Chapter 380. Behavioral Treatment Options in Pediatric Dentistry

This chapter discusses various behavior treatment options for comprehensive dental treatment in infants, young children, adolescents, and persons with special health care needs.

The task of the pediatric dentist has not changed in the last 50 years: to perform precise surgical procedures, measured in millimeters, on children whose behavior may range from cooperative to apprehensive to defiant. Additionally, these very precise surgical procedures require the child’s full attention and commitment for varying lengths of time. This need for full attention for varying lengths of time comes at an age when children appear to be more easily frustrated, focus on more egocentric thinking, and have more difficulty with impulsivity and inattentive behavior than ever before. Many parents today attempt to “become a friend” (perhaps a “Woodstock” effect of the baby boomer generation) to their child and lose the ability to set boundaries. In a survey of the American Academy of Pediatric Dentistry members on the use of behavior management techniques, the great majority of pediatric dental specialists (88%) believe that parenting styles have changed during their years of practice and that these changes may have contributed to an increase in behavior management problems in the dental setting.2 In a recent survey, 50% of parents bringing their children to a Children’s Hospital emergency department for after-hours emergency care expected that their child would be sedated for dental treatment.3

As American families in the 21st century become increasingly culturally diverse and better educated, and as they develop in new, perhaps more remote, family and social contexts, the US health care delivery system is experiencing parallel changes and is becoming more complex than ever before. Good evidence shows that parenting styles, parental attitudes toward and expectations of the delivery of pediatric dental care, the legal system, the insurance industry, and digital electronic advances are driving the available options for behavior management of children who require dental care.

Today’s pediatric dental environment is designed to be child friendly. Consumer electronics, 21st-century esthetic dental materials, leading-edge digital dental technology, and well-trained dental auxiliaries add to the child-friendly environment of today’s pediatric dental office. Decisions regarding behavior management of the pediatric dental patient must be made in concert with the parent and the dentist. Neither the dentist nor the parent can totally dictate the approach. Parents who call to request sedation or general anesthesia for appointments to clean the child’s teeth because the child “cried at the last visit” clearly do not understand the indications, risks, benefits, limitations, or costs of anesthesia or sedation.4 Similarly, the pediatric dentist must evaluate as part of the overall treatment plan the child’s potential for cooperation in light of age, individual growth and development, prior overall health and dental experiences, and the family’s attitude toward dental health. The pediatric dentist must then provide safe, competent, comprehensive, and relatively pain-free care in an affordable manner without creating fear. There is a considerable amount of literature on childhood fears in the dental setting.5 Dental fears in children may be related to selected anxiety or fears and personality characteristics of that child.6 Some authors suggest that the child may resist dental treatment because of noncompliant behaviors present in their daily activities.7

The American Academy of Pediatric Dentistry has a long history of developing guidelines for behavior management. The most recent guidelines state that behavior guidance techniques must be tailored to the individual patient and practitioner.8 Successful behavior guidance enables the oral health team to perform quality treatment safely and efficiently and to nurture a positive dental attitude in the child. The goal is to establish communication, alleviate fear and anxiety, deliver quality dental care, build a trusting relationship between the dentist and child, and promote the child’s positive attitude toward oral/dental health care.8 Communication between the child and pediatric dentist is developed through an ongoing process of dialogue, both verbal and nonverbal, that involves facial expressions, body language, and voice tone, always taking into consideration the cognitive level of the child. This is a comprehensive, continuous method meant to be individualized for each child. All behavior guidance techniques, other than communicative techniques, utilized by the practitioner must involve the consent of the parent/guardian and, if appropriate, the child. The parent must be informed of the nature, risks, and benefits of the technique to give informed consent.9 Communicative techniques, because they are basic to any dialogue with the child, require no informed consent.

Most behavior guidance techniques used in pediatric dentistry are “behavior shaping” communicative procedures, such as tell-show-do (eTable 380.1). This technique involves verbal explanations of procedures in phrases appropriate to the developmental level of the patient (tell); demonstration for the patient of the visual, auditory, olfactory, and tactile aspects of the procedures in a carefully defined, nonthreatening setting (show); and then, without deviating from the explanation and demonstration, completion of the procedure (do). The tell-show-do technique is used with continuous communication skills (verbal and nonverbal) and positive reinforcement.8 Once beyond the tell-show-do explanation, the pediatric dentist may use positive reinforcement, role modeling, voice control, and time out, perhaps contingent on some accomplishment.10 Time out or contingent escape gives children a sense of control over the dental procedure and trust in the dentist. By being able to raise to a hand to stop the dental procedure when they perceive discomfort or just need a break, children feel an element of control over their environment, and the technique encourages communication through cooperative behavior. This approach provides immediate feedback to teach children more adaptive coping behaviors.10

Positive reinforcement is also a common and effective technique whereby the desired behaviors are rewarded in an effort to strengthen those behaviors and eliminate undesirable responses. The technique includes positive voice modulation, verbal praise, and small tokens such as stickers (which are never withheld). Voice control is a controlled alteration of voice volume, tone, or pace to influence and direct the patient’s behavior. By necessity, it may be the initial way to gain the child’s attention and compliance so that tell-show-do may be utilized. Parents who are unfamiliar with the technique should have an explanation of the procedure prior to its use to prevent misunderstanding. Distraction is the technique of diverting the patient’s attention away from an unpleasant procedure. Giving the child a mirror to hold during the procedure or allowing the child to wear headphones or watch a movie are all effective distraction techniques.8 Role modeling may be found in many pediatric dental offices where children can observe behavior and treatment of other children who share a similar experience and who will help them feel more at ease by example.

Nonverbal communication is used throughout the procedure with appropriate eye contact, posture, facial expression, and body language to reinforce and enhance communicative behavior guidance. The presence of the parent, particularly with very young children, can sometimes be used to gain a child’s cooperation for the procedure. While there is disagreement among practitioners regarding parental presence or absence during pediatric dental treatment, there are clearly more parents present in the dental operatory today. These attitudes reflect the evolving parenting styles in the United States in recent decades.11 Parental presence during treatment is now more common and more expected in our society where parents are involved in treatment and decisions. Parents must be educated so that they do not hover above or smother their child nor indicate their own discomfort through words or body language. While authoritarian methods of guidance are less acceptable today, restraint in the form of mouth props (to avoid inadvertently biting on the instruments) or parental stabilization are often utilized when treatment is medically necessary and the child is uncooperative.

Once beyond communicative efforts and minimal levels of restraint, dentists may turn to the use of pharmacologic agents. Guidelines developed by the American Academy of Pediatric Dentistry and the Academy of Pediatrics divide sedation into 3 definable levels: minimal, moderate, and deep.12 Nitrous oxide administration is the most commonly used minimal sedation technique by pediatric dentists to reduce anxiety.13,14

The use of nitrous oxide requires a nasal mask (inhaler) and depends on the child’s understanding and willingness to breathe through the nose. When children are able to cooperate in the inhalation process, nitrous oxide/oxygen is an excellent, safe, and effective technique to reduce anxiety and enhance effective communication in children with anxiety. Administered by nasal mask, its onset and recovery is rapid, and the effects are easily titrated and reversible. By raising the pain threshold, increasing the tolerance for the procedure and longer appointments, reducing the gag reflex, and potentiating the effect of other sedatives (if utilized), nitrous oxide analgesia has a predictable effect among the majority of the pediatric population.12 But the use of nitrous oxide/oxygen alone in children who are severely disruptive may prove futile. Precooperative or noncooperative children (or adults with disabilities) often breathe through their mouth, crying or moving about in the dental chair, thus negating the effects of any nitrous oxide/oxygen administered through a nasal inhaler. Children with compulsive personalities or “take-charge” children may not like the feeling of loss of control associated with nitrous oxide, and they may unilaterally terminate the procedure. In addition, nitrous oxide/oxygen inhalation will have a very low success rate in children who have upper respiratory tract or other acute respiratory infections. Any respiratory problem that prevents the use of the nasal inhaler as the route of entry for the gases (ie, common cold, acute or chronic sinusitis, chronic mouth breathing, enlarged tonsils and/or adenoids, allergic rhinitis, tuberculosis, bronchitis, cough, chronic obstructive pulmonary disease (COPD), emphysema) represents a situation in which the technique of inhalation anxiolysis would be ineffective and should be avoided. The use of nitrous oxide/oxygen analgesia is also best avoided in the pregnant patient during the first trimester to avoid increasing the possibility of spontaneous abortion.15 Medical consultation between the dentist and obstetrician is always advisable for the pregnant patient. Additionally, air spaces in the maxillary sinus, vestibulocochlear complex, and bowel can be displaced by nitrous oxide. These nonrigid spaces can enlarge and cause discomfort as a result of high concentration and prolonged use of nitrous oxide/oxygen analgesia. The avoidance of hypoxia is especially important in children with congenital methemoglobinemia.16

Most children can be treated effectively with communicative measures or minimal sedation using nitrous oxide. Some children, however, are uncooperative and do not accept the nasal hood; they require more advanced (less interactive) methods of behavioral guidance. The techniques commonly used when children present with significant dental disease and behavioral considerations that cannot be controlled in the usual manner are protective medical stabilization, sedation, or general anesthesia. The pediatric dentist must consider the associated risks and possible consequences of use of these alternative behavior guidance techniques based on the dental needs of the patient, the effect on the quality of care, the child’s emotional and chronological development, and the child’s physical and medical considerations. These techniques are often indicated for children who cannot cooperate due to lack of psychological, emotional, or chronological maturity; mental, physical, or medical disability; or young age with overwhelming caries.

For children who cannot control their own response because of their chronological or developmental age, moderate or deep sedation is an option to allow the safe completion of dental procedures. Some children younger than 6 years and those who are American Society of Anesthesiologists (ASA) Class I (healthy) and II (mild systemic disease) are considered appropriate candidates for moderate or deep sedation. The use of various intranasal, oral, rectal, or intravenous drugs such as chloral hydrate, hydroxyzine, midazolam, and Demerol, used alone or in combination, can provide moderate or deep sedation. Children who are ASA III (severe systemic disease) or IV (severe life-threatening disease), children with special needs, and those with anatomic airway abnormalities or extreme tonsillar hypertrophy present airway issues that require additional and individual consideration, particularly for moderate and deep sedation.17 Moderate or deep sedation of pediatric patients has serious associated risks, such as hypoventilation, apnea, airway obstruction, laryngospasm, and cardiopulmonary impairment. Pediatric dentists must consult with appropriate subspecialists and/or anesthesiologists for patients at increased risk of experiencing adverse sedation events because of their underlying medical or surgical conditions. Parental informed consent must be obtained and appropriately documented. Appropriate drug selection for the dental procedure must take into account the amount of time necessary for the procedure and the depth to which the child must be sedated. Additionally, the dentist and staff must possess the skills necessary to rescue the child from any adverse response. Appropriate physiologic monitoring and continuous observation during and after the procedure must be made by personnel not directly involved with the procedure so they can rapidly diagnose complications and initiate appropriate rescue interventions. Understanding, training, and experience in rescue techniques are essential to safe sedation in dentistry. Children under 6 years of age are particularly vulnerable to the sedating medication’s effects on respiratory drive, patency of the airway, and protective reflexes. It is common for children to pass from the intended level of sedation to a deeper, unintended level of sedation.12

For some infants, children, adolescents, and children with special health care needs, the use of nonpharmacologic behavior management techniques, minimal sedation (nitrous oxide anxiolysis), or moderate sedation are still not adequate for dental procedures. Because of extensive treatment needs, acute situational anxiety, uncooperative behaviors, cognitive disabilities, or ASA III or IV medical conditions, these children benefit from dental care under general anesthesia or deep sedation. This approach allows comprehensive dental treatment in a safe and humane environment, all accomplished in one event. Deep sedation and general anesthesia must be provided by qualified and appropriately trained individuals in accordance with state regulations. The choice of hospital dentistry is an integral part of the behavior management training of the pediatric dentist. If deep sedation or general anesthesia is provided in a dental office, the pediatric dentist is responsible for providing a safe environment for the care and the recovery as well as assuring the qualifications of the anesthesia provider.18,19 Again, pediatric dental care under general anesthesia represents the treatment modality of last resort and concedes the inability to provide safe, comprehensive, and effective chairside care utilizing the nonpharmacologic methods described in this chapter. It is important to note that the high cost of dental care under general anesthesia in the safety of the hospital setting, combined with the reluctance of some states or third-party payers to cover those costs, leaves many children in lower socioeconomic settings without access to the care that optimum general health goals demand.