Behavioral management of pediatric dental patient

Positive pre-visit imagery

• Description: Patients preview positive photographs or images of dentistry and dental treatment before the dental appointment.

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.

• 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 verbal 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, non threatening setting (allows the permanent molars to drift mesially into these spaces and develop a Class I occlusion. ); 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.

• 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.

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 dem-onstrations 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.

• 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 imple-mentation; 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 ac-cepted, use of an assertive voice may be considered aversive to some parents unfamiliar with this technique. An explana-tion before its use may prevent misunderstanding.

• 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.

• 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 and descriptive praise

• Description: In the process of establishing desirable patient behavior, it is essential to give appropriate feedback. Positive reinforcement rewards desired behaviors thereby strengthening the likelihood of recurrence of those behav-iors. Social reinforcers include positive voice modulation, facial expression, verbal praise, and appropriate physical demonstrations of affection by all members of the dental the crest may be considered as a significant influence on marginal bone stability around implants.

. 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”).82 Nonsocial reinforcers include tokens and toys .

The objective of positive reinforcement and

descriptive praise is to reinforce desired behavior.

• 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 un-pleasant 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 eye-glasses) effects. Giving the patient a short break during a stressful procedure can be an effective use of distraction before considering more advanced behavior guidance techniques.

• Objectives: The objectives of distraction are to:

— 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 pro-cedure, extraction) are restructured into positive memories using information suggested after the event has taken place.

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.

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 visits.

• Contraindications: None.

Desensitization to dental setting and procedures

• Description: Systematic desensitization is a psychologicaltechnique that can be applied to modify behaviors of anxious patients in the dental setting. 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 compo-nents 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

Protective stabilization

• Description: The use of any type of protective stabilization in the treatment of infants, children, adolescents, or patients with special health care needs is a topic that concerns health care providers and care givers.

Protective stabilization is the restriction of a patient’s freedom of movement, with or without the patient’s permission, to decrease risk of injury while allowing safe completion of treatment. “A restraint is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely; or a drug or medication when it is used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treat-ment or dosage for the patient’s condition”.128 Protective stabilization can be performed by the dentist, staff, or parent with or without the aid of a stabilization device. If the restriction involves another person(s), it is considered active restraint. If a patient stabilization device is utilized, it is considered passive restraint. Active and passive restraint can be used in combination.

Stabilization devices such as a papoose board (passive restraint) placed around the chest may restrict respirations.

They must be used with caution, especially for patients with respiratory compromise (e.g., asthma) 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 use, the dentist is encouraged to evaluate thoroughly their use on each patient and possible alternatives. Careful, continuous monitoring of the patient is mandatory during protective stabilization.

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. The use of a mouth prop in a compliant child is not considered protective stabilization.

The need to diagnose, treat, and protect the safety of the patient, practitioner, staff, and parent should be considered prior to the use of protective stabilization. The decision to use protective stabilization must take into consideration:

— alternative behavior guidance modalities;

— dental needs of the patient;

— the effect on the quality of dental care;

— the patient’s emotional development; and

— the patient’s medical and physical considerations.

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 appropriate, an explanation to the patient regarding the need for restraint, with an opportunity for the patient to respond, should occur.

• 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 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 help complete a procedure and/or stabilize the patient;

— an uncooperative patient who requires limited (e.g., quadrant) treatment and sedation or general anesthesiamay 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 exhibits uncontrolled movements that would be harmful or significantly interfere with the quality of care.

• Contraindications: Patient stabilization is contraindicated for:

— a cooperative non-sedated patient;

— an uncooperative patient when there is not a clear need to provide treatment at that particular visit;

— a patient who cannot be immobilized safely due to asso-ciated 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, the parent, and the staff.

• Precautions: The following precautions are recommended:

— the patient’s medical history must be reviewed careful-ly to ascertain if there are any medical conditions (e.g., asthma) which may compromise respiratory function;

— 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.

• Documentation: The patient’s record must include:

— indication for stabilization;

— type of stabilization;

— informed consent for protective stabilization;

— reason for parental exclusion during protective stabiliza-tion (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: Sedation can be used safely and effectively with patients who are unable to cooperate due to lack of psy-chological or 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 by the AAPD and the American Academy of Pediatrics.

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. The decision to use sedation must take into consideration:

— alternative behavioral guidance modalities;

— dental needs of the patient;

— the effect on the quality of dental care;

— the patient’s emotional development; and

— the patient’s medical and physical considerations.

• Objectives: The goals of sedation are to:

— guard the patient’s safety and welfare;

— minimize physical discomfort and pain;

— manage anxiety, minimize psychological trauma, and

maximize the potential for amnesia;

— manage behavior and/or movement so as to allow the

safe completion of the procedure; and

— return the patient to a state in which safe discharge

from medical supervision, as determined by recognized

criteria, is possible.

• 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 psycho-

logical 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:

— informed consent that is obtained from the parent and documented prior to the use of sedation;

— pre- and post-operative 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, in-cluding 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 the AAPD’s Use of anesthesia providers in the administration of office-based deep sedation/general anesthesia to the pediatric dental patient.

Because laws and codes vary from state to state, each prac-titioner 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 proce-dures. Increasing evidence from research studies suggests the benefits of these agents should be considered in the context of their potential to cause harmful effects. Additional research is needed to identify any possible risks to young children. “In the absence of conclusive evidence, it would be unethical to withhold sedation and anesthesia when necessary”.

The decision to use general anesthesia must take into consideration:

— alternative modalities;

— the age of the patient;

— risk benefit analysis;

— treatment deferral;

— 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 non-communicative

child or adolescent;

— 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.

Behavioral management of pediatric dental patient