Bibliographic Source(s)

• American Academy of Pediatric Dentistry (AAPD). Guideline on behavior guidance for the pediatric dental patient. Chicago (IL): American Academy of Pediatric Dentistry (AAPD); 2006. 9 p. [62 references]

Guideline Status

Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary.

Guideline Category

Counseling
Management
Prevention
Risk Assessment
Treatment

Intended Users

Allied Health Personnel
Dentists
Health Care Providers
Nurses
Patients
Physicians

Guideline Objective(s)

To educate health care providers parents and other interested parties about many behavior guidance techniques used in contemporary pediatric dentistry

Target Population

Infants children and adolescents undergoing dental procedures

Interventions and Practices Considered

Behavior Guidance Techniques

1. Obtaining informed consent
2. Patient communication
3. Tell-show-do technique
4. Voice control
5. Nonverbal communication
6. Positive reinforcement
7. Distraction
8. Parental presence/absence
9. Nitrous oxide/oxygen inhalation
10. Protective stabilization
11. Sedation
12. General anesthesia

Major Outcomes Considered

• Co-operative patient behavior
• Patient satisfaction

Methods Used to Collect/Select Evidence

Searches of Electronic Databases

Description of Methods used to Collect/Select the Evidence

This guideline was developed following the American Academy of Pediatric Dentistry's (AAPD's) 1989 consensus conference on behavior management for the pediatric dental patient. In 2003 the AAPD held another symposium on behavior guidance with proceedings published in Pediatric Dentistry. This revision reflects a review of those proceedings other dental and medical literature related to behavior guidance of the pediatric patient and sources of recognized professional expertise and stature including both the academic and practicing pediatric dental communities and the standards of the Commission on Dental Accreditation. MEDLINE searches were performed using key terms such as "behavior management in children" "behavior management in dentistry" "child behavior and dentistry" "child and dental anxiety" "child preschool and dental anxiety" "child personality and test" "child preschool personality and test" "patient cooperation" "dentists and personality" "dentist-patient relations" "patient assessment" "treatment deferral" and "restraint."

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence

Expert Consensus (Committee)

Rating Scheme for the Strength of the Evidence

Not applicable

Methods Used to Analyze the Evidence

Review

Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations

Expert Consensus

Description of Methods Used to Formulate the Recommendations

The oral health policies and clinical guidelines of the American Academy of Pediatric Dentistry (AAPD) are developed under the direction of the Board of Trustees utilizing the resources and expertise of its membership operating through the Council on Clinical Affairs (CCA).

Proposals to develop or modify policies and guidelines may originate from 4 sources:

1. The officers or trustees acting at any meeting of the Board of Trustees
2. A council committee or task force in its report to the Board of Trustees
3. Any member of the AAPD acting through the Reference Committee hearing of the General Assembly at the Annual Session
4. Officers trustees council and committee chairs or other participants at the AAPD's Annual Strategic Planning Session.

Regardless of the source proposals are considered carefully and those deemed sufficiently meritorious by a majority vote of the Board of Trustees are referred to the CCA for development or review/revision.

Once a charge (directive from the Board of Trustees) for development or review/revision of an oral health policy or clinical guideline is sent to the CCA it is assigned to 1 or more members of the CCA for completion. CCA members are instructed to follow the specified format for a policy or guideline. All oral health policies and clinical guidelines are based on 2 sources of evidence: (1) the scientific literature; and (2) experts in the field. Members may call upon any expert as a consultant to the council to provide expert opinion. The Council on Scientific Affairs provides input as to the scientific validity of a policy or guideline.

The CCA meets on an interim basis (midwinter) to discuss proposed oral health policies and clinical guidelines. Each new or reviewed/revised policy and guideline is reviewed discussed and confirmed by the entire council.

Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation

Peer Review

Description of Method of Guideline Validation

Once developed by the Council on Clinical Affairs (CCA) the proposed policy or guideline is submitted for the consideration of the Board of Trustees. While the board may request revision in which case it is returned to the council for modification once accepted by majority vote of the board it is referred for Reference Committee hearing at the upcoming Annual Session. At the Reference Committee hearing the membership may provide comment or suggestion for alteration of the document before presentation to the General Assembly. The final document then is presented for ratification by a majority vote of the membership present and voting at the General Assembly. If accepted by the General Assembly either as proposed or as amended by that body the document then becomes the official American Academy of Pediatric Dentistry (AAPD) oral health policy or clinical guideline for publication in the AAPD's Reference Manual and on the AAPD's Web site.

Major Recommendations

Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary. The recommendations that follow are based on the previous version of the guideline.

Background Summary

1. Behavior guidance is based on scientific principles. The proper implementation of behavior guidance requires an understanding of these principles. Behavior guidance however is more than pure science and requires skills in communication empathy coaching and listening. As such behavior guidance is a clinical art form and skill built on a foundation of science.
2. The goals of behavior guidance are to establish communication alleviate fear and anxiety deliver quality dental care build a trusting relationship between dentist and child and promote the child's positive attitude towards oral/dental health and oral health care.
3. The urgency of the child's dental needs must be considered when planning treatment. Deferral or modification of treatment sometimes may be appropriate until routine care can be provided using appropriate behavior guidance techniques.
4. All decisions regarding use of behavior guidance techniques must be based upon a benefit vs. risk evaluation. As part of the process of obtaining informed consent the dentist's recommendations regarding use of techniques (other than communicative guidance) must be explained to the parent's understanding and acceptance. Parents share in the decision-making process regarding treatment of their children.
5. The dental staff must be trained carefully to support the doctor's efforts and properly welcome the patient and parent into a child-friendly environment that will facilitate behavior guidance and a positive dental visit.

Basic Behavior Guidance

Communication and Communicative Guidance

Communicative management and appropriate use of commands are used universally in pediatric dentistry with both the cooperative and uncooperative child. In addition to establishing a relationship with the child and allowing for the successful completion of dental procedures these techniques may help the child develop a positive attitude toward oral health. Communicative management comprises a host of techniques that when integrated enhance the evolution of a cooperative patient. Rather than being a collection of singular techniques communicative management is an ongoing subjective process that becomes an extension of the personality of the dentist. Associated with this process are the specific techniques of tell-show-do voice control nonverbal communication positive reinforcement and distraction. The dentist should consider the cognitive development of the patient as well as the presence of other communication deficits (e.g. hearing disorder) when choosing specific communicative management techniques.

Tell-Show-Do

Description: Tell-show-do is a technique of behavior shaping used by many pediatric professionals. 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 (show); and then without deviating from the explanation and demonstration completion of the procedure (do). The tell-show-do technique is used with communication skills (verbal and nonverbal) and positive reinforcement.

Objectives: The objectives of the tell-show-do are to:

1. Teach the patient important aspects of the dental visit and familiarize the patient with the dental setting
2. Shape the patient's response to procedures through desensitization and well-described expectations

Indications: May be used with any patient.

Contraindications: None.

Voice Control

Description: Voice control is a controlled alteration of voice volume tone or pace to influence and direct the patient's behavior. Parents unfamiliar with this technique may benefit from an explanation prior to its use to prevent misunderstanding.

Objectives: The objectives of voice control are to:

1. Gain the patient's attention and compliance
2. Avert negative or avoidance behavior
3. Establish appropriate adult-child roles

Indications: May be used 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:

1. Enhance the effectiveness of other communicative management techniques
2. Gain or maintain the patient's attention and compliance

Indications: May be used with any patient.

Contraindications: None.

Positive Reinforcement

Description: In the process of establishing desirable patient behavior it is essential to give appropriate feedback. Positive reinforcement is an effective technique to reward desired behaviors and thus strengthen the recurrence of those behaviors. Social reinforcers include positive voice modulation facial expression verbal praise and appropriate physical demonstrations of affection by all members of the dental team. Nonsocial reinforcers include tokens and toys.

Objective: To reinforce desired behavior.

Indications: May be useful for any patient.

Contraindications: None.

Distraction

Description: Distraction is the technique of diverting the patient's attention from what may be perceived as an unpleasant procedure. Giving the patient a short break during a stressful procedure can be an effective use of distraction prior to considering more advanced behavior guidance techniques.

Objectives: The objectives of distraction are to:

1. Decrease the perception of unpleasantness
2. Avert negative or avoidance behavior

Indications: May be used with any patient.

Contraindications: None.

Parental Presence/Absence

Description: The presence or absence of the parent sometimes can be used to gain cooperation for treatment. A wide diversity exists in practitioner philosophy and parental attitude regarding parents' presence or absence during pediatric dental treatment.

Parenting styles in America have evolved in recent decades (Long 2004). Practitioners are faced with challenges from an increasing number of children who many times are ill-equipped with the coping skills and self-discipline necessary to deal with new experiences in the dental office. Frequently parental expectations for the child's behavior are unrealistic while expectations for the dentist who guides their behavior are great (Sheller 2004).

Practitioners agree that good communication is important among the dentist patient and parent. Practitioners also are united in the fact that effective communication between the dentist and the child is paramount and requires focus on the part of both parties. Children's responses to their parents' presence or absence can range from very beneficial to very detrimental. Each practitioner has the responsibility to determine the communication and support methods that best optimize the treatment setting recognizing his/her own skills the abilities of the particular child and the desires of the specific parent involved.

Objectives: The objectives of parental presence/absence are to:

1. Gain the patient's attention and improve compliance
2. Avert negative or avoidance behaviors
3. Establish appropriate dentist-child roles
4. Enhance effective communication among the dentist child and parent
5. Minimize anxiety and achieve a positive dental experience

Indications: May be used with any patient.

Contraindications: Parents who are unwilling or unable to extend effective support (when asked).

Nitrous Oxide/Oxygen Inhalation

Description: Nitrous oxide/oxygen inhalation is a safe and effective technique to reduce anxiety and enhance effective communication. Its onset of action is rapid the effects easily are titrated and reversible and recovery is rapid and complete. Additionally nitrous oxide/oxygen inhalation mediates a variable degree of analgesia amnesia and gag reflex reduction.

The need to diagnose and treat as well as the safety of the patient and practitioner should be considered before the use of nitrous oxide/oxygen analgesia/anxiolysis. Detailed information concerning the indications contraindications and additional clinical considerations may be found in the National Guideline Clearinghouse (NGC) summary of the American Academy of Pediatric Dentistry's (AAPD) Clinical Guideline on Appropriate Use of Nitrous Oxide for Pediatric Dental Patients.

Advanced Behavior Guidance

Most children can be managed effectively using the techniques outlined in basic behavior guidance. These basic behavior guidance techniques should form the foundation for all of the management activities provided by the dentist. Children however occasionally present with behavioral considerations that require more advanced techniques. The advanced behavior guidance techniques commonly used and taught in advanced pediatric dental training programs include protective stabilization sedation and general anesthesia (Adair et al. 2004). They are extensions of the overall behavior guidance continuum with the intent to facilitate the goals of communication cooperation and delivery of quality oral health care in the difficult patient. Appropriate diagnosis of behavior and safe and effective implementation of these techniques necessitate knowledge and experience that are generally beyond the core knowledge students receive during predoctoral dental education. Dentists considering the use of these advanced behavior guidance techniques should seek additional training through a residency program a graduate program and/or an extensive continuing education course that involves both didactic and experiential mentored training.

Protective Stabilization

Description: The use of any type of protective stabilization in the treatment of infants children adolescents or persons with special health care needs is a topic that concerns healthcare providers care givers and the public (Connick Palat & Puagliese 2000; Crossley & Joshi 2002; Peretz & Zadik 1999; Peretz & Gluck 2002; Brill 2002; Law & Blain 2003; Kupietzky 2004; Manley 2004; Morris 2004). The broad definition of protective stabilization is the restriction of patient's freedom of movement with or without the patient's permission to decrease risk of injury while allowing safe completion of treatment. The restriction may involve another human(s) a patient stabilization device or a combination thereof. The use of protective stabilization has the potential to produce serious consequences such as physical or psychological harm loss of dignity violation of a patient's rights and even death. Because of the associated risks and possible consequences of use the dentist is encouraged to evaluate thoroughly its use on each patient and possible alternatives (Joint Commission on Accreditation of Healthcare Organizations 2004).

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. Protective stabilization can be performed by the dentist staff or parent with or without the aid of a restrictive device. 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 for the use of protective stabilization. The decision to use patient stabilization should take into consideration:

1. Alternate behavior guidance modalities
2. Dental needs of the patient
3. The effect on the quality of dental care
4. The patient's emotional development
5. The patient's physical considerations

Protective stabilization with or without a restrictive device 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. Due to the possible aversive nature of the technique informed consent also should be obtained prior to a parent's performing protective stabilization during dental procedures. Furthermore when appropriate an explanation to the patient regarding the need for restraint with an opportunity for the patient to respond should occur ("The use of physical restraint" 1997).

In the event of an unanticipated reaction to dental treatment it is incumbent upon the practitioner to protect the patient and staff from harm. Following immediate intervention to assure safety if techniques must be altered to continue delivery of care the dentist must have informed consent for the alternative methods.

The patient's record must include:

1. Informed consent for stabilization
2. Indication for stabilization
3. Type of stabilization
4. The duration of application of stabilization
5. Frequency of stabilization evaluation and safety adjustments
6. Behavior evaluation/rating during stabilization

Objectives: The objectives of patient stabilization are to:

1. Reduce or eliminate untoward movement
2. Protect patient staff dentist or parent from injury
3. Facilitate delivery of quality dental treatment

Indications: Patient stabilization is indicated when:

1. Patients require immediate diagnosis and/or limited treatment and cannot cooperate due to lack of maturity
2. Patients require immediate diagnosis and/or limited treatment and cannot cooperate due to mental or physical disability
3. The safety of the patient staff dentist or parent would be at risk without the use of protective use of stabilization
4. Sedated patients require limited stabilization to help reduce untoward movement

Contraindications: Patient stabilization is contraindicated for:

1. Cooperative non-sedated patients
2. Patients who cannot be immobilized safely due to associated medical or physical conditions
3. Patients who have experienced previous physical or psychological trauma from protective stabilization (unless no other alternatives are available)
4. Nonsedated patients with nonemergent treatment requiring lengthy appointments

Precautions: The following precautions should be taken prior to patient stabilization:

1. Tightness and duration of the stabilization must be monitored and reassessed at regular intervals
2. Stabilization around extremities or the chest must not actively restrict circulation or respiration
3. 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

Sedation

Description: Sedation can be used safely and effectively with patients unable to receive dental care for reasons of age or mental physical or medical condition. Background information and documentation for the use of sedation is detailed in the NGC summary of the AAPD's Guidelines for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures.

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:

1. Alternative behavioral guidance modalities
2. Dental needs of the patient
3. The effect on the quality of dental care
4. The patient's emotional development
5. The patient's physical considerations

Documentation shall include: (See the NGC summary of the AAPD's Guidelines for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures).

1. Informed consent. Informed consent must be obtained from the parent and documented prior to the use of sedation
2. Instructions and information provided to the parent
3. Health evaluation
4. A time-based record that includes the name route site time dosage and patient effect of administered drugs
5. The patient's level of consciousness responsiveness heart rate blood pressure respiratory rate and oxygen saturation at the time of treatment and until predetermined discharge criteria have been attained.
6. Adverse events (if any) and their treatment
7. Time and condition of the patient at discharge

Objectives: The goals of sedation are to:

1. Guard the patient's safety and welfare
2. Minimize physical discomfort and pain
3. Control anxiety minimize psychological trauma and maximize the potential for amnesia
4. Control behavior and/or movement so as to allow the safe completion of the procedure
5. 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:

1. Fearful anxious patients for whom basic behavior guidance techniques have not been successful
2. Patients who cannot cooperate due to a lack of psychological or emotional maturity and/or mental physical or medical disability
3. 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:

1. The cooperative patient with minimal dental needs
2. Predisposing medical conditions which would make sedation inadvisable

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. The use of general anesthesia sometimes is necessary to provide quality dental care for the child. Depending on the patient this can be done in a hospital or an ambulatory setting including the dental office. Additional background information may be found in the American Academy of Pediatric Dentistry's Clinical Guideline on Use of Anesthesia Care Providers in the Administration of In-office Deep Sedation/General Anesthesia to the Pediatric Dental Patient (2006).

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. The decision to use general anesthesia must take into consideration:

1. Alternative behavioral guidance modalities
2. Dental needs of the patient
3. The effect on the quality of dental care
4. The patient's emotional development
5. The patient's medical status

Prior to the delivery of general anesthesia appropriate documentation shall address the rationale for use of general anesthesia informed consent instructions provided to the parent dietary precautions and preoperative health evaluation. Because laws and codes vary from state to state minimal requirements for a time-based anesthesia record should include:

1. The patient's heart rate blood pressure respiratory rate and oxygen saturation at specific intervals throughout the procedure and until predetermined discharge criteria have been attained
2. The name route site time dosage and patient effect of administered drugs including local anesthesia
3. Adverse events (if any) and their treatment
4. That discharge criteria have been met the time and condition of the patient at discharge and into whose care the discharge occurred

Objectives: The goals of general anesthesia are to:

1. Provide safe efficient and effective dental care
2. Eliminate anxiety
3. Reduce untoward movement and reaction to dental treatment
4. Aid in treatment of the mentally physically or medically compromised patient
5. Eliminate the patient's pain response

Indications: General anesthesia is indicated for:

1. Patients who cannot cooperate due to a lack of psychological or emotional maturity and/or mental physical or medical disability
2. Patients for whom local anesthesia is ineffective because of acute infection anatomic variations or allergy
3. The extremely uncooperative fearful anxious or uncommunicative child or adolescent
4. Patients requiring significant surgical procedures
5. Patients for whom the use of general anesthesia may protect the developing psyche and/or reduce medical risk
6. Patients requiring immediate comprehensive oral/dental care

Contraindications: The use of general anesthesia is contraindicated for:

1. A healthy cooperative patient with minimal dental needs
2. Predisposing medical conditions which would make general anesthesia inadvisable

Clinical Algorithm(s)

None provided

References Supporting the Recommendations

• Adair SM Rockman RA Schafer TE Waller JL. Survey of behavior management teaching in pediatric dentistry advanced education programs. Pediatr Dent 2004 Mar-Apr;26(2):151-8. PubMed



• American Academy of Pediatric Dentistry. Clinical guideline on use of anesthesia care providers in the administration of in-office deep sedation/general anesthesia to the pediatric dental patient. Pediatr Dent 2006;28(Suppl):133-5.



• American Academy of Pediatrics Committee on Pediatric Emergency Medicine. The use of physical restraint interventions for children and adolescents in the acute care setting. American Academy of Pediatrics Committee on Pediatric Emergency Medicine. Pediatrics 1997 Mar;99(3):497-8. PubMed



• Brill WA. Parents' assessment and children's reactions to a passive restraint device used for behavior control in a private pediatric dental practice. ASDC J Dent Child 2002 Sep-Dec;69(3):310-3 236. PubMed



• Connick C Palat M Pugliese S. The appropriate use of physical restraint: considerations. ASDC J Dent Child 2000 Jul-Aug;67(4):256-62 231. [25 references] PubMed



• Crossley ML Joshi G. An investigation of pediatric dentists' attitudes towards parent accompaniment and behavioral management techniques in the UK. Br Dent J 2002;192:517-21.



• Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Comprehensive accreditation manual for hospitals 2004-2005. Oakbrook Terrace (IL): Joint Commission on Accreditation of Healthcare Organizations (JCAHO); 2004. pc25-40 p.



• Kupietzky A. Strap him down or knock him out: Is conscious sedation with restraint an alternative to general anaesthesia. Br Dent J 2004 Feb 14;196(3):133-8. PubMed



• Law CS Blain S. Approaching the pediatric dental patient: a review of nonpharmacologic behavior management strategies. J Calif Dent Assoc 2003 Sep;31(9):703-13. PubMed



• Long N. The changing nature of parenting in America. Pediatr Dent 2004 Mar-Apr;26(2):121-4. PubMed



• Manley MC. A UK perspective. Br Dent J 2004 Feb 14;196(3):138-9. PubMed



• Morris CD. A commentary on the legal issues. Br Dent J 2004 Feb 14;196(3):139-40. PubMed



• Peretz B Gluck GM. The use of restraint in the treatment of paediatric dental patients: old and new insights. Int J Paediatr Dent 2002 Nov;12(6):392-7. PubMed



• Peretz B Zadik D. Parents' attitudes toward behavior management techniques during dental treatment. Pediatr Dent 1999 May-Jun;21(3):201-4. PubMed



• Sheller B. Challenges of managing child behavior in the 21st century dental setting. Pediatr Dent 2004 Mar-Apr;26(2):111-3. PubMed

Type of Evidence supporting the Recommendations

The type of evidence supporting the recommendations is not specifically stated for each recommendation.  In general all oral health policies and clinical guidelines are based on 2 sources of evidence: (1) the scientific literature; and (2) experts in the field.

Potential Benefits

Appropriate behavior guidance techniques used in contemporary pediatric dentistry

Potential Harms

The use of protective stabilization has the potential to produce serious consequences such as physical or psychological harm loss of dignity violation of a patient's rights and even death.

Contraindications

• Parental presence is contraindicated when parents are unwilling or unable to extend effective support (when asked).
• Voice control techniques are contraindicated in patients who are hearing impaired.
• Patient stabilization is contraindicated for:
  • Cooperative nonsedated patients
  • Patients who cannot be immobilized safely due to associated medical or physical conditions
  • Patients who have experienced previous physical or psychological trauma from protective stabilization (unless no other alternatives are available)
  • Nonsedated patients with nonemergent treatment requiring lengthy appointments
• The use of sedation is contraindicated for:
  • The cooperative patient with minimal dental needs
  • Predisposing medical conditions which would make sedation inadvisable
• The use of general anesthesia is contraindicated for:
  • A healthy cooperative patient with minimal dental needs
  • Predisposing medical conditions which would make general anesthesia inadvisable

Qualifying Statements

• The American Academy of Pediatric Dentistry (AAPD) recognizes that in providing oral health care for infants children adolescents and persons with special health care needs a continuum of both nonpharmacological and pharmacological behavior guidance techniques may be used by dental health care providers. The various behavior guidance techniques used must be tailored to the individual patient and practitioner. Promoting a positive dental attitude safety and quality of care are of the utmost importance. This guideline is intended to educate health care providers parents and other interested parties about many behavior guidance techniques used in contemporary pediatric dentistry. It will not attempt to duplicate information found in greater detail in the AAPD's Clinical Guideline on Appropriate Use of Nitrous Oxide for Pediatric Dental Patients Guidelines for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures: An Update and Clinical Guideline on the Use of Anesthesia Care Providers in the Administration of In-office Deep Sedation/General Anesthesia to the Pediatric Dental Patient.
• Some of the behavior guidance techniques in this document are intended to maintain communication while others are intended to extinguish inappropriate behavior and establish communication. As such these techniques cannot be evaluated on an individual basis as to validity but must be assessed within the context of the child's total dental experience. Each technique must be integrated into an overall behavior guidance approach individualized for each child. Therefore behavior guidance is as much an art as it is a science. It is not an application of individual techniques created to "deal" with children but rather a comprehensive continuous method meant to develop and nurture the relationship between patient and doctor which ultimately builds trust and allays fear and anxiety.

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools

Chart Documentation/Checklists/Forms

For information about availability see the "Availability of Companion Documents" and "Patient Resources" fields below.

IOM Care Need

Staying Healthy

IOM Domain

Effectiveness
Patient-centeredness

Bibliographic Source(s)

• American Academy of Pediatric Dentistry (AAPD). Guideline on behavior guidance for the pediatric dental patient. Chicago (IL): American Academy of Pediatric Dentistry (AAPD); 2006. 9 p. [62 references]

Adaptation

Not applicable: The guideline was not adapted from another source.

Source(s) of Funding

American Academy of Pediatric Dentistry

Guideline Committee

Council on Clinical Affairs -- Committee on Behavior Guidance

Composition of Group that Authored the Guideline

Not stated

Financial Disclosures/Conflicts of Interest

Council members are asked to identify potential conflicts of interest; none was disclosed.

Guideline Status

Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary.

Guideline Availability

Electronic copies of the updated guideline: Available from the American Academy of Pediatric Dentistry Web site.

Print copies: Available from the American Academy of Pediatric Dentistry 211 East Chicago Avenue Suite 1700 Chicago Illinois 60611

Availability of Companion Documents

The following are available:

• Overview. American Academy of Pediatric Dentistry 2007-08 definitions oral health policies and clinical guidelines. Available from the American Academy of Pediatric Dentistry Web site.
• Sedation record. Available in Portable Document Format (PDF) from the American Academy of Pediatric Dentistry Web site.

Patient Resources

None available

NGC STATUS

This NGC summary was completed by ECRI on August 18 2005. This NGC summary was updated by ECRI Institute on August 6 2007. The updated information was verified by the guideline developer on August 23 2007.

COPYRIGHT STATEMENT

This summary is based on the original guideline which is subject to the guideline developer's copyright restrictions.

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