with muscular tone disorders prone to unintentional movement
124
;
— a patient whose strong or hypersensitive gag reflex interferes with dental care
128
;
— a patient for whom profound local anesthesia or analgesia cannot be obtained
129
; and
— a cooperative child undergoing a lengthy dental procedure who would benefit from alleviating
treatment fatigue.
• Contraindications: Contraindications for use of nitrous oxide/oxygen inhalation may include:
— chronic obstructive pulmonary diseases;
123(pp29-30),124,130-132(pg82)
— current upper respiratory tract infections (e.g., cold, cough, tonsillitis)
124,133(pg121)
; sinusitis
124,130
; or
other conditions (e.g., seasonal allergies) that inhibit nasal breathing;
130
— recent middle ear disturbance or infection (e.g., acute otitis media);
123(p30),124,130,133(pg121)
— recent (within 14 days) ear, nose, and/or throat operations
124,130
— raised intraocular pressure (e.g., glaucoma), up to three months post retinal surgery.
124,126
— severe emotional disturbances or drug-related dependencies;
123(pp31-32);124,130,132(pg82)
— first trimester of pregnancy;
132(pg82),134
— treatment with bleomycin sulfate;
123(pg31),124,135
and
— untreated cobalamin (vitamin B-12) deficiency
123(p31)124,136
.
Advanced behavior guidance
Most children can be managed effectively using the techniques outlined in basic behavior guidance. Such
techniques form the foundation for all behavior guidance provided by the dentist. Children, however, occasionally
present with behavioral considerations that require more advanced techniques. These children often cannot
cooperate due to lack of psychological or emotional maturity and/or a mental, physical, or medical condition.
The advanced behavior guidance techniques commonly used and taught in advanced pediatric dental training
programs include protective stabilization, sedation, and general anesthesia.
66
The use of general anesthesia or
sedation for dental rehabilitation may improve quality of life in children. It is unclear if these behavior guidance
techniques address factors that contribute to the initial dental fear and anxiety.
137-140
Protective stabilization,
active or passive, may not always be accepted by parents who may be more accepting of pharmacologic behavior
guidance.
141
Consideration of advanced behavior guidance techniques requires the practitioner to thoroughly assess the
patient’s medical, dental, and social histories and temperament. Attention must be paid to the oral health needs
of the patient and the effect of the chosen behavior guidance modality on the quality of dental care. Risks,
benefits, and alternatives should be discussed prior to obtaining an informed consent for the recommended
technique.
69,142
Skillful diagnosis of behavior and safe and effective implementation of these techniques
necessitate knowledge and experience that are generally beyond the core knowledge students receive during
predoctoral dental education. While most predoctoral programs provide didactic exposure to treatment of very
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young children (i.e., aged birth through two years), patients with special health care needs, and patients requiring
advanced behavior guidance I techniques, hands-on experience is lacking.
66,143
Dentists considering the use of
advanced behavior guidance techniques should seek additional training through a residency program, a graduate
program, and/or an extensive continuing education course that involves both didactic and experiential mentored
training.
Protective stabilization
• Description: Protective stabilization is the term utilized in dentistry for the physical limitation of a patient’s
movement by a person or restrictive equipment, materials, or devices for a finite period of time
144
in order to
safely provide examination, diagnosis, and/or treatment.
145
Other terms such as medical immobilization and
medical immobilization/protective stabilization have been used as descriptors for procedures categorized
as protective stabilization.
66,144
Active immobilization involves restriction of movement by another person
such as the parent, dentist, or dental auxiliary.
66
Passive immobilization utilizes a restraining device.
66
Stabilization devices (passive restraint) placed around the chest may restrict respirations. They must be used
with caution, especially for patients with special medical conditions and/or for patients who will receive
medications (e.g., local anesthetics, sedatives) that can depress respirations. Because of the associated risks
and possible consequences of protective stabilization, the dentist is encouraged to evaluate thoroughly the
rationale for its use for each patient visit and consider possible alternatives.
71,146
Consultation with a medical
provider may be indicated prior to use of protective stabilization if there are concerns for adverse outcomes
due to a patient’s medical history. Careful, continuous monitoring of the patient’s physical and psychological
well-being is mandatory during protective stabilization.
71,146
Partial or complete stabilization of the patient sometimes is necessary to protect the patient, practitioner, staff,
or the parent from injury while providing dental care. The dentist always should use the least restrictive but
safe and effective protective stabilization.
71,146
The use of a mouth prop in a compliant child is not considered
protective stabilization.
Protective stabilization, with or without a restrictive device, led by the dentist and performed by the dental
team requires informed consent from a parent. Informed consent must be obtained and documented in the
patient’s record prior to use of protective stabilization. Furthermore, when the patient reasonably can
understand, an explanation to the patient regarding the need for restraint, with an opportunity for the patient
to respond, should occur.
69,71,147
• Objectives: The objectives of patient stabilization are to:
— reduce or eliminate untoward movement;
— protect patient, staff, dentist, or parent from injury; and
— facilitate delivery of quality dental treatment.
• Indications: Patient stabilization is indicated for:
— a patient who requires immediate diagnosis and/or urgent limited treatment (e.g., toddler with acute
dental trauma) and cannot cooperate due to developmental levels (emotional or cognitive), lack of
maturity, or mental or physical conditions;
— a patient who requires urgent care and uncontrolled movements risk the safety of the patient, staff,
dentist, or parent without the use of protective stabilization;
— a previously cooperative patient who quickly becomes uncooperative and cooperation cannot be
regained by basic behavior guidance techniques in order to protect the patient’s safety and efficiently
complete a procedure and/or stabilize the patient;
— an uncooperative patient whose treatment needs are limited (e.g., requires only a single quadrant of
care) and sedation or general anesthesia may not be an option because the patient does not meet
sedation criteria or because of a long operating room wait time, financial considerations, and/or
parental preferences after other options have been discussed;
— a sedated patient requires limited stabilization to help reduce untoward movement during treatment;
and
— a patient with SHCN who exhibits uncontrolled movements that would be harmful to the patient or
clinician or significantly interfere with the quality of care.
5
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• Contraindications: Protective stabilization is contraindicated for:
— a cooperative nonsedated patient;
— an uncooperative patient when there is not a clear need to provide at that particular visit;
— a patient who cannot be immobilized safely due to associated medical, psychological, or physical
conditions;
— a patient with a history of physical or psychological trauma, including physical or sexual abuse or
other trauma that would place the individual at greater psychological risk during restraint;
— a patient with non-emergent treatment needs in order to accomplish full mouth or multiple quadrant
dental rehabilitation;
— a practitioner’s convenience; and
— a dental team without the requisite knowledge and skills in patient selection and restraining
techniques to prevent or minimize psychological stress and/or decrease risk of physical injury to
the patient, parent, clinician, and staff.
• Precautions: The following precautions are recommended:
— the patient’s medical history must be reviewed carefully to ascertain any medical conditions or
medications that can compromise physiologic function, may contraindicate the use of protective
stabilization, or are associated with specific risk factors including;
cardiac instability.
148(pg253)
pulmonary and respiratory instability.
148(pg253)
musculoskeletal alignment issues or weakness.
148(pg253)
joint hypermobility.
148(pg253)
bone fragility.
148(pg253)
cutaneous vulnerability to mechanical stress.
psychological instability.
148(pg253)
thermoregulation disorders.
148(pg253)
psychotropic medications.
149
— tightness and duration of the stabilization must be monitored and reassessed at regular intervals;
— stabilization around extremities or the chest must not actively restrict circulation or respiration;
— observation of body language and pain assessment must be continuous to allow for procedural
modifications at the first sign of distress; and
— stabilization should be terminated as soon as possible in a patient who is experiencing severe stress
or hysterics to prevent possible physical or psychological trauma.
The dental provider should acknowledge and abide by the principle to “do no harm” when considering
completion of excessive amounts of treatment while the patient is immobilized with protective
stabilization.
150
The physical and psychological health of the patient should override other factors
(e.g., practitioner convenience, financial compensation).
150
• Documentation: The patient’s record must include:
— indication for stabilization;
— type of stabilization;
— informed consent for protective stabilization;
— reason for parental exclusion during protective stabilization (when applicable);
— the duration of application of stabilization;
— behavior evaluation/rating during stabilization;
— any untoward outcomes, such as skin markings; and
— management implication for future appointments.
Sedation
• Description: Procedural sedation is a drug-induced state along a continuum ranging from minimal
(anxiolysis) and moderate (depression of consciousness during which patients respond purposefully to verbal
commands or after light tactile sensation) to deep (depression of consciousness during which patients cannot
be easily aroused but respond purposefully after repeated verbal or painful stimulation).6 Sedation can be
used safely and effectively with patients who are unable to cooperate due to lack of psychological or
OFFICIAL BUT UNFORMATTED
emotional maturity and/or mental, physical, or medical conditions. Background information and
documentation for the use of sedation is detailed in the Guideline for Monitoring and Management of
Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures.
6
• The need to diagnose and treat, as well as the safety of the patient, practitioner, and staff, should be considered
for the use of sedation.
• Objectives: The goals of sedation are to:
— guard the patient’s safety and welfare;
— minimize physical discomfort and pain;
— control anxiety, minimize psychological trauma, and maximize the potential for amnesia;
— modify behavior and/or movement so as to allow the safe completion of the procedure; and
— return the patient to a state in which discharge from medical/dental supervision is safe, as determined
by recognized criteria.
6
• Indications: Sedation is indicated for:
— fearful/anxious patients for whom basic behavior guidance techniques have not been successful;
— patients who cannot cooperate due to a lack of psychological or emotional maturity and/or mental,
physical, or medical conditions; and
— patients for whom the use of sedation may protect the developing psyche and/or reduce medical risk.
• Contraindications: The use of sedation is contraindicated for:
— the cooperative patient with minimal dental needs; and
— predisposing medical and/or physical conditions which would make sedation inadvisable.
• Documentation: The patient’s record shall include:
6
— informed consent that is obtained from the parent and documented prior to the use of sedation;
— pre- and postoperative instructions and information provided to the parent;
— health evaluation;
— a time-based record that includes the name, route, site, time, dosage, and effect on patient of
administered drugs;
— the patient’s level of consciousness, responsiveness, heart rate, blood pressure, respiratory rate, and
oxygen saturation prior to treatment, at the time of treatment, and post-operatively until
predetermined discharge criteria have been attained;
— adverse events (if any) and their treatment; and
— time and condition of the patient at discharge.
General anesthesia
• Description: General anesthesia is a controlled state of unconsciousness accompanied by a loss of protective
reflexes, including the ability to maintain an airway independently and respond purposefully to physical
stimulation or verbal command. Depending on the patient, general anesthesia can be administered in a
hospital or an ambulatory setting, including the dental office. Practitioners who provide in-office general
anesthesia (dentist and the anesthesia provider) should be familiar with and follow the recommendations
found in AAPD’s Use of Anesthesia Providers in the Administration of Office-Based deep Sedation/General
Anesthesia to the Pediatric Dental Patient.
3
Because laws and codes vary from state to state, each practitioner must be familiar with his state guidelines
regarding office-based general anesthesia. The need to diagnose and treat, as well as the safety of the patient,
practitioner, and staff should be considered for the use of general anesthesia. Anesthetic and sedative drugs
are used to help ensure the safety, health, and comfort of children undergoing procedures. Increasing evidence
from research studies suggests the benefits of these agents should be considered in the context of their
potential to cause harmful effects.
151
Additional research is needed to identify any possible risks to young
children.
152
The decision to use general anesthesia must take into consideration:
— alternative modalities;
— the age of the patient;
— risk benefit analysis;
— treatment deferral;
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— dental needs of the patient;
— the effect on the quality of dental care;
— the patient’s emotional development;
— the patient’s medical status; and
— barriers to care (e.g., finances).
• Objectives: The goals of general anesthesia are to:
provide safe, efficient, and effective dental care;
— eliminate anxiety;
— eliminate untoward movement and reaction to dental treatment;
— aid in treatment of the mentally-, physically-, or medically-compromised patient; and
— minimize the patient’s pain response.
• Indications: General anesthesia is indicated for patients:
— who cannot cooperate due to a lack of psychological or emotional maturity and/or mental, physical,
or medical disability;
— for whom local anesthesia is ineffective because of acute infection, anatomic variations, or allergy;
— who are extremely uncooperative, fearful, or anxious;
— who are precommunicative or noncommunicative;
— requiring significant surgical procedures that can be combined with dental procedures to reduce the
number of anesthetic exposures;
— for whom the use of general anesthesia may protect the developing psyche and/or reduce medical
risk; and
— requiring immediate, comprehensive oral/dental care (e.g., due to dental trauma, severe
infection/cellulitis, acute pain).
Contraindications: The use of general anesthesia is contra-indicated for:
— a healthy, cooperative patient with minimal dental needs;
— a very young patient with minimal dental needs that can be addressed with therapeutic interventions
(e.g., ITR, fluoride varnish, SDF) and/or treatment deferral;
— patient/practitioner convenience; and
— predisposing medical conditions which would make general anesthesia inadvisable.
• Documentation: Prior to the delivery of general anesthesia, appropriate documentation shall address the
rationale for use of general anesthesia, informed consent, instructions provided to the parent, dietary
precautions, and preoperative health evaluation. Because laws and codes vary from state to state, each
practitioner must be familiar with her state guidelines. For information regarding requirements for a time-
based anesthesia record, refer to AAPD’s Use of Anesthesia Providers in the Administration of Office-based
Deep Sedation/General Anesthesia to the Pediatric Dental Patient.
3
References appear after Appendices.
Appendices
Appendix 1. SEARCH STRATEGIES PubMed®/MEDLINE—date limit August 2023
Search #1. (ped & dental) 3712 results
((((((“behavior management”[tiab] OR “behavior guidance” [tiab] OR “child behavior”[tiab] OR “dental
anxiety”[tiab] OR “personality test”[tiab] OR “patient cooperation”[tiab] OR “dentist-patient relations”[tiab]
OR “behavior assessment” [tiab] OR “temperament assessment”[tiab] OR “personality assessment”[tiab] OR
“treatment deferral”[tiab] OR “treatment delay”[tiab] OR compliance[tiab] OR adherence[tiab] OR
“protective stabilization”[tiab] OR immobilization[tiab] OR restraints [tiab] OR Sedation [tiab] OR general
anesthesia[tiab] OR “Restraint, Physical” [mesh] OR “Protective Devices”[mesh] OR “Immobilization”
[mesh] OR “Behavior Control”[mesh] OR “child behavior” [mesh] OR “dental anxiety”[mesh] OR
“personality tests” [mesh] OR “patient compliance”[mesh] OR “dentist-patient relations”[mesh] OR
“personality assessment”[mesh] OR “patient compliance”[mesh] OR “anesthesia, general”[mesh] OR
“Conscious Sedation”[Mesh]))) AND (((dental[tiab] OR “dental health services”[MeSH Terms] OR dentistry
[TIAB] OR “dentistry”[MeSH Terms] OR “dental care” [tiab] OR “dental care”[MeSH Terms] OR
dentist[tiab] OR “dentists”[MeSH Terms] OR “Dental Care for Children” [mesh] OR “Pediatric
OFFICIAL BUT UNFORMATTED
Dentistry”[mesh])))) AND (((“infant” [MeSH Terms] OR “infant”[tiab]) OR (“child”[MeSH Terms] OR
“child”[tiab]) OR (“adolescent”[MeSH Terms] OR “adolescent”[tiab]) OR “pediatrics”[MeSH Terms] OR
“pediatrics”[tiab] OR “pediatric”[tiab])))) AND ((“2009/ 01/01”[PDAT]: “3000/12/31”[PDAT]) AND english
[filter] NOT (“animals”[MeSH Terms] NOT “humans” [MeSH Terms]))
Search #2. (ped & medical) 1631 results
((“behavior management”[tiab] OR “behavior guidance”[tiab] OR “toxic stress”[tiab] OR “protective
stabilization”[tiab] OR restraints[tiab] OR “Restraint, Physical”[majr] OR “Behavior Control”[majr])) AND
((((“infant”[MeSH Terms] OR “infant”[tiab]) OR (“child”[MeSH Terms] OR “child” [tiab]) OR
(“adolescent”[MeSH Terms] OR “adolescent” [tiab]) OR “pediatrics”[MeSH Terms] OR “pediatrics”
[tiab]OR “pediatric”[tiab])) AND (((“2009/01/01” [PDAT]: “3000/12/31”[PDAT]) AND english[filter] NOT
(“animals”[MeSH Terms] NOT “humans”[MeSH Terms]))))
Search #3. (adults & dentists) 88 results
(((“personality test” OR “personality tests”[MeSH Terms] OR “personality assessment”[MeSH Terms] OR
personality[tiab] OR “gender shifts”[tiab] OR “gender equality” OR ((“Women, Working”[mesh] OR
“Dentists, Women”[mesh]) AND “Practice Patterns, Dentists’”[MeSH Terms]))) AND (dentist[TIAB] OR
dentist[TIAB] OR “Dentists”[Mesh])) AND ((“2009/01/01”[PDAT]: “3000/12/31”[PDAT]) AND
english[filter] NOT (“animals”[MeSH Terms] NOT “humans”[MeSH Terms]))
Search #4. (adults & parents) 332 results
(((((dental[tiab] OR “dental health services”[MeSH Terms] OR dentistry[TIAB] OR “dentistry”[MeSH Terms]
OR “dental care”[tiab] OR “dental care”[MeSH Terms] OR dentist[tiab] OR “dentists”[MeSH Terms] OR
“Dental Care for Children”[mesh] OR “Pediatric Dentistry”[mesh]))) AND ((Parents[tiab] OR Fathers[tiab] OR
mothers[tiab] OR parental[tiab] OR Parent[tiab] OR Father[tiab] OR mother[tiab] or “mothers”[MeSH Terms]
OR “fathers” [MeSH Terms] OR “parents”[MeSH Terms]))) AND (“behavior management”[tiab] OR “behavior
guidance” [tiab] OR “dentist parent relations”[tiab] OR “Informed consent”[tiab] OR “family compliance”[tiab]
OR “parent compliance”[tiab] OR “family adherence”[tiab] OR “parent adherence”[tiab] OR “parenting
style”[tiab] OR “dentist-patient relations”[tiab] OR “dentist-patient relations” [MeSH Terms] OR “Behavior
Control”[mesh] OR “patient compliance”[MeSH Terms] OR “Informed Consent” [Mesh])) AND
(((“2009/01/01”[PDAT]: “3000/12/31” [PDAT]) AND english[filter] NOT (“animals”[MeSH Terms] NOT
“humans”[MeSH Terms])))
Appendix 2. FRANKL BEHAVIORAL RATING SCALE
1 _ _ Definitely negative. Refusal of treatment, forceful crying, fearfulness, or any other overt evidence of
extreme negativism.
2 _ Negative. Reluctance to accept treatment, uncooperative, some evidence of negative attitude but not
pronounced (sullen, withdrawn).
3 + Positive. Acceptance of treatment, cautious behavior at times, willingness to comply with the dentist,
at times with reservation, but patient follows the dentist’s directions cooperatively.
4 ++ Definitely positive. Good rapport with the dentist, interest in the dental procedures, laughter and
enjoyment.
Appendix 3. SAMPLE COMMUNICATION TECHNIQUES FOR PATIENTS & PARENTS
1
BEHAVIORAL
RATING SCALE
OFFICIAL BUT UNFORMATTED
When clinicians share information, they predominantly TELL information, often in too much detail, and in
terms that sometimes alarm patients. Information sharing is most effective when it is sensitive to the emotional
impact of the words used. By using a technique of ask-tell-ask, it is possible to improve the patients’
understanding and promote adherence. According to the adult learning theory, it is important to stay in
dialogue (not monologue), begin with an assessment of the patient’s or parents’ needs, tell small chunks of
information tailored to those needs, and check on the patient’s understanding, emotional reactions, and
concerns. This is summarized by the three-step format Ask-Tell-Ask.
ASK to assess the patient’s emotional state and their desire for information. TELL small amounts of
information in simple language, and ASK about the patient’s understanding, emotional reactions, and
concerns. Many conversations between clinicians and parents sound like Tell-Tell-Tell, a process known as
doctor babble, because clinicians seem to talk to themselves, rather than have a conversation with parents or
patients.
The Ask-Tell-Ask format maintains dialogue with patients and their parents. The important areas for sharing
include:
ASK to assess patient needs:
1. Make sure the setting is conducive.
2. Assess the patient’s physical and emotional state. If patients are upset or anxious, address their emotions
and concerns before trying to share information. Sharing information when the patient is sleepy, sedated,
in pain, or emotionally distraught is not respectful and the information won’t be remembered.
3. Assess the patient’s informational needs. Find out what information the patient wants, and in what
format. Some patients want detailed information about their conditions, tests, and proposed treatments;
recommendations for reading; websites; self-help groups; and/or referrals to other consultants. Others
want an overview and general understanding. Patients may want other family members to be present for
support or to help them remember key points. Reaching agreement with the patient about what information
to review may require negotiation if the clinician understands the issues, priorities, or goals differently
than the patient. Also, some patients may need more time, and so it might be wise to discuss the key points
and plan to address others later or refer them to other staff or health educators. Instead of asking, “Do you
have any questions?” to which patients often reply, “No,” instead ask, “What questions or concerns do
you have?” Be sure to ask, “Anything else?”
4. Assess the patient’s knowledge and understanding. Find out what previous knowledge or relevant
experience patients have about a symptom or about a test or treatment.
5. Assess the patient’s attitudes and motivation. Patients will not be interested in hearing your health
information if they are not motivated or if they have negative attitudes about the outcomes of their efforts,
so ask about this directly. Start by asking general questions about attitudes and motivation: “So – tell me
how you feel about all of this?” “This is a complicated regimen. How do you think you will manage?” If
patients are not motivated, ask why and help the patient work through the issues.
TELL information:
1. Keep each bit of information brief. It is difficult to understand and retain large amounts of information,
especially when one is physically ill, upset, or fearful.
2. Use a systematic approach. For example, name the problem, the next step, what to expect, and what the
patient can do.
3. Support the patient’s prior successes. Explicitly mention and appreciate patients’ previous efforts and
accomplishments in coping with previous problems or illness.
4. Personalize the information. Personalize your information by referring to the patient’s personal and
family history.
5. Use simple language; avoid jargon. Be mindful of how key points are framed.
6. Choose words that do not unnecessarily alarm. Words and phrases a practitioner takes for granted may
be misinterpreted or alarm patients and families.
OFFICIAL BUT UNFORMATTED
7. Use visual aids and share supplemental resources. Find reliable resources and educational aids to meet
the needs of your patients.
ASK: Continue to assess needs, comprehension, and concerns.
After each bit of telling, stop and check in with patients. When finished with information sharing, make a final
check. This step closes the feedback loop with patients and helps the practitioner understand what patients
hear, whether they are taking home the intended messages, and how they feel about the situation. The second
ASK section consists of the following items:
1. Check for patients’ comprehension. ASK about the patients’ understanding. This ASK improves
patient recall, satisfaction, and adherence.
2. Check for emotional responses and respond appropriately. Letting patients know their concerns
and worries have been heard is compassionate, improves outcomes, and takes little time.
3. Check about barriers. Patients may face external obstacles as well as internal emotional responses
that inhibit them from overcoming obstacles.
Teach Back
A strategy called teach back is similar. The dentist or dental staff asks the patient to teach back what he has
learned. This may be especially effective for patients with low literacy who cannot rely on written reminders.
It is important to present the process as part of the normal routine. This pertains to explanations or
demonstrations: “I always check in with my patients to make sure that I’ve demonstrated things clearly. Can
you show me how you’re going to floss your teeth?” If the patient’s demonstration is incorrect, the dentist may
say, “I’m sorry, I guess I didn’t explain things all that well: let me try again.” Then go over the information
again and ask the patient to teach it back to you again.
Motivational Interviewing
Motivational interviewing facilitates behavior change by helping patients or parents explore and resolve their
ambivalence about change. It is done in a collaborative style which supports the autonomy and self-efficacy
of the patient and uses the patient’s own reasons for change. It increases the patient’s confidence and reduces
defensiveness. Motivational interviewing keeps the responsibility to change with the patient and/or parent,
which helps to decrease staff burnout. In dentistry, it is useful in counseling about brushing, flossing, fluoride
varnish, reducing sugar sweetened beverages, and smoking cessation. Open-ended questions, affirmations,
reflective listening, and summarizing (OARS) characterize the patient-centered approach. It is especially
helpful in higher levels of resistance, anger, or entrenched patterns. Motivational interviewing is empowering
to both staff and patients and, by design, is not adversarial or shaming.
1
Adapted from Goleman J. Cultural factors affecting behavior guidance and family compliance. Pediatr Dent 2014;36(2):121-7. Copyright ©
2014, American Academy of Pediatric Dentistry, “www.aapd.org”.
References
1. American Academy of Pediatric Dentistry. Policy on medically necessary care. The Reference Manual of
Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry; 2024:PENDING.
2. American Academy of Pediatric Dentistry. Pain management in infants, children, adolescents, and individuals
with special health care needs. The Reference Manual of Pediatric Dentistry. Chicago, Ill.: American
Academy of Pediatric Dentistry; 2024:XX.
3. American Academy of Pediatric Dentistry. Use of anesthesia providers in the administration of office-based
deep sedation/general anesthesia to the pediatric dental patient. The Reference Manual of Pediatric Dentistry.
Chicago, Ill.: American Academy of Pediatric Dentistry; 2024:XX.
4. American Academy of Pediatric Dentistry. Use of nitrous oxide for pediatric dental patients. The Reference
Manual of Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry; 2024.
5. American Academy of Pediatric Dentistry. Use of protective stabilization for pediatric dental patients. The
Reference Manual of Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry;
2024:PENDING.
OFFICIAL BUT UNFORMATTED
6. Coté CJ, Wilson S, American Academy of Pediatric Dentistry, American Academy of Pediatrics. Guidelines
for monitoring and management of pediatric patients before, during and after sedation for diagnostic and
therapeutic procedures. Pediatrics 2019;143(6):e201910000.
7. American Academy of Pediatric Dentistry Clinical Affairs Committee Behavior Management Subcommittee.
Guidelines for behavior management. Boston, Mass.: American Academy of Pediatric Dentistry; May 1990.
8. American Academy of Pediatric Dentistry. Behavior guidance for the pediatric dental patient. The Reference
Manual of Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry; 2020:292-310.
9. American Academy of Pediatric Dentistry. Proceedings of the conference on behavior management for the
pediatric dental patient. Pediatr Dent 2004;26(2):110-83.
10. American Academy of Pediatric Dentistry. Behavior Symposium III: Conference Papers. Pediatr Dent
2014;36(2):102-60.
11. Commission on Dental Accreditation. Accreditation Standards for Advanced Specialty Education Programs
in Pediatric Dentistry. Chicago, Ill.: American Dental Association; 2022:25-6. Available at:
“https://coda.ada.org/-/media/project/ada-
organization/ada/coda/files/pediatric_dentistry_standards.pdf?rev=50a8557ef6474199b75d531b22f05e60
&hash=12EE1B109A4B6FD893950812B9CC2EC9”. Accessed March 6, 2024.
12. Dhar V, Gosnell E, Jayaraman J, et al. Nonpharmacological behavior guidance for the pediatric dental
patient. Pediatr Dent 2023;45(5):385-410.
13. National Maternal and Child Oral Health Resource Center. 2018. Special Care: An Oral Health Professional’s
Guide to Serving Young Children with Special Health Care Needs, 2nd ed. Washington, D.C.: National
Maternal and Child Oral Health Resource Center. Available at:
“https://www.mchoralhealth.org/SpecialCare/5-behavior/”. Accessed August 16, 2023.
14. Baier K, Milgrom P, Russell S, Mancl L, Yoshida T. Children’s fear and behavior in private pediatric
dentistry practices. Pediatr Dent 2004;26(4):316-21.
15. Brill WA. The effect of restorative treatment on children’s behavior at the first recall visit in a private
pediatric dental practice. J Clin Pediatr Dent 2002;26(4):389-94.
16. Howenstein J, Kumar A, Casamassimo PS, McTigue D, Coury D, Yin H. Correlating parenting styles with
child behavior and caries. Pediatr Dent 2015;37(1):59-64.
17. Long N. The changing nature of parenting in America. Pediatr Dent 2004;26(2):121-4.
18. Sheller B. Challenges of managing child behavior in the 21st century dental setting. Pediatr Dent
2004;26(2):111-3.
19. Stigers JI. Nonpharmacologic management of children’s behaviors. In: Dean JA, ed. McDonald and Avery’s
Dentistry for the Child and Adolescent. 11th ed. St. Louis, Mo.: Elsevier; 2022:340-55.
20. Arnup K, Broberg AG, Berggren U, Bodin L. Lack of cooperation in pediatric dentistry: The role of child
personality characteristics. Pediatr Dent 2002;24(2):119-28.
21. Klingberg G, Broberg AG. Temperament and child dental fear. Pediatr Dent 1998;20(4):237-43.
22. Seligman LD, Hovey JD, Chacon K, Ollendick TH. Dental anxiety: An understudied problem in youth. Clin
Psychol Rev 2017;55:25-40.
23. Boyce TW. The lifelong effects of early childhood adversity and toxic stress. Pediatr Dent 2014;36(2):102-
7.
24. da Fonseca MA. Eat or heat? The effects of poverty on children’s behavior. Pediatr Dent 2014;36(2):132-7.
25. Long N. Stress and economic hardship: The impact on children and parents. Pediatr Dent 2014;36(2):109-
14.
26. Goleman J. Cultural factors affecting behavior guidance and family compliance. Pediatr Dent
2014;36(2):121-7.
27. Chen AH, Youdelman MK, Brooks J. The legal framework for language access in healthcare settings: Title
VI and beyond. J Gen Intern Med 2007;22(suppl 2):362-7.
28. U.S. Department of Health and Human Services. Section 1557 of the Patient Protection and Affordable Care
Act. Final rule June 19, 2020. Available at: “https://www.gov info.gov/content/pkg/FR-2020-06-
19/pdf/2020-11758. pdf ”. Accessed July 15, 2023.
29. American Academy of Pediatric Dentistry. Policy on the dental home. The Reference Manual of Pediatric
Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry; 2024:XX.
30. Feigal RJ. Guiding and managing the child dental patient: A fresh look at old pedagogy. J Dent Educ
2001;65(12):1369-77.
OFFICIAL BUT UNFORMATTED
31. Versloot J, Craig KD. The communication of pain in paediatric dentistry. Eur Arch Paediatr Dent
2009;10(2);61-6.
32. Yigit T, Topal BG, Ozgocmen E. The effect of parental presence and dental anxiety on children’s fear during
dental procedures: A randomized trial. Clin Child Psychol Psychiatry 2022;27(4):1234-45.
33. Gupta RC, Randell KA, Dowd MD. Addressing parental adverse childhood experiences in the pediatric
setting. Adv Pediatr 2021;68:71-88.
34. Boland L, Graham ID, Légaré F, et al. Barriers and facilitators of pediatric shared decision-making: A
systematic review. Implement Sci 2019;14(1):7
35. Riba H, Al-Shahrani A, Al-Ghutaimel H, Al-Otaibi A, Al-Kahtani S. Parental presence/absence in the dental
operatory as a behavior management technique: A review and modified view. J Contemp Dent Pract
2018;19(2):237-41.
36. Pinkham JR. An analysis of the phenomenon of increased parental participation during the child’s dental
experience. J Dent Child 1991;58(6):458-63.
37. American Academy of Pediatric Dentistry. Behavior Management for the Pediatric Dental Patient.
Conference/Workshop. Iowa City, Iowa. September 30-October 2, 1988. Final Proceedings. Chicago, Ill.:
American Academy of Pediatric Dentistry; 1989.
38. Hamzah HS, Gao X, Yung Yiu CK, McGrath C, King NM. Managing dental fear and anxiety in pediatric
patients: A qualitative study from the public’s perspective. Pediatr Dent 2014;36(1):29-33.
39. Shroff S, Hughes C, Mobley C. Attitudes and preferences of parents about being present in the dental
operatory. Pediatr Dent 2015;37(1):51-5.
40. American Academy of Pediatric Dentistry. Management of dental patients with special health care needs.
The Reference Manual of Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry;
2024:XX.
41. Townsend JA, Wells MH. Behavior guidance in the pediatric patient. In: Nowak AJ, Christensen JR, Mabry
TR, Townsend JA, Wells MH. eds. Pediatric Dentistry - Infancy through Adolescence. 6th ed. St Louis, Mo.,
Elsevier-Saunders Co.; 2019:352-70.
42. Law CS, Blain S. Approaching the pediatric dental patient: A review of nonpharmacologic behavior manage-
ment strategies. J Calif Dent Assoc 2003;31(9):703-13.
43. Sharma A, Kumar D, Anand A, Mittal V, Singh A, Aggarwal N. Factors predicting behavior management
problems during initial dental examination in children aged 2 to 8 years. Int J Clin Pediatr Dent 2017;10(1):5-
9.
44. Aguirre-González G, De Ávila-Rojas P, García-Flores R, et al. Inclusive dentistry: Integral management of
pediatric patients with intellectual disability and/or communication impairments. Case-series reports. J Clin
Pediatr Dent 2020;44(4):221-7.
45. Jensen B, Stjernqvist K. Temperament and acceptance of dental treatment under sedation in preschool
children. Acta Odontol Scand 2002;60(4):231-6.
46. Lochary ME, Wilson S, Griffen AL, Coury DL. Temperament as a predictor of behavior for conscious
sedation in dentistry. Pediatr Dent 1993;15(5):348-52.
47. Oliver K, Manton DJ. Contemporary behavior management techniques in clinical pediatric dentistry: Out
with the old and in with the new? J Dent Child (Chic) 2015;82(1):22-8.
48. Radis FG, Wilson S, Griffen AL, Coury DL. Temperament as a predictor of behavior during initial dental
examination in children. Pediatr Dent 1994;16(2):121-7.
49. Arnup K, Broberg AG, Berggren U, Bodin L. Treatment outcome in subgroups of uncooperative child dental
patients: An exploratory study. Int J Paediatr Dent 2003;13(5):304-19.
50. Paiva ACF, Rabelo-Costa D, Fernandes IB, et al. The relationship between temperament and dental fear and
anxiety: A systematic review. Evid Based Dent 2023;24(1):42.
51. Holst A, Hallonsten AL, Schroder U, Ek L, Edlund K. Prediction of behavior-management problems in 3-
year-old children. Scand J Dent Res 1993;101(2):110-4.
52. Shonkoff JP, Garner AS. The lifelong effects of early childhood adversity and toxic stress. Pediatrics
2012;129 (1):e232-46.
53. Fischer-Owens SA, Lukefahr JL, Tate AR. American Academy of Pediatrics, Section on Oral Health;
Committee on Child Abuse and Neglect; American Academy of Pediatric Dentistry, Council on Clinical
Affairs, Council on Scientific Affairs; Ad Hoc Work Group on Child Abuse and Neglect. Oral and dental
aspects of child abuse and neglect. Pediatrics 2017;140(2):e20171487.
OFFICIAL BUT UNFORMATTED
54. Strickhouser JE, Sutin AR. Family and neighborhood socioeconomic status and temperament development
from childhood to adolescence. J Pers 2020;99(3):515-29.
55. Forkey H, Szilagyi M, Kelly ET, et al. Trauma-informed care. Pediatrics 2021;148 (2):e2021052580.
56. National Child Traumatic Stress Network. Glossary of Terms Related to Trauma-Informed, Integrated
Healthcare. Available at
“https://www.nctsn.org/sites/default/files/resources//glossary_of_terms_related_to_trauma-
Informed_integrated_healthcare.pdf”. Accessed August 16, 2023.
57. Duffee, J, Szilagyi M, Forkey H, et al. Trauma-informed care in child health systems. Pediatrics
2021;148(2):e2021052579.
58. Raja S, Hoersch M, Rajagopalan CF, Chang P. Treating patients with traumatic life experiences: Providing
trauma-informed care. J Am Dent Assoc 2014;145(3):238-45.
59. Hall JA, Roter DL, Katz NR. Task versus socio-emotional behaviors in physicians. Med Care
1987;25(5):399-412.
60. Chambers DW. Communicating with the young dental patient. J Am Dent Assoc 1976;93(4):793-9.
61. Harper DC, D'Alessandro DM. The child's voice: Understanding the contexts of children and families today.
Pediatr Dent 2004;26(2):114-20.
62. Nash DA. Engaging children’s cooperation in the dental environment through effective communication.
Pediatr Dent 2006;28(5):455-9.
63. Zhou Y, Cameron E, Forbes, G, Humphris G. Systematic review of the effect of dental staff behavior on
child dental patient anxiety and behavior. Patient Educ Couns 2011;85(1):4-13.
64. Schouten BC, Eijkman MA, Hoogstraten J. Dentists’ and patients’ communicative behavior and their
satisfaction with the dental encounter. Community Dent Health 2003;20(1):11-5.
65. Wells M, McTigue DJ, Casamassimo PS, Adair S. Gender shifts and effects on behavior guidance. Pediatr
Dent 2014;36(2):138-44.
66. Adair SM, Schafer TE, Rockman RA, Waller JL. Survey of behavior management teaching in predoctoral
pediatric dentistry programs. Pediatr Dent 2004;26(2):143-50.
67. Eaton JJ, McTigue DJ, Fields HW Jr, Beck M. Attitudes of contemporary parents toward behavior
management techniques used in pediatric dentistry. Pediatr Dent 2005; 27(2):107-13.
68. Freeman R. Communicating with children and parents: Recommendations for a child-parent-centered
approach for paediatric dentistry. Eur Arch Paediatr Dent 2008;9 (1):16-22.
69. American Academy of Pediatric Dentistry. Informed consent. The Reference Manual of Pediatric Dentistry.
Chicago, Ill.: American Academy of Pediatric Dentistry; 2024:XX.
70. American Dental Association. Documentation/Patient Records. Available at:
“https://www.ada.org/en/resources/practice/practice-management/documentation-patient-records”.
Accessed March 6, 2024.
71. Nunn J, Foster M, Master S, Greening S. British Society of Paediatric Dentistry: A policy document on
consent and the use of physical intervention in the dental care of children. Int J Paediatr Dent 2008;18(suppl
1):39-46.
72. Seale NS. Behavior Management Conference Panel III Report: Legal issues associated with managing
children’s behavior in the dental office. Pediatr Dent 2004;26(2): 175-9.
73. Burgess J, Meyers A. Pain management in dentistry. Available at: “https://moodle2.units.it/pluginfile.php/
89098/mod_resource/content/2/Pain%20Management% 20in%20Dentistry.pdf ”. Accessed July 18, 2023.
74. Tickle M, Milson K, Crawford FI, Aggarwal VR. Predictors of pain associated with routine procedures
performed in general dental practice. Community Dent Oral Epidemiol 2012;40(4):343-50.
75. American Academy of Pediatric Dentistry. Use of local anesthesia for pediatric dental patients. The
Reference Manual of Pediatric Dentistry. Chicago, Ill.: The American Academy of Pediatric Dentistry;
2024:XX.
76. Nakai Y, Milgrom P, Mancl L, Coldwell SE, Domoto PK, Ramsay DS. Effectiveness of local anesthesia in
pediatric dental practice. J Am Dent Assoc 2000;131(12):1699-705.
77. Nutter DP. Good clinical pain practice for pediatric procedure pain: Target considerations. J Calif Dent Assoc
2009;37(10):719-22.
78. Nutter DP. Good clinical pain practice for pediatric procedure pain: Iatrogenic considerations. J Calif Dent
Assoc 2009;37(10):713-8.
OFFICIAL BUT UNFORMATTED
79. Nutter DP. Good clinical pain practice for pediatric procedure pain: Neurobiologic considerations. J Calif
Dent Assoc 2009;37(10):705-10.
80. Klingberg G. Dental anxiety and behaviour management problems in paediatric dentistry: A review of
background factors and diagnostics. Eur Arch Paediatr Dent 2007;8(4):11-5.
81. Versloot J, Veerkamp JS, Hoogstraten J. Children’s self-reported pain at the dentist. Pain 2008;137(2):389-
94.
82. Stinson JN, Kavanagh T, Yamada J, Gill N, Stevens B. Systematic review of the psychometric properties,
interpretability and feasibility of self-reporting pain intensity measures for use in clinical trials in children
and adolescents. Pain 2006;125(1):143-57.
83. Trottier ED, Ali S, Dore-Gergeron M-J, Chavin-Kimoff L. Best practices in pain management and assessment
for children. Paediatr Child Health 2022;27(7):429-37.
84. McWhorter A, Townsend J. Behavior Symposium Workshop A Report-Current guidelines/revision. Pediatr
Dent 2014;36(2):152-3.
85. Frankl SN, Shiere FR, Fogels HR. Should the parent remain with the child in the dental operatory? J Dent
Child 1962;29:150-63.
86. American Academy of Pediatric Dentistry. Policy on the use of silver diamine fluoride for pediatric dental
patients. The Reference Manual of Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric
Dentistry; 2024:XX.
87. Crystal YO, Marghalani AA, Ureles SD, et al. Use of silver diamine fluoride for dental caries management
in children and adolescents, including those with special health care needs. Pediatr Dent 2017;39(5):E135-
E145.
88. American Academy of Pediatric Dentistry. Pediatric restorative dentistry. The Reference Manual of Pediatric
Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry; 2024:XX.
89. American Academy of Pediatric Dentistry. Policy on interim therapeutic restorations (ITR). The Reference
Manual of Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry; 2024:XX.
90. Lim SM, Kiang L, Manohara R, et al. Interim therapeutic restoration approach versus treatment under general
anaesthesia approach. Int J Paediatr Dent 2017;27(6):551-7.
91. Nelson T. An improved interim therapeutic restoration technique for management of anterior early childhood
caries: Report of two cases. Pediatr Dent 2013;35(4):124-8.
92. Makansi N, Carnevale FA, Macdonald ME. The conceptualization of childhood in North American pediatric
dentistry texts: A discursive case study analysis. Int J Paediatr Dent 2018;28(2):189-97.
93. Fox C, Newton JT. A controlled trial of the impact of exposure to positive images of dentistry on anticipatory
dental fear in children. Community Dent Oral Epidemiol 2006;34(6):455-9.
94. Alnamankany, A. Video modeling and dental anxiety in children. A randomized clinical trial. Eur J Paediatr
Dent 2019;20(3):242-6. KD.
95. Melamed BG, Hawes RR, Heiby E, Glick J. Use of filmed modeling to reduce uncooperative behavior of
children during dental treatment. J Dent Res 1975;54(4): 797-801.
96. Kamath PS. A novel distraction technique for pain management during local anesthesia administration in
pediatric patients. J Clin Pediatr Dent 2013;38(1):45-7.
97. Pickrell JE, Heima M, Weinstein P, et al. Using memory restructuring strategy to enhance dental behaviour.
Int J Paediatr Dent 2007;17(6):439-48.
98. Nelson T, Sheller B, Friedman C, Bernier R. Educational and therapeutic behavioral approaches to providing
dental care for patients with autism spectrum disorder. Spec Care Dentist 2015;35(3):105-13.
99. Campbell C, Soldani F, Busuttil-Naudi A, Chadwick B: British Society of Paediatric Dentistry Guidelines:
Update of non-pharmacological behaviour management guideline, 2011. Available at:
“https://www.bspd.co.uk/Portals/ 0/Public/Files/Guidelines/Non-pharmacological%20
behaviour%20management%20.pdf”. Accessed July 4, 2023.
100. Levi M, Bossù M, Luzzi V, et al. Breathing out dental fear: A feasibility crossover study on the effectiveness
of diaphragmatic breathing in children sitting on the dentist's chair. Int J Paediatr Dent 2022;32(6):801-11.
101. Roberts JF, Curzon ME, Koch G, Martens LC. Review: Behaviour management techniques in paediatric
dentistry. Eur Arch Paediatr Dent 2010;11(4):166-74.
102. Bodison SC, Parham DL. Specific sensory techniques and sensory environment modifications for children
and youth with sensory integration difficulties: A systematic review. Am J Occup Ther
OFFICIAL BUT UNFORMATTED
2018;72(1):7201190040p1-7201190040p11. Available at: “http://doi.org/10.5014/ ajot.2018.029413”.
Accessed July 4, 2023.
103. Cermak SA. Stein Duker LI, Williams ME, et al. Feasibility of a sensory-adapted dental environment for
children with autism. Am J Occup Ther 2015;69(3):6903220020p1-10. Available at: “http://dx.doi.org/10.
5014/ajot.2015.013714”. Accessed July 4, 2023.
104. Cruz-Fierro N, Vanegas-Farfano M, González-Ramírez MT. Dog-assisted therapy and dental anxiety: A
pilot study. Animals 2019;9(8):512.
105. Flippin M, Reszka S, Watson LR. The effectiveness of picture exchange communication system (PECS) on
communication and speech for children with autism spectrum disorders: A meta-analysis. Am J Speech Lang
Pathol 2010;19(2):178-95.
106. Ganz JB, Davis JL, Lund EM, Goodwyn FD, Simpson RL. Meta-analysis of PECS with individuals with
ASD: Investigation of targeted versus non-targeted outcomes, participant characteristics, and
implementation phase. Res Dev Disabil 2012;33(2):406-18.
107. American Academy of Pediatrics, Section on Integrative Medicine. Mind-body therapies in children and
youth. Pediatrics 2016;138(3):e20161896.
108. Birnie KA, Noel M, Chambers CT, et al. Psychological interventions for needle-related procedural pain and
distress in children and adolescents. Cochrane Database Syst Rev 2018;10(10):CD005179.
109. Padminee K, Hemalatha R, Shankar P, et al. Effectiveness of biofeedback relaxation and audiovisual
distraction on dental anxiety among 7- to 12-year-old children while administering local anaesthesia: A
randomized clinical trial. Int J Paediatr Dent 2022;32(1):31-40.
110. Ramírez-Carrasco A, Butrón-Téllez Girón C, Snachez-Armass OK, et al. Effectiveness of hypnosis in
combination with conventional techniques of behavior management in anxiety/pain reduction during dental
anesthetic infiltration. Pain Res Manag 2017:1434015.
111. Prado IM, Carcavalli L, Abreu LG, Serra-Negra JM, Paiva SM, Martins CC. Use of distraction techniques
for the management of anxiety and fear in paediatric dental practice: A systematic review of randomized
controlled trials. Int J Paediatr Dent 2019;29(5):650-68.
112. Thrash WJ, Marr JN, Boone SE. Continuous self-monitoring of discomfort in the dental chair and feedback
to the dentist. J Behav Assess 1982;4(3):273-84.
113. Fisher-Owens S. Broadening perspectives on pediatric oral health care provision: Social determinants of
health and behavioral management. Pediatr Dent 2014;36(2):115-20.
114. Cermak SA, Stein Duker LI, Williams ME, et al. Sensory adapted dental environment to enhance oral care
for children with autism spectrum disorders: A randomized controlled pilot study. J Autism Dev Disord
2015;45(9):2876-88.
115. Cajares CM, Rutledge CM, Haney TS. Animal assisted therapy in a special needs dental practice: An
interprofessional model for anxiety reduction. J of Intell Disabl 2016;4(1):25-8.
116. Gussard AM, Weese JS, Hensten A, Jokstad A. Dog-assisted therapy in the dental clinic. Part B. Hazards
and assessment of potential risks to the health and safety of the dental therapy dog. Clin Exp Dent Res
2019;5(6):701-11.
117. Zink AG, Molina EC, Diniz MB, Santos MTBR, Guaré RO. Communication applications for use during the
first dental visit for children and adolescents with autism spectrum disorders. Pediatr Dent 2018;40(1):18-
22.
118. McClintock AS, McCarrick SM, Garland EL et al. Brief mindfulness-based interventions for acute and
chronic pain: A systematic review. J Altern Complement Med 2019;25(3):265-78.
119. Tieri M, Cosi A, Lombardi L, et al. Nitrous oxide and hypnotherapy in paediatric dentistry. Eur J Paediatr
Dent 2023;24(3):229-37.
120. Anthonappa RP, Ashley PF, Bonetti DL, et al. Non‐pharmacological interventions for managing dental
anxiety in children. Cochrane Database Syst Rev 2017(6):CD012676.
121. Bahrololoomi Z, Sadeghiyeh T, Rezaei M, Maghsoudi N. The effect of breathing exercise using bubble
blower on anxiety and pain during inferior alveolar nerve block in children aged 7 to 10 years: A crossover
randomized clinical trial. Pain Res Manag 2022:7817267.
122. Clark MS, Brunick AL. Anatomy and physiology of respiration and airway management. In: Handbook of
Nitrous Oxide and Oxygen Sedation. 5th ed. Maryland Heights, Md.: Mosby Elsevier; 2019:74.
OFFICIAL BUT UNFORMATTED
123. Gupta K, Ritwik P. Rationale for using nitrous oxide in pediatric dentistry. In Gupta K, Emmanouil D, Sethi
A, eds. Nitrous Oxide in Pediatric Dentistry: A Clinical Handbook. Switzerland: Springer Nature; 2020:1-
43. 25 26 29-30 31-32
124. Ashley P, Anand P, Andersson K. Best clinical practice guidance for conscious sedation of children
undergoing dental treatment: An EAPD policy document. Eur Arch Paediatr Dent 2021; 22(6):989-1002.
125. Saxen M. Pharmacologic management of patient behavior. In: Dean JA, ed. McDonald and Avery’s
Dentistry for the Child and Adolescent. 11th ed. St. Louis, Mo.: Elsevier; 2022:367.
126. Buhre W, Disma N, Hendrickx J, et al. European Society of Anaesthesiology Task Force on Nitrous Oxide:
A narrative review of its role in clinical practice. Br J Anaesth 2019;122(5):587-604.
127. Pasarón R, Burnweit C, Zerpa J, et al. Nitrous oxide procedural sedation in non-fasting pediatric patients
undergoing minor surgery: A 12-year experience with 1,058 patients. Pediatr Surg Int 2015;31(2):173-80.
128. De Veaux CK, Montagnese TA, Heima M, et al. The effect of various concentrations of nitrous oxide and
oxygen on the hypersensitive gag reflex. Anesth Prog 2016;63(4):181-4.
129. Arcari S, Moscati M. Nitrous oxide analgesic effect on children receiving restorative treatment on primary
molars. Eur J Paediatr Dent 2018;19(3):205-12.
130. Becker DE, Rosenberg M. Nitrous oxide and the inhalation anesthetics. Anesth Prog 2008;55(4):124-31.
131. Chino K, Ganzberg S, Mendoza K. Office-based sedation/ general anesthesia for COPD Patients, Part II.
Anesth Prog 2019;66(1):44-51.
132. Clark MS, Brunick AL. N
2
O and its interaction with the body. In: Handbook of Nitrous Oxide and Oxygen
Sedation. 5th ed. Maryland Heights, Md.: Mosby Elsevier; 2019:103-13. 82
133. Thikkurissy S, Gosnell ES. Pain reaction control: Sedation. In: Nowak AJ, Christensen JR, Mabry, TR,
Townsend JA, Wells MH, eds. Pediatric Dentistry: Infancy through Adolescence. 6th ed, St. Louis, Mo.:
Elsevier; 2019:121.
134. American Academy of Pediatric Dentistry. Oral health care for the pregnant pediatric dental patient. The
Reference Manual of Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry; 2024:XX.
135. Fleming P, Walker PO, Priest JR. Bleomycin therapy: A contraindication to the use of nitrous oxide-oxygen
psycho-sedation in the dental office. Pediatr Dent 1988;10(4):345-6.
136. Sanders RDB, Weimann J, Maze M. Biologic effects of nitrous oxide: A mechanistic and toxicologic review.
Anesthesiology 2008;109(4):707-22.
137. Aldossari GS, Aldosari AA, Alasmari AA, Aldakheel RM, Al-Natsha RR, Aldossary MS. The long-term
effect of previous dental treatment under general anesthesia on children’s dental fear and anxiety. Int J
Paediatr Dent 2019;29(2):177-84.
138. Cantekin K, Yildirim MD, Cantekin I. Assessing change in quality of life and dental anxiety in young
children following dental rehabilitation under general anesthesia. Pediatr Dent 2014;36(1):12E-17E.
139.Guney S, Araz C, Tirali R, Cehreli S. Dental anxiety and oral health-related quality of life in children
following dental rehabilitation under general anesthesia or intravenous sedation: A prospective cross
sectional study. Niger J Clin Pract 2019;21(10):1304-10.
140. Klaassen MA, Veerkamp JS, Hoogstraten J. Young children's oral health-related quality of life and dental
fear after treatment under general anaesthesia: A randomized controlled trial. Eur J Oral Sci
2009;117(3):273-8.
141. Patel M, McTigue DJ, Thikkurissy S, Fields HW. Parental attitudes toward advanced behavior guidance
techniques used in pediatric dentistry. Pediatr Dent 2016;38(1):30-6.
142. Hulin J, Baker S, Marshman Z, Albadri S, Rodd H. The decisional needs of young patients faced with the
decision to undergo dental treatment with sedation or GA. SAAD Digest 2017;33:18-23.
143. Weishuhn D, Scully A, Amini H, Salzmann L, Boynton JR. Contemporary predoctoral paediatric behaviour
guidance education in the United States and Canada. Eur J Dent Educ 2022;26(1):85-92.
144. New York State. Office for People with Developmental Disabilities. Administrative Memorandum – #2010-
02. Medical immobilization/protective stabilization (MIPS) and sedation for medical/dental appointments.
2010;1-7. Available at: “https://opwdd.ny.gov/system/files/documents/2020/01/mips-and-sedation.pdf”.
Accessed February 5, 2024.
145. Chavis SE, Wu E, Munz SM. Considerations for protective stabilization in community general dental
practice for adult patients with special healthcare needs. Compend Contin Educ Dent 2021;42(3):134-8.
Available at: “https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8281605/”. Accessed February 23, 2024.
OFFICIAL BUT UNFORMATTED
146. Centers for Medicare and Medicaid Services. State Operations Manual Appendix A - Survey protocol.
Regulations, and Interpretive Guidelines for Hospitals. §482.13 Condition of Participation: Patient Rights
A-0154 §482.13(e) Standard: Restraint or Seclusion. (Rev. 216, 07-21-23). Available at:
“https://www.cms.gov/Regulations-and-Guidance/
Guidance/Manuals/downloads/som107ap_a_hospitals.pdf”. Accessed March 16, 2024.
147. American Academy of Pediatrics Committee on Pediatric Emergency Medicine. The use of physical restraint
interventions for children and adolescents in the acute care setting. Pediatrics 1997;99(3):497-8.
148. Townsend JA. Protective stabilization in the dental setting. In: Nelson TM, Webb JR, eds. Dental Care for
Children with Special Needs. Cham, Switzerland: Springer Nature; 2019:253.
149. Mohr WK, Petti TA, Mohr BD. Adverse effects associated with physical restraint. Can J Psychiatry. 2003
Jun;48(5):330-7.
150. American Dental Association. Principles of Ethics and Code of Professional Conduct. With official advisory
opinions revised to March 2023. Available at: “https://www.ada.org/-/media/project/ada-
organization/ada/ada-org/files/about/ada_code_of_ethics.pdf?rev=ba22edfdf1a646be9249fe2d870d7d31
&hash=CCD76FCDC56D6F2CCBC46F1751F51B96”. Accessed February 23, 2024.
151. American Academy of Pediatrics. The pediatrician’s role in the evaluation and preparation of pediatric
patients undergoing anesthesia. Pediatrics 2014;134(3):497-8.
152. Ing C, Warner DO, Sun LS, et al. Anesthesia and developing brains: Unanswered questions and proposed
paths forward. Anesthesiology 2022;136(3):500-12.
