Best Practices: Behavior Guidance for Pediatric Dental Patients PDF

BEST PRACTICES: BEHAVIOR GUIDANCE Behavior Guidance for the Pediatric Dental Patient Latest Revision How to Cite: American Academy of Pediatric Dentistry. Behavior 2020...

BEST PRACTICES: BEHAVIOR GUIDANCE Behavior Guidance for the Pediatric Dental Patient Latest Revision How to Cite: American Academy of Pediatric Dentistry. Behavior 2020 guidance for the pediatric dental patient. The Reference Manual of Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry; 2022:321-39. 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 non-pharmacological and pharmacological options. The following items should be addressed before, during, and after patient treatment: informed consent, pain assessment, behavior documentation, and preventive and deferred treat- ment considering all behavior guidance options. 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, and nitrous oxide-oxygen inhalation. Advanced behavior guidance includes protective stabilization, sedation, and general anesthesia. Each option should be assessed for objectives, indications, contraindications, and precautions. Knowledge of these options will aid healthcare professionals in providing appropriate 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, BEHAVIOR THERAPY, CHILD, INFORMED CONSENT, NITROUS OXIDE, PAIN MEASUREMENT Purpose last revised in 2015.8 The original guidance was developed The American Academy of Pediatric Dentistry (AAPD) subsequent to the AAPD’s 1988 conference on behavior recognizes that dental care is medically necessary for the pur- management and modified following the AAPD’s symposia pose of preventing and eliminating orofacial disease, infection, on behavior guidance in 2003 10 and 2013.11 This update and pain, restoring the form and function of the dentition, reflects a review of the most recent proceedings, other dental and correcting facial disfiguration or dysfunction.1 Behavior and medical literature related to behavior guidance of the pedi- guidance techniques, both nonpharmalogical and pharma- atric patient, and sources of recognized professional expertise logical, are used to alleviate anxiety, nurture a positive dental and stature including both the academic and practicing attitude, and perform quality oral health care safely and pediatric dental communities and the standards of the American efficiently for infants, children, adolescents, and persons with Dental Association Commission on Dental Accreditation.12 In special health care needs (SHCN). Selection of techniques must be tailored to the needs of the individual patient and the skills ® addition, a search of the PubMed /MEDLINE electronic database was performed, (see Appendix 1 after References). of the practitioner. The AAPD offers these recommendations Articles were screened by viewing titles and abstracts. Data was to inform health care providers, parents, and other interested abstracted and used to summarize research on behavior parties about influences on the behavior of pediatric dental guidance for infants and children through adolescents, includ- patients and the many behavior guidance techniques used in ing those with special healthcare needs. When data did not contemporary pediatric dentistry. Information regarding pain appear sufficient or were inconclusive, recommendations were management, protective stabilization, and pharmacological based upon expert and/or consensus opinion by experienced behavior management for pediatric dental patients is provided researchers and clinicians. in greater detail in additional AAPD best practices documents.2-6 ABBREVIATIONS Methods AAPD: American Academy of Pediatric Dentistry. AAT: Animal- Recommendations on behavior guidance were developed assisted therapy. ITR: Interim therapeutic restoration. PECS: Picture by the Clinical Affairs Committe, Behavior Management exchange communication system. SADE: Sensory-adapted dental environment. SDF: Silver diamine fluoride. SHCN: Special health- Subcommittee and adopted in 1990.7 This document by the care needs. Council of Clinical Affairs is a revision of the previous version, THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 321 BEST PRACTICES: BEHAVIOR GUIDANCE Background If the level of fear is incongruent with the circumstances and Dental practitioners are expected to recognize and effectively the patient is not able to control impulses, disruptive behavior treat childhood dental diseases that are within the knowledge is likely.20 and skills acquired during their professional education. Safe Cultural and linguistic factors also may play a role in patient and effective treatment of these diseases requires an under- cooperation and selection of behavior guidance techniques.23-26 standing of and, at times, modifying the child’s and family’s Since every culture has its own beliefs, values, and practices, response to care. Behavior guidance a continuum of interaction it is important to understand how to interact with patients involving the dentist and dental team, the patient, and parent from different cultures and to develop tools to help navigate directed toward communication and education, while also their encounters. Translation services should be made available ensuring the safety of both oral health professionals and the for those families who have limited English proficiency. 26,27 child, during the delivery of medically necessary care. Goals A federal mandate requires translation services for non-English of behavior guidance are to: 1) establish communication, 2) speaking families be available at no cost to the family in alleviate the child’s dental fear and anxiety, 3) promote pa- healthcare facilities that receive federal funding for services.28 tient’s and parents’ awareness of the need for good oral health As is true for all patients/families, the dentist/staff must listen and the process by which it is achieved, 4) promote the child’s actively and address the patient’s/parents’ concerns in a sensitive positive attitude toward oral health care, 5) build a trusting and respectful manner.23 relationship between dentist/staff and child/parent, and 6) provide quality oral health care in a comfortable, minimally- Parental influences restrictive, safe, and effective manner. Behavior guidance tech- Parents influence their child’s behavior at the dental office in niques range from establishing or maintaining communication several ways. Positive attitudes toward oral health care may to stopping unwanted or unsafe behaviors.13 Knowledge of lead to the early establishment of a dental home. Early pre- the scientific basis of behavior guidance and skills in com- ventive care leads to less dental disease, decreased treatment munication, empathy, tolerance, cultural sensitivity, and needs, and fewer opportunities for negative experiences.29,30 flexibility are requisite to proper implementation. Behavior Parents who have had negative dental experiences as a patient guidance should never be punishment for misbehavior, power may transmit their own dental anxiety or fear to the child assertion, or use of any strategy that hurts, shames, or belittles thereby adversely affecting her attitude and response to a patient. care. 14,17,31,32 Long term economic hardship leads to stress, which can lead to parental adjustment problems such as de- Predictors of child behaviors pression, anxiety, irritability, substance abuse, and violence.23 Patient attributes Parental depression may result in parenting changes, including A dentist who treats children should be able to accurately decreased supervision, caregiving, and discipline for the child, assess the child’s developmental level, dental attitudes, and thereby placing the child at risk for a wide variety of adjust- temperament to anticipate the child’s reaction to care. The ment issues including emotional and behavior problems.23 In response to the demands of oral health care is complex and America, evolving parenting styles17,18 and parental behaviors determined by many factors. influenced by economic hardship have left practitioners Factors that may contribute to noncompliance during the challenged by an increasing number of children ill-equipped dental appointment include fears, general or situational with the coping skills and self-discipline necessary to contend anxiety, a previous unpleasant and/or painful dental/medical with new experiences.23,24,26 Frequently, parental expectations experience, pain, inadequate preparation for the encounter, for the child’s response to care (e.g., no tears) are unrealistic, and parenting practices.13-19 In addition, cognitive age, devel- while expectations for the dentist who guides their behavior opmental delay, inadequate coping skills, general behavioral are great.19 considerations, negative emotionality, maladaptive behaviors, physical/mental disability, and acute illness or chronic disease Orientation to dental environment are potential reasons for noncompliance during the dental The nonclinical office staff plays an important role in appointment.13-19 behavior guidance. The scheduling coordinator or receptionist Dental behavior management problems often are more often will be the first point of contact with a prospective readily recognized than dental fear/anxiety due to associations patient and family, either through the internet or a telephone with general behavioral considerations (e.g., activity, impul- conversation. The tone of the communication should be wel- sivity) versus temperamental traits (e.g., shyness, negative coming. The scheduling coordinator or receptionist should emotionality) respectively. 20 Only a minority of children actively engage the patient and family to determine their with uncooperative behavior have dental fears, and not all primary concerns, chief complaint, and any special health care fearful children present with dental behavior guidance prob- or cultural/linguistic needs. The communication can provide lems.14,21,22 Fears may occur when there is a perceived lack of insights into patient or family anxiety or stress. Staff should control or potential for pain, especially when a child is aware help set expectations for the initial visit by providing relevant of a dental problem or has had a painful healthcare experience. information and may suggest a pre-appointment visit to the 322 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY  BEST PRACTICES: BEHAVIOR GUIDANCE office to meet the doctor and staff and tour the facility.20 The Dentist/dental team behaviors nonclinical staff should confirm the office’s location, offer The behaviors of the dentist and dental staff members are the directions, and ask if there are any further questions. Such primary tools used to guide the behavior of the pediatric encounters serve as educational tools that help to allay fears patient. The dentist’s attitude, body language, and communi- and better prepare the family and patient for the first visit. cation skills are critical to creating a positive dental visit for The parent’s/patient’s initial contact with the dental practice the child and to gain trust from the child and parent.29 Dentist allows both parties to address the child’s primary oral health and staff behaviors that can help reduce anxiety and encourage needs and to confirm the appropriateness of scheduling an patient cooperation include giving clear and specific instruc- appointment.33 From a behavioral standpoint, many factors tions, having empathetic communication style, and offering are important when appointment times are determined. 20 verbal reassurance.43 Dentists and staff must continue to be Appointment-related concerns include patient age, presence attentive to their communication styles throughout interactions of a special health care need, the need for sedation, distance with patients and families.44 the parent/patient travels, length of appointment, additional Communication (i.e., imparting or interchange of thoughts, staffing requirements, parent’s work schedule, and time of day. opinions, or information) may occur by a number of means Emergent or urgent treatment should not be delayed on these but, in the dental setting, it is accomplished primarily through grounds alone.34 Appointment scheduling should be tailored dialogue, tone of voice, facial expression, and body language.45 to the needs of the individual patient’s circumstances and the Communication between the doctor/staff and the child and skills of the practitioner. The practitioner should formulate parent is vital to successful outcomes in the dental office. a policy regarding scheduling, and scheduling should not The four essential ingredients of communication are: be left to chance. 20 Appointment duration should not be 1. the sender, prolonged beyond a patient’s tolerance level solely for the 2. the message, including the facial expression and body practitioner’s convenience. 20 Consideration of appointment language of the sender, scheduling will benefit the parent/patient and practitioner by 3. the context or setting in which the message is sent, and building a trusting relationship that promotes the patient’s 4. the receiver.46 positive attitude toward oral health care. Reception staff are usually the first team members the For successful bi-directional communication to take place, patient meets upon arrival at the office. The caring and assuring all four elements must be present and consistent. Without manner in which the child is welcomed into the practice consistency, there may be a poor fit between the intended at the first and subsequent visits is important.19,35 A child- message and what is understood.45 friendly reception area (e.g., age-appropriate toys and games) Communicating with children poses special challenges can provide a distraction for and comfort young patients. for the dentist and the dental team. A child’s cognitive These first impressions may influence future behaviors. development will dictate the level and amount of information interchange that can take place.26 With a basic understanding Patient assessment of the cognitive development of children, the dentist can use An evaluation of the child’s cooperative potential is essential appropriate vocabulary and body language to send messages for treatment planning. No single assessment method or tool consistent with the receiver’s intellectual development.26,45 is completely accurate in predicting a patient’s behavior, but Communication may be impaired when the sender’s expres- awareness of the multiple influences on a child’s response to sion and body language are not consistent with the intended care can aid in treatment planning.36 Initially, information can message. When body language conveys uncertainty, anxiety, be gathered from the parent through questions regarding the or urgency, the dentist cannot effectively communicate con- child’s cognitive level, temperament/personality characteris- fidence or a calm demeanor.45 tics,15,22,37,38,39 anxiety and fear,14,22,40 reaction to strangers,41 In addition, the operatory may contain distractions (e.g., and behavior at previous medical/dental visits, as well as how another child crying) that, for the patient, produce anxiety the parent anticipates the child will respond to future dental and interfere with communication. Dentists and other mem- treatment. Later, the dentist can evaluate cooperative potential bers of the dental team may find it advantageous to discuss by observation of and interaction with the patient. Whether certain information (e.g., postoperative instructions, the child is approachable, somewhat shy, or definitely shy preventive counseling) away from the operatory and its many and/or withdrawn may influence the success of various com- distractions.19 municative techniques. Assessing the child’s development, The communicative behavior of dentists is a major factor past experiences, and current emotional state allows the in patient satisfaction.46,47 Dentist actions that are reported to dentist to develop a behavior guidance plan to accomplish the correlate with low parent satisfaction include rushing through necessary oral health care.20 During delivery of care, the dentist appointments, not taking time to explain procedures, barring must remain attentive to physical and/or emotional indicators parents from the examination room, and generally being of stress.23-26,42 Changes in behaviors may require alterations impatient.37,43 However, when a provider offers compassion, to the behavioral treatment plan. empathy, and genuine concern, there may be better acceptance THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 323 BEST PRACTICES: BEHAVIOR GUIDANCE of care.43 While some patients may express a preference for a Pain assessment and management during treatment provider of a specific gender, female and male practitioners Pain has a direct influence on behavior and should be assessed have been found to treat patients and parents in a similar and managed throughout treatment.58 Anxiety may be a pre- manner.39 dictor of increased pain perception.59 Findings of pain or a The clinical staff is an extension of the dentist in behavior painful past health care visit are important considerations in guidance. A collaborative approach helps assure that both the the patient’s medical/dental history that will help the dentist patient and parent have a positive dental experience. All den- anticipate possible behavior problems. 2,53,58 Prevention or tal team members are encouraged to expand their skills and reduction of pain during treatment can nurture the relation- knowledge through dental literature, video presentations, and/ ship between the dentist and the patient, build trust, allay fear or continuing education courses.49 and anxiety, and enhance positive dental attitudes for future visits.60-64 Pain can be assessed using self-report, behavioral, and Informed consent biological measures. In addition, there are several pain assess- All behavior guidance decisions must be based on a review of ment instruments that can be used in patients.2 The subjective the patient’s medical, dental, and social history followed by an nature of pain perception, varying patient responses to painful evaluation of current behavior. Decisions regarding the use stimuli, and lack of use of accurate pain assessment scales may of behavior guidance techniques other than communicative hinder the dentist’s attempts to diagnose and intervene during management cannot be made solely by the dentist. They must procedures.31,61,62,65-67 Observing changes in patient behavior involve a parent and, if appropriate, the child. The practitioner, (e.g., facial expressions, crying, complaining, body movement as the expert on dental care (i.e., the timing and techniques during treatment) as well as biologic measures (e.g., heart by which treatment can be delivered), should effectively com- rate, sweating) is important in pain evaluation. 2,61,64 The municate behavior and treatment options, including potential patient is the best reporter of her pain. 31,62,65,66 Listening to benefits and risks, and help the parent decide what is in the the child at the first sign of distress will facilitate assessment child’s best interests. 29 Successful completion of diagnostic and any needed procedural modifications.62 At times, dental and therapeutic services is viewed as a partnership of dentist, providers may underestimate a patient’s level of pain or may parent, and child.29,50,51 The conversation should allow questions develop pain blindness as a defense mechanism and continue from the parent and patient in order to clarify issues and to to treat a child who really is in pain.31,61,68-71 Misinterpreted or verify the parents’ and child’s comprehension. This should be ignored changes in behavior due to painful stimuli can cause done in the family’s preferred language, with assistance of a sensitization for future appointments as well as psychological trained interpreter if needed.13,28 trauma.72 Communicative management, by virtue of being a basic element of communication, requires no specific consent. All Documentation of patient hehaviors other behavior guidance techniques require informed consent Recording the child’s behavior serves as an aid for future consistent with AAPD’s Informed Consent 52 and applicable appointments.66 One of the more reliable and frequently used state laws. A signature on the consent form does not neces- behavior rating systems in both clinical dentistry and research sarily constitute informed consent. Informed consent implies is the Frankl Scale.20,66,73 This scale (see Appendix 2) separates information was provided to the parent, risks/benefits and observed behaviors into four categories ranging from definitely alternatives were discussed, questions were answered, and negative to definitely positive.20,66,73 In addition to the rating permission was obtained prior to administration of treat- scale, an accompanying descriptor (e.g., “+, non-verbal”) will ment. 13 If the parent refuses treatment after discussions of help practitioners better plan for subsequent visits. the risks/benefits and alternatives of the proposed treatment and behavior guidance techniques, an informed refusal Treatment deferral form should be signed by the parent and retained in the Dental disease usually is not life-threatening, and the type and patient’s record.53 If the dentist believes the informed refusal timing of dental treatment can be deferred in certain circum- violates proper standard of care, he should recommend the stances. When a child’s cognitive abilities or behavior prevents patient seek another opinion and/or dismiss the patient routine delivery of oral health care using communicative from the practice. 52 If the dentist suspects dental neglect 54, guidance techniques, the dentist must consider the urgency of he is obligated to report to appropriate authorities.52,55 dental need when determining a plan of treatment.56,57 In some In the event of an unanticipated behavioral reaction to cases, treatment deferral may be considered as an alternative dental treatment, it is incumbent upon the practitioner to pro- to treating the patient under sedation or general anesthesia. tect the patient and staff from harm. Following immediate However, rapidly advancing disease, trauma, pain, or infection intervention to assure safety, if a new behavior guidance plan is usually dictates prompt treatment. Deferring some or all treat- developed to complete care, the dentist must obtain informed ment or employing therapeutic interventions (e.g., silver consent for the alternative methods.52,56,57 diamine fluoride [SDF] 74 interim therapeutic restoration [ITR],75,76 fluoride varnish, antibiotics for infection control) until the child is able to cooperate may be appropriate when 324 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY  BEST PRACTICES: BEHAVIOR GUIDANCE based upon an individualized assessment of the risks and may establish teacher/student roles in order to develop an benefits of that option. The dentist must explain the risks and educated patient and deliver quality dental treatment safely.20,29 benefits of deferred or alternative treatments clearly, and Once a procedure begins, bi-directional communication informed consent must be obtained from the parent.52,53,56 In should be maintained, and the dentist should consider the select cases where ITR or SDF is employed, regular reevalu- child as an active participant in his well-being and care.83 ations are recommended and retreatment may be needed.77,78 With this two-way interchange of information, the dentist also Treatment deferral also should be considered in cases when can provide one-way guidance of behavior through directives. treatment is in progress and the patient’s behavior becomes Use of self-disclosing assertiveness techniques (e.g., “I need hysterical or uncontrollable. In such cases, the dentist should you to open your mouth so I can check your teeth”, “I need halt the procedure as soon as possible, discuss the situation you to sit still so we can take an X-ray”) tells the child exactly with the patient/parent, and either select another approach what is required to be cooperative.82 The dentist can ask the for treatment or defer treatment based upon the dental needs child ‘yes’ or ‘no’ questions where the child can answer with of the patient. If the decision is made to defer treatment, the a ‘thumbs up’ or ‘thumbs down’ response. Also, observation practitioner immediately should complete the necessary steps of the child’s body language is necessary to confirm the to bring the procedure to a safe conclusion before ending the message is received and to assess comfort and pain level.60,61,82 appointment.57,75,76 Communicative guidance comprises a host of specific tech- Caries risk should be reevaluated when treatment options niques that, when integrated, enhance the evolution of a are compromised due to child behavior.79 An individualized cooperative patient. Rather than being a collection of singular preventive program, including appropriate parent education techniques, communicative guidance is an ongoing subjective and a dental recall schedule, should be recommended after process that becomes an extension of the personality of the evaluation of the patient’s caries risk, oral health needs, and dentist. Associated with this process are the specific techniques abilities. Topical fluorides (e.g., brush-on gels, fluoride of pre-visit imagery, direct observation, tell-show-do, varnish, professional application during prophylaxis) may ask-tell-ask, voice control, nonverbal communication, positive be indicated. 80 ITR may be useful as both preventive and reinforcement, various distraction techniques (e.g., audio, therapeutic approaches.75,76 visual, imagination, thoughtful designs of clinic), memory restructuring desensitization to dental setting and procedures, Behavior guidance techniques parental presence/absence, enhanced control, additional Since children exhibit a broad range of physical, intellectual, considerations for patients with anxiety or SHCN and nitrous emotional, and social development and a diversity of attitudes oxide/oxygen inhalation. 81 The dentist should consider the and temperament, it is important that dentists have a wide development of the patient, as well as the presence of other range of behavior guidance techniques to meet the needs of communication deficits (e.g., hearing disorder), when choosing the individual child and be tolerant and flexible in their specific communicative guidance techniques. implementation.18,25 Behavior guidance is not an application of individual techniques created to deal with children, but Positive pre-visit imagery rather a comprehensive, continuous method meant to develop Description: Patients preview positive photographs or and nurture the relationship between the patient and doctor, images of dentistry and dental treatment before the dental which ultimately builds trust and allays fear and anxiety. Some appointment.84 of the behavior guidance techniques in this document are in- tended to maintain communication, while others are intended Objectives: The objectives of positive pre-visit imagery are to extinguish inappropriate behavior and establish communi- to: cation. As such, these techniques cannot be evaluated on an — provide children and parents with visual information individual basis as to validity but must be assessed within the on what to expect during the dental visit; and context of the child’s total dental experience. Techniques must — provide children with context to be able to ask providers be integrated into an overall behavior guidance approach relevant questions before dental procedures commence. individualized for each child. Consequently, behavior guidance Indications: Use with any patient. is as much an art as it is a science. Contraindication: None. Recommendations Direct observation Basic behavior guidance Description: Patients are shown a video or are permitted Communication and communicative guidance to directly observe a young cooperative patient undergoing Communicative management and appropriate use of commands dental treatment.85,86 are applied universally in pediatric dentistry with both the Objectives: The objectives of direct observation are to: cooperative and uncooperative child. At the beginning of — familiarize the patient with the dental setting and a dental appointment, asking questions and active/reflective specific steps involved in a dental procedure; and listening can help establish rapport and trust.81,82 The dentist THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 325 BEST PRACTICES: BEHAVIOR GUIDANCE — provide an opportunity for the patient and parent to — avert negative or avoidance behavior; and ask questions about the dental procedure in a safe — establish appropriate adult-child roles. environment. Indications: Use with any patient. Indications: Use with any patient. Contraindications: Patients who are hearing impaired. Contraindications: None. Nonverbal communication Tell-show-do Description: Nonverbal communication is the reinforcement Description: The technique involves verbal explanations of and guidance of behavior through appropriate contact, procedures in phrases appropriate to the developmental posture, facial expression, and body language.29,34,35,51,81 level of the patient (tell); demonstrations for the patient of Objectives: The objectives of nonverbal communication are to: the visual, auditory, olfactory, and tactile aspects of the — enhance the effectiveness of other communicative procedure in a carefully defined, nonthreatening setting guidance technique; and (show); and then, without deviating from the explanation — gain or maintain the patient’s attention and compliance. and demonstration, completion of the procedure (do). The Indications: Use with any patient. tell-show-do technique operates with communication skills Contraindications: None. (verbal and nonverbal) and positive reinforcement.29,34,35,81 Objectives: The objectives of tell-show-do are to: Positive reinforcement and descriptive praise — teach the patient important aspects of the dental visit Description: In the process of establishing desirable patient and familiarize the patient with the dental setting and behavior, it is essential to give appropriate feedback. armamentarium; and Positive reinforcement rewards desired behaviors thereby — shape the patient’s response to procedures through strengthening the likelihood of recurrence of those behav- desensitization and well-described expectations. iors. Social reinforcers include positive voice modulation, Indications: Use with any patient. facial expression, verbal praise, and appropriate physical Contraindications: None. demonstrations of affection by all members of the dental team. Descriptive praise emphasizes specific cooperative Ask-tell-ask behaviors (e.g., “Thank you for sitting still”, “You are doing Description: This technique involves inquiring about the a great job keeping your hands in your lap”) rather than a patient’s visit and feelings toward or about any planned generalized praise (e.g., “Good job”).82 Nonsocial reinforcers procedures (ask); explaining the procedures through dem- include tokens and toys. onstrations and non-threatening language appropriate to Objective: The objective of positive reinforcement and the cognitive level of the patient (tell); and again inquiring descriptive praise is to reinforce desired behavior.20,34,45,81,87 if the patient understands and how she feels about the Indications: Use with any patient. impending treatment (ask). If the patient continues to have Contraindications: None. concerns, the dentist can address them, assess the situation, and modify the procedures or behavior guidance techniques Distraction if necessary.26 Description: Distraction is the technique of diverting the Objectives: The objectives of ask-tell-ask are to: patient’s attention from what may be perceived as an un- — assess anxiety that may lead to noncompliant behavior pleasant procedure. Distraction may be achieved by during treatment; imagination (e.g., stories), clinic design, and audio (e.g., — teach the patient about the procedures and their imple- music) and/or visual (e.g., television, virtual reality eye- mentation; and glasses) effects.81,88 Giving the patient a short break during — confirm the patient is comfortable with the treatment a stressful procedure can be an effective use of distraction before proceeding. before considering more advanced behavior guidance Indications: Use with any patient able to dialogue. techniques.20,45,87 Contraindications: None. Objectives: The objectives of distraction are to: — decrease the perception of unpleasantness; and Voice control — avert negative or avoidance behavior. Description: Voice control is a deliberate alteration of voice Indications: Use with any patient. volume, tone, or pace to influence and direct the patient’s Contraindications: None. behavior. While a change in cadence may be readily ac- cepted, use of an assertive voice may be considered aversive Memory restructuring to some parents unfamiliar with this technique. An explana- Description: Memory restructuring is a behavioral approach tion before its use may prevent misunderstanding.20,29,34,35 in which memories associated with a negative or difficult Objectives: The objectives of voice control are to: event (e.g., first dental visit, local anesthesia, restorative pro- — gain the patient’s attention and compliance; cedure, extraction) are restructured into positive memories 326 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY  BEST PRACTICES: BEHAVIOR GUIDANCE using information suggested after the event has taken place.89 Indications: Use with patients who have experienced fear- This approach was utilized with children who received local invoking stimuli, anxiety, and/or neurodevelopmental anesthesia at an initial restorative dental visit and showed disorders (e.g., autism spectrum disorder). a change in local anesthesia-related fears and behaviors at Contraindications: None. subsequent treatment visits.89,90 Restructuring involves four components: (1) visual reminders; (2) positive reinforcement Enhancing control through verbalization; (3) concrete examples to encode Description: Enhancing control is a technique used to allow sensory details; and (4) sense of accomplishment. A visual the patient, especially an anxious/fearful one, to assume an reminder could be a photograph of the child smiling at the active role in the dental experience. The dentist provides the initial visit (i.e., prior to the difficult experience). Positive patient a signal (e.g., raising a hand) to use if he becomes reinforcement through verbalization could be asking if the uncomfortable or needs to briefly interrupt care. The patient child had told her parent what a good job she had done at should practice this gesture before treatment is initiated to the last appointment. The child is asked to role-play and emphasize it is a limited movement away from the operatory to tell the dentist what she had told the parent. Concrete field. When the patient employs the signal during dental examples to encoding sensory details include praising the procedures, the dentist should quickly respond with a pause child for specific positive behavior such as keeping her hands in treatment and acknowledge the patient’s concern. En- on her lap or opening her mouth wide when asked. The child hancing control has been shown to be effective in reducing then is asked to demonstrate these behaviors, which leads to intraoperative pain.92 a sense of accomplishment. Objectives: The objective is to allow a patient to have some Objectives: The objectives of memory restructuring are to: measure of control during treatment in order to contain — restructure difficult or negative past dental experiences; emotions and deter disruptive behaviors.92,93 and Indications: Use with patients who can communicate. — improve patient behaviors at subsequent dental visits. Contraindications: None, but if used prematurely, fear may Indications: Use with patients who had a negative or increase due to an implied concern about the impending difficult dental visit. procedure. Contraindications: None. Communication techniques for parents (and age-appropriate Desensitization to dental setting and procedures patients) Description: Systematic desensitization is a psychological Because parents are the legal guardians of minors, successful technique that can be applied to modify behaviors of bi-directional communication between the dentist/staff and the anxious patients in the dental setting.91 It is a process that parent is essential to assure effective guidance of the child’s diminishes emotional responsiveness to a negative, aversive, behavior.52 Socioeconomic status, stress level, marital discord, or positive stimulus after progressive exposure to it. Patients dental attitudes aligned with a different cultural heritage, and are exposed gradually through a series of sessions to compo- linguistic skills may present challenges to open and clear nents of the dental appointment that cause them anxiety. communication. 23,26,94 Communication techniques such as Patients may review information regarding the dental office ask-tell-ask, teach back, and motivational interviewing can and environment at home with a preparation book or video reflect the dentist/staff’s caring for and engaging in a patient/ or by viewing the practice website. Parents may model actions parent centered-approach.26 These techniques are presented in (e.g., opening mouth and touching cheek) and practice Appendix 3. with the child at home using a dental mirror. Successful approximations would continue with an office tour during Parental presence/absence non-clinical hours and another visit in the dental operatory Description: The presence or absence of the parent some- to explore the environment. After successful completion of times can be used to gain cooperation for treatment. A wide each step, an appointment with the dentist and staff may diversity exists in practitioner philosophy and parents’ atti- be attempted.91 tude regarding parental presence/absence during pediatric Objectives: The objective of systematic desensitization is for dental treatment. As establishment of a dental home by 12 the patient to: months of age continues to grow in acceptance, parents will — proceed with dental care after habituation and successful expect to be with their infants and young children during progression of exposure to the environment; examinations as well as during treatment. Parental involve- — identify his fears; ment, especially in their children’s health care, has changed — develop relaxation techniques for those fears; and dramatically in recent years.29,95 Parents’ desire to be present — be gradually exposed, with developed techniques, to during their child’s treatment does not mean they intellec- situations that evoke his fears and diminish the emotional tually distrust the dentist; it might mean they are uncom- responses.34 fortable if they visually cannot verify their child’s safety. It is important to understand the changing emotional needs THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 327 BEST PRACTICES: BEHAVIOR GUIDANCE of parents because of the growth of a latent but natural safe and comforting relationship, thereby reducing treatment- sense to be protective of their children. 96 Practitioners related stress. For each visit, the goals and results of the should become accustomed to this added involvement of intervention should be documented. parents and welcome the questions and concerns for their Objectives: The objectives of AAT include to: children. Practitioners must consider parents’ desires and — enhance interactions between the patient and dental team; wishes and be open to a paradigm shift in their own think- — calm or comfort an anxious or fearful patient; ing.9,19,29,81,96,97 — provide a distraction from a potentially stressful situation; Objectives: The objectives of parental presence/absence for and parents are to: — decrease perceived pain.102 — participate in examinations and treatment; The health and safety of the animal and its handler need — offer physical and psychological support; and to be maintained.102 — observe the reality of their child’s treatment. Indications: Use AAT as an adjunctive technique to decrease The objectives of parental presence/absence for practitioners a patient’s anxiety, pain, or emotional distress. to: Contraindications: The contraindications for the parent: — gain the patient’s attention and improve compliance; — allergy or other medical condition (e.g., asthma, — avert negative or avoidance behaviors; compromised immune system) aggravated by exposure — establish appropriate dentist-child roles; to the animal; and — enhance effective communication among the dentist, — lack of interest in or fear of the therapy animal. child, and parent; The contraindications for the parent: — minimize anxiety and achieve a positive dental experience; — a situation that presents a significant risk to one’s health and or safety.103 — facilitate rapid informed consent for changes in treatment or behavior guidance. Picture exchange communication system (PECS) Indications: Use with any patient. Description: PECS is a communication technique developed Contraindications: Parents who are unwilling or unable to for individuals with limited to no verbal communication extend effective support. abilities, specifically those with autism. The individual shares a picture card with a recognizable symbol to express a Additional considerations for dental patients with anxiety or request or thought. PECS has a one-to-one correspondence special health care needs with objects, people, and concepts, thereby reducing the Sensory-adapted dental environments (SADE) degree of ambiguity in communication.104 The patient is Description: The SADE intervention includes adaptions of able to initiate communication, and no special training is the clinical setting (e.g., dimmed lighting, moving projec- required by the recipient. tions such as fish or bubbles on the ceiling, soothing Objectives: The objective is to allow individuals with limited background music, application of wrap/blanket around the to no verbal communication abilities to express requests or child to provide deep pressure input) to produce a calming thoughts using symbolic imagery. A prepared picture board effect.91,98 may be present for the dental appointment so the dentist Objectives: The objective of SADE is to enhance relaxation can communicate the steps required for completion (e.g., and avert negative or avoidance behaviors.99 pictures of a dental mirror, handpiece). The patient may Indications: Use with patients having autism spectrum have symbols (e.g., a stop sign) to show they need a brief disorder, sensory processing difficulties, other disabilities, or interruption in the procedure.105 dental anxiety.100 Indications: Use as an adjunctive approach to assist individ- Contraindications: None. uals with limited to no verbal communication abilities improve exchange of ideas.91,106 Animal-assisted therapy (AAT) Contraindications: None.107 Description: AAT has been beneficial in a variety of settings including the dental environment.101 It is a goal-oriented Nitrous oxide/oxygen inhalation intervention which utilizes a trained animal in a healthcare Description: Nitrous oxide/oxygen inhalation is a safe and setting to improve interactions or decrease a patient’s anxiety, effective technique to reduce anxiety and enhance effective pain, or distress. Unlike animal-assisted activities (e.g., a pet communication. Its onset of action is rapid, the effects entertains patients in the waiting area), AAT appointments easily are titrated and reversible, and recovery is rapid and are scheduled for specific time and duration to include an complete. Additionally, nitrous oxide/oxygen inhalation animal that has undergone temperament testing, rigorous mediates a variable degree of analgesia, amnesia, and gag training, and certification. The animal, which is available reflex reduction. The need to diagnose and treat, as well for companionship during the dental visit, can help break as the safety of the patient and practitioner, should be communication barriers and enable the patient to establish a considered before the use of nitrous oxide/oxygen analgesia/ 328 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY  BEST PRACTICES: BEHAVIOR GUIDANCE anxiolysis. If nitrous oxide/oxygen inhalation is used in con- techniques commonly used and taught in advanced pediatric centrations greater than 50 percent or in combination with dental training programs include protective stabilization, other sedating medications (e.g., benzodiazepines, opioids), sedation, and general anesthesia.49 The use of general anesthesia the likelihood for moderate or deep sedation increases.108 In or sedation for dental rehabilitation may improve quality of life these situations, the clinician must be prepared to institute in children. It is unclear if these behavior guidance techniques the guidelines for moderate or deep sedation. 5 Detailed address factors that contribute to the initial dental fear and information concerning the indications, contraindications, anxiety.114,115 Protective stabilization, active or passive, may not and additional clinical considerations appear in AAPD’s always be accepted by parents who may be more accepting of Use of Nitrous Oxide for Pediatric Dental Patients 4 and pharmacologic behavior guidance.116 Guidelines for Monitoring and Management of Pediatric Consideration of advanced behavior guidance techniques Patients Before, During and After Sedation for Diagnostic requires the practitioner to thoroughly assess the patient’s and Therapeutic Procedures 5 by the AAPD and the American medical, dental, and social histories and temperament. Risks, Academy of Pediatrics. benefits, and alternatives should be discussed prior to obtaining Objectives: The objectives of nitrous oxide/oxygen inhala- an informed consent for the recommended technique.117 Skill- tion include to: ful diagnosis of behavior and safe and effective implementation — reduce or eliminate anxiety; of these techniques necessitate knowledge and experience that — reduce untoward movement and reaction to dental are generally beyond the core knowledge students receive treatment; during predoctoral dental education. While most predoctoral — enhance communication and patient cooperation; programs provide didactic exposure to treatment of very — raise the pain reaction threshold; young children (i.e., aged birth through two years), patients — increase tolerance for longer appointments; with special health care needs, and patients requiring advanced — aid in treatment of the mentally/physically disabled or behavior guidance techniques, hands-on experience is lacking.49 medically compromised patients; Dentists considering the use of advanced behavior guidance — reduce gagging; and techniques should seek additional training through a residency — potentiate the effect of sedatives. program, a graduate program, and/or an extensive continuing Indications: Indications for use of nitrous oxide/oxygen education course that involves both didactic and experiential inhalation analgesia/anxiolysis include: mentored training. — a fearful, anxious, or obstreperous patient; — certain patients with SHCN; Protective stabilization — a patient whose gag reflex interferes with dental care; Description: The use of any type of protective stabilization — a patient for whom profound local anesthesia cannot in the treatment of infants, children, adolescents, or patients be obtained; and with special health care needs is a topic that concerns health — a cooperative child undergoing a lengthy dental pro- care providers and care givers.56,118-127 Protective stabilization cedure. is the restriction of a patient’s freedom of movement, with Contraindications: Contraindications for use of nitrous or without the patient’s permission, to decrease risk of oxide/oxygen inhalation may include: injury while allowing safe completion of treatment. “A — some chronic obstructive pulmonary diseases;108,109 restraint is any manual method, physical or mechanical — current upper respiratory tract infections;109 device, material, or equipment that immobilizes or reduces — recent middle ear disturbance/surgery;109 the ability of a patient to move his or her arms, legs, body, — severe emotional disturbances or drug-related de- or head freely; or a drug or medication when it is used as a pendencies;108,109 restriction to manage the patient’s behavior or restrict the — first trimester of pregnancy;108,110 patient’s freedom of movement and is not a standard treat- — treatment with bleomycin sulfate; 111 ment or dosage for the patient’s condition”.128 Protective — methylenetetrahydrofolate reductase deficiency;112 and stabilization can be performed by the dentist, staff, or — cobalamin (vitamin B-12) deficiency113. parent with or without the aid of a stabilization device.56 If the restriction involves another person(s), it is considered Advanced behavior guidance active restraint. If a patient stabilization device is utilized, it Most children can be managed effectively using the techniques is considered passive restraint. Active and passive restraint outlined in basic behavior guidance. Such techniques should can be used in combination. form the foundation for all behavior guidance provided by Stabilization devices such as a papoose board (passive the dentist. Children, however, occasionally present with restraint) placed around the chest may restrict respirations. behavioral considerations that require more advanced tech- They must be used with caution, especially for patients with niques. These children often cannot cooperate due to lack respiratory compromise (e.g., asthma) and/or for patients of psychological or emotional maturity and/or mental, phys- who will receive medications (e.g., local anesthetics, sedatives) ical, or medical disability. The advanced behavior guidance that can depress respirations. Because of the associated risks THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 329 BEST PRACTICES: BEHAVIOR GUIDANCE and possible consequences of use, the dentist is encouraged Contraindications: Patient stabilization is contraindicated to evaluate thoroughly their use on each patient and possible for: alternatives. 56,128 Careful, continuous monitoring of the — a cooperative nonsedated patient; patient is mandatory during protective stabilization.56,128 — an uncooperative patient when there is not a clear need Partial or complete stabilization of the patient sometimes to provide treatment at that particular visit; is necessary to protect the patient, practitioner, staff, or the — a patient who cannot be immobilized safely due to asso- parent from injury while providing dental care. The dentist ciated medical, psychological, or physical conditions; always should use the least restrictive, but safe and effective, — a patient with a history of physical or psychological protective stabilization.56,128 The use of a mouth prop in a trauma, including physical or sexual abuse or other compliant child is not considered protective stabilization. trauma that would place the individual at greater The need to diagnose, treat, and protect the safety of the psychological risk during restraint; patient, practitioner, staff, and parent should be considered — a patient with non-emergent treatment needs in order prior to the use of protective stabilization. The decision to to accomplish full mouth or multiple quadrant dental use protective stabilization must take into consideration: rehabilitation; — alternative behavior guidance modalities; — a practitioner’s convenience; and — dental needs of the patient; — a dental team without the requisite knowledge and skills — the effect on the quality of dental care; in patient selection and restraining techniques to prevent — the patient’s emotional development; and or minimize psychological stress and/or decrease risk of — the patient’s medical and physical considerations. physical injury to the patient, the parent, and the staff. Protective stabilization, with or without a restrictive Precautions: The following precautions are recommended: device, led by the dentist and performed by the dental team — the patient’s medical history must be reviewed careful- requires informed consent from a parent. Informed consent ly to ascertain if there are any medical conditions (e.g., must be obtained and documented in the patient’s record asthma) which may compromise respiratory function; prior to use of protective stabilization. Furthermore, when — tightness and duration of the stabilization must be appropriate, an explanation to the patient regarding the monitored and reassessed at regular intervals; need for restraint, with an opportunity for the patient to — stabilization around extremities or the chest must not respond, should occur.52,56,129 actively restrict circulation or respiration; Objectives: The objectives of patient stabilization are to: — observation of body language and pain assessment must — reduce or eliminate untoward movement; be continuous to allow for procedural modifications at — protect patient, staff, dentist, or parent from injury; and the first sign of distress; and — facilitate delivery of quality dental treatment. — stabilization should be terminated as soon as possible in Indications: Patient stabilization is indicated for: a patient who is experiencing severe stress or hysterics — a patient who requires immediate diagnosis and/or to prevent possible physical or psychological trauma. urgent limited treatment and cannot cooperate due to Documentation: The patient’s record must include: developmental levels (emotional or cognitive), lack of — indication for stabilization; maturity, or mental or physical conditions; — type of stabilization; — a patient who requires urgent care and uncontrolled — informed consent for protective stabilization; movements risk the safety of the patient, staff, dentist, or — reason for parental exclusion during protective stabiliza- parent without the use of protective stabilization; tion (when applicable); — a previously cooperative patient who quickly becomes — the duration of application of stabilization; uncooperative and cooperation cannot be regained by — behavior evaluation/rating during stabilization; basic behavior guidance techniques in order to protect — any untoward outcomes, such as skin markings; and the patient’s safety and help complete a procedure and/ — management implication for future appointments. or stabilize the patient; — an uncooperative patient who requires limited (e.g., Sedation quadrant) treatment and sedation or general anesthesia Description: Sedation can be used safely and effectively with may not be an option because the patient does not meet patients who are unable to cooperate due to lack of psycho- sedation criteria or because of a long operating room wait logical or emotional maturity and/or mental, physical, or time, financial considerations, and/or parental preferences medical conditions. Background information and docu- after other options have been discussed; mentation for the use of sedation is detailed in the Guideline — a sedated patient requires limited stabilization to help for Monitoring and Management of Pediatric Patients reduce untoward movement during treatment; and During and After Sedation for Diagnostic and Therapeutic — a patient with SHCN exhibits uncontrolled movements Procedures.5 that would be harmful or significantly interfere with the The need to diagnose and treat, as well as the safety of quality of care.3 the patient, practitioner, and staff, should be considered 330 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY  BEST PRACTICES: BEHAVIOR GUIDANCE for the use of sedation. The decision to use sedation must should be familiar with and follow the recommendations take into consideration: found in AAPD’s Use of Anesthesia Providers in the Adminis- — alternative behavioral guidance modalities; tration of Office-Based deep Sedation/General Anesthesia to the — dental needs of the patient; Pediatric Dental Patient.6 — the effect on the quality of dental care; Because laws and codes vary from state to state, each prac- — the patient’s emotional development; and titioner must be familiar with his state guidelines regarding — the patient’s medical and physical considerations. office-based general anesthesia. The need to diagnose and Objectives: The goals of sedation are to: treat, as well as the safety of the patient, practitioner, and — guard the patient’s safety and welfare; staff should be considered for the use of general anesthesia. — minimize physical discomfort and pain; Anesthetic and sedative drugs are used to help ensure the — manage anxiety, minimize psychological trauma, and safety, health, and comfort of children undergoing proce- maximize the potential for amnesia; dures. Increasing evidence from research studies suggests the — manage behavior and/or movement so as to allow the benefits of these agents should be considered in the context safe completion of the procedure; and of their potential to cause harmful effects. 130 Additional — return the patient to a state in which safe discharge research is needed to identify any possible risks to young from medical supervision, as determined by recognized children. “In the absence of conclusive evidence, it would criteria, is possible. be unethical to withhold sedation and anesthesia when Indications: Sedation is indicated for: necessary”.131 — fearful/anxious patients for whom basic behavior The decision to use general anesthesia must take into guidance techniques have not been successful; consideration: — patients who cannot cooperate due to a lack of psycho- — alternative modalities; logical or emotional maturity and/or mental, physical, — the age of the patient; or medical conditions; and — risk benefit analysis; — patients for whom the use of sedation may protect the — treatment deferral; developing psyche and/or reduce medical risk. — dental needs of the patient; Contraindications: The use of sedation is contraindicated — the effect on the quality of dental care; for: — the patient’s emotional development; — the cooperative patient with minimal dental needs; and — the patient’s medical status; and — predisposing medical and/or physical conditions which — barriers to care (e.g., finances). would make sedation inadvisable. Objectives: The goals of general anesthesia are to: Documentation: The patient’s record shall include:5 — provide safe, efficient, and effective dental care; — informed consent that is obtained from the parent and — eliminate anxiety; documented prior to the use of sedation; — eliminate untoward movement and reaction to dental — pre- and postoperative instructions and information treatment; provided to the parent; — aid in treatment of the mentally- physically-, or — health evaluation; medically-compromised patient; and — a time-based record that includes the name, route, site, — minimize the patient’s pain response. time, dosage, and effect on patient of administered drugs; Indications: General anesthesia is indicated for patients: — the patient’s level of consciousness, responsiveness, — who cannot cooperate due to a lack of psychological or heart rate, blood pressure, respiratory rate, and oxygen emotional maturity and/or mental, physical, or medical saturation prior to treatment, at the time of treatment, disability; and post-operatively until predetermined discharge — for whom local anesthesia is ineffective because of acute criteria have been attained; infection, anatomic variations, or allergy; — adverse events (if any) and their treatment; and — who are extremely uncooperative, fearful, or anxious; — time and condition of the patient at discharge. — who are precommunicative or noncommunicative child or adolescent; General anesthesia — requiring significant surgical procedures that can be Description: General anesthesia is a controlled state of combined with dental procedures to reduce the number unconsciousness accompanied by a loss of protective reflexes, of anesthetic exposures; including the ability to maintain an airway independently — for whom the use of general anesthesia may protect and respond purposefully to physical stimulation or verbal the developing psyche and/or reduce medical risk; and command. Depending on the patient, general anesthesia can — requiring immediate, comprehensive oral/dental care be administered in a hospital or an ambulatory setting, (e.g., due to dental trauma, severe infection/cellulitis, including the dental office. Practitioners who provide in- acute pain). office general anesthesia (dentist and the anesthesia provider) THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 331 BEST PRACTICES: BEHAVIOR GUIDANCE Contraindications: The use of general anesthesia is contra- Documentation: Prior to the delivery of general anesthesia, indicated for: appropriate documentation shall address the rationale — a healthy, cooperative patient with minimal dental for use of general anesthesia, informed consent, instructions needs; provided to the parent, dietary precautions, and preoperative — a very young patient with minimal dental needs that health evaluation. Because laws and codes vary from state can be addressed with therapeutic interventions (e.g., to state, each practitioner must be familiar with her state ITR, fluoride varnish, SDF) and/or treatment deferral; guidelines. For information regarding requirements for a — patient/practitioner convenience; and time-based anesthesia record, refer to AAPD’s Use of — predisposing medical conditions which would make Anesthesia Providers in the Administration of Office-based general anesthesia inadvisable. Deep Sedation/General Anesthesia to the Pediatric Dental Patient.6 References appear after Appendices. Appendices “Behavior Control”[majr])) AND ((((“infant”[MeSH Terms] OR “infant”[tiab]) OR (“child”[MeSH Terms] OR “child” Appendix 1. SEARCH STRATEGIES [tiab]) OR (“adolescent”[MeSH Terms] OR “adolescent” PubMed®/MEDLINE—date limit August 2019 [tiab]) OR “pediatrics”[MeSH Terms] OR “pediatrics” Search #1. (ped & dental) 2557 results [tiab]OR “pediatric”[tiab])) AND (((“2009/01/01” [PDAT]: “3000/12/31”[PDAT]) AND english[filter] NOT ((((((“behavior management”[tiab] OR “behavior guidance” (“animals”[MeSH Terms] NOT “humans”[MeSH Terms])))) [tiab] OR “child behavior”[tiab] OR “dental anxiety”[tiab] OR “personality test”[tiab] OR “patient cooperation”[tiab] OR Search #3. (adults & dentists) 62 results “dentist-patient relations”[tiab] OR “behavior assessment” (((“personality test” OR “personality tests”[MeSH Terms] OR [tiab] OR “temperament assessment”[tiab] OR “personality “personality assessment”[MeSH Terms] OR personality[tiab] assessment”[tiab] OR “treatment deferral”[tiab] OR OR “gender shifts”[tiab] OR “gender equality” OR ((“Wom- “treatment delay”[tiab] OR compliance[tiab] OR en, Working”[mesh] OR “Dentists, Women”[mesh]) AND adherence[tiab] OR “protective stabilization”[tiab] OR “Practice Patterns, Dentists’”[MeSH Terms]))) AND immobilization[tiab] OR restraints [tiab] OR Sedation (dentist[TIAB] OR dentist[TIAB] OR “Dentists”[Mesh])) [tiab] OR general anesthesia[tiab] OR “Restraint, Physical” AND ((“2009/01/01”[PDAT]: “3000/12/31”[PDAT]) AND [mesh] OR “Protective Devices”[mesh] OR “Immobilization” english[filter] NOT (“animals”[MeSH Terms] NOT [mesh] OR “Behavior Control”[mesh] OR “child behavior” “humans”[MeSH Terms])) [mesh] OR “dental anxiety”[mesh] OR “personality tests” [mesh] OR “patient compliance”[mesh] OR “dentist-patient Search #4. (adults & parents) 226 results relations”[mesh] OR “personality assessment”[mesh] OR (((((dental[tiab] OR “dental health services”[MeSH Terms] “patient compliance”[mesh] OR “anesthesia, general”[mesh] OR dentistry[TIAB] OR “dentistry”[MeSH Terms] OR OR “Conscious Sedation”[Mesh]))) AND (((dental[tiab] “dental care”[tiab] OR “dental care”[MeSH Terms] OR OR “dental health services”[MeSH Terms] OR dentistry dentist[tiab] OR “dentists”[MeSH Terms] OR “Dental Care [TIAB] OR “dentistry”[MeSH Terms] OR “dental care” for Children”[mesh] OR “Pediatric Dentistry”[mesh]))) [tiab] OR “dental care”[MeSH Terms] OR dentist[tiab] OR AND ((Parents[tiab] OR Fathers[tiab] OR mothers[tiab] “dentists”[MeSH Terms] OR “Dental Care for Children” OR parental[tiab] OR Parent[tiab] OR Father[tiab] OR [mesh] OR “Pediatric Dentistry”[mesh])))) AND (((“infant” mother[tiab] or “mothers”[MeSH Terms] OR “fathers” [MeSH Terms] OR “infant”[tiab]) OR (“child”[MeSH [MeSH Terms] OR “parents”[MeSH Terms]))) AND Terms] OR “child”[tiab]) OR (“adolescent”[MeSH Terms] (“behavior management”[tiab] OR “behavior guidance” OR “adolescent”[tiab]) OR “pediatrics”[MeSH Terms] OR [tiab] OR “dentist parent relations”[tiab] OR “Informed “pediatrics”[tiab] OR “pediatric”[tiab])))) AND ((“2009/ consent”[tiab] OR “family compliance”[tiab] OR “parent 01/01”[PDAT]: “3000/12/31”[PDAT]) AND english compliance”[tiab] OR “family adherence”[tiab] OR “parent [filter] NOT (“animals”[MeSH Terms] NOT “humans” adherence”[tiab] OR “parenting style”[tiab] OR “dentist- [MeSH Terms])) patient relations”[tiab] OR “dentist-patient relations” Search #2. (ped & medical) 1081 results [MeSH Terms] OR “Behavior Control”[mesh] OR “pa- tient compliance”[MeSH Terms] OR “Informed Consent” ((“behavior management”[tiab] OR “behavior guidance”[tiab] [Mesh])) AND (((“2009/01/01”[PDAT]: “3000/12/31” OR “toxic stress”[tiab] OR “protective stabilization”[tiab] [PDAT]) AND english[filter] NOT (“animals”[MeSH OR restraints[tiab] OR “Restraint, Physical”[majr] OR Terms] NOT “humans”[MeSH Terms]))) 332 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY  BEST PRACTICES: BEHAVIOR GUIDANCE 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 pro- nounced (sullen, withdrawn). 3 + Positive. Acceptance of treatmen, 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 When clinicians share information, they predominantly TELL information, often in too much detail, and in terms that some- times 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 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. THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 333 BEST PRACTICES: BEHAVIOR GUIDANCE 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 misinter- preted or alarm patients and families. 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, satis- faction, 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. 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