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Behavior Guidance for the Pediatric Dental Patient

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Behavior Guidance for the Pediatric Dental Patient 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; 2020:292-310. Purpose Background The American Academy of Pediatric Dentistry (AAPD) Dental practitioners are expected to recognize and effectively recognizes that dental care is medically necessary for the pur- treat childhood dental diseases that are within the knowledge pose of preventing and eliminating orofacial disease, infection, and skills acquired during their professional education. Safe and pain, restoring the form and function of the dentition, and effective treatment of these diseases requires an under- and correcting facial disfiguration or dysfunction.1 Behavior standing of and, at times, modifying the child’s and family’s guidance techniques, both nonpharmalogical and pharma- response to care. Behavior guidance a continuum of interaction logical, are used to alleviate anxiety, nurture a positive dental involving the dentist and dental team, the patient, and parent attitude, and perform quality oral health care safely and directed toward communication and education, while also efficiently for infants, children, adolescents, and persons with ensuring the safety of both oral health professionals and the special health care needs (SHCN). Selection of techniques must child, during the delivery of medically necessary care. Goals be tailored to the needs of the individual patient and the skills of behavior guidance are to: 1) establish communication, 2) of the practitioner. The AAPD offers these recommendations alleviate the child’s dental fear and anxiety, 3) promote pa- to inform health care providers, parents, and other interested tient’s and parents’ awareness of the need for good oral health parties about influences on the behavior of pediatric dental and the process by which it is achieved, 4) promote the child’s patients and the many behavior guidance techniques used in positive attitude toward oral health care, 5) build a trusting contemporary pediatric dentistry. Information regarding pain relationship between dentist/staff and child/parent, and 6) management, protective stabilization, and pharmacological provide quality oral health care in a comfortable, minimally- behavior management for pediatric dental patients is provided restrictive, safe, and effective manner. Behavior guidance tech- in greater detail in additional AAPD best practices documents.2-6 niques range from establishing or maintaining communication to stopping unwanted or unsafe behaviors.13 Knowledge of Methods the scientific basis of behavior guidance and skills in com- Recommendations on behavior guidance were developed munication, empathy, tolerance, cultural sensitivity, and by the Clinical Affairs Committe, Behavior Management flexibility are requisite to proper implementation. Behavior Subcommittee and adopted in 1990.7 This document by the guidance should never be punishment for misbehavior, power Council of Clinical Affairs is a revision of the previous version, assertion, or use of any strategy that hurts, shames, or belittles last revised in 2015.8 The original guidance was developed a patient. subsequent to the AAPD’s 1988 conference on behavior management and modified following the AAPD’s symposia Predictors of child behaviors on behavior guidance in 200310 and 2013.11 This update Patient attributes reflects a review of the most recent proceedings, other dental A dentist who treats children should be able to accurately and medical literature related to behavior guidance of the pedi- assess the child’s developmental level, dental attitudes, and atric patient, and sources of recognized professional expertise temperament to anticipate the child’s reaction to care. The and stature including both the academic and practicing response to the demands of oral health care is complex and pediatric dental communities and the standards of the American determined by many factors. Dental Association Commission on Dental Accreditation.12 In Factors that may contribute to noncompliance during the addition, a search of the PubMed®/MEDLINE electronic dental appointment include fears, general or situational database was performed, (see Appendix 1 after References). anxiety, a previous unpleasant and/or painful dental/medical Articles were screened by viewing titles and abstracts. Data was abstracted and used to summarize research on behavior ABBREVIATIONS guidance for infants and children through adolescents, includ- AAPD: American Academy of Pediatric Dentistry. AAT: Animal- ing those with special healthcare needs. When data did not assisted therapy. ITR: Interim therapeutic restoration. PECS: Picture appear sufficient or were inconclusive, recommendations were exchange communication system. SADE: Sensory-adapted dental based upon expert and/or consensus opinion by experienced environment. SDF: Silver diamine fluoride. SHCN: Special health- researchers and clinicians. care needs. 292 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY BEST PRACTICES: BEHAVIOR GUIDANCE 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 non-clinical 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 If the level of fear is incongruent with the circumstances and office to meet the doctor and staff and tour the facility.20 The the patient is not able to control impulses, disruptive behavior non-clinical staff should confirm the office’s location, offer is likely.20 directions, and ask if there are any further questions. Such Cultural and linguistic factors also may play a role in patient encounters serve as educational tools that help to allay fears cooperation and selection of behavior guidance techniques.23-26 and better prepare the family and patient for the first visit. Since every culture has its own beliefs, values, and practices, The parent’s/patient’s initial contact with the dental practice it is important to understand how to interact with patients allows both parties to address the child’s primary oral health from different cultures and to develop tools to help navigate needs and to confirm the appropriateness of scheduling an their encounters. Translation services should be made available appointment.33 From a behavioral standpoint, many factors for those families who have limited English proficiency.26,27 are important when appointment times are determined.20 A federal mandate requires translation services for non-English Appointment-related concerns include patient age, presence speaking families be available at no cost to the family in of a special health care need, the need for sedation, distance healthcare facilities that receive federal funding for services.28 the parent/patient travels, length of appointment, additional As is true for all patients/families, the dentist/staff must staffing requirements, parent’s work schedule, and time of day. listen actively and address the patient’s/parents’ concerns in a Emergent or urgent treatment should not be delayed on these sensitive and respectful manner.23 grounds alone.34 Appointment scheduling should be tailored to the needs of the individual patient’s circumstances and the Parental influences skills of the practitioner. The practitioner should formulate Parents influence their child’s behavior at the dental office in a policy regarding scheduling, and scheduling should not several ways. Positive attitudes toward oral health care may be left to chance.20 Appointment duration should not be lead to the early establishment of a dental home. Early pre- prolonged beyond a patient’s tolerance level solely for the ventive care leads to less dental disease,
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