354 Part 3 The Primary Dentition Years: Three to Six Years
problems. Dental fear and/or anxiety is the feeling the patient has
regarding dentistry, whereas behavior management problems are
the experiences the dentist has treating the patient.
dental behavior management problems and fear are dierent entities,
but because of their signicant association, they will be discussed
together as we explore variables related to uncooperative
Most studies nd that negative behavior in the dental oce is
most intense in younger children and decreases as children grow
Dental anxiety also decreases as the child grows older,
as does needle phobia,
most likely due to maturing com-
munication and coping skills. However, it is important to assess
the patient’s degree of psychological development because that
may be more important than chronologic age when predicting
e role of gender in dental anxiety and misbehavior is not as
clear. e majority of studies found increased anxiety in females,
particularly after children pass early school age,
found no dierence.
Klingberg and Broberg
in a 2007 review of the literature that a clear trend exists, with
girls being both more dentally anxious and exhibiting more behavior
management problems, which was in contrast with an early 1982
review where no clear dierence in gender was found.
be in part due to increased willingness for females to verbalize
fears because of cultural norms for gender.
e inuence of environment on health or social determinants of
health has been an area of recent interest. Toxic stress is the “result
of strong, frequent, or prolonged activation of the body’s stress
response systems in the absence of the buering protection of a
supportive adult relationship.”
is type of stress may be a result
of child abuse and neglect, exposure to violence, poverty, or maternal
Exposure can begin prenatally and can result in lasting
changes to the neural architecture, resulting in persistent devel-
opmental and physiologic harm and increasing risks for lifelong
Evidence suggests individual dierences are
present in physiologic reactivity to stress, as measured by the amount
of corticotropin hormone released in stressful situations.
children, dubbed dandelion children, are low reactors and exhibit
little physiologic change when presented with toxic stress, but
other children, dubbed orchid children, exhibit extreme physiologic
changes (i.e., high reactors).
Studies have linked dental anxiety and resultant behavior
management problems to socioeconomic status and household
Explanations for this behavior may include
increased caries history and resultant invasive treatment and/or
lack of access to dentists with experience treating children.
management problems have also been linked to single parent homes,
possibly due to increased economic and social pressures in these
environments. Emerging areas of study are the correlation between
dental behavior and residence in an area at high risk for toxic
stressors such as violence and low socioeconomic status.
Culture may be dened as a system of shared beliefs, values,
customs, and behaviors that members of society use to cope
with their world; it is a shared system of attitudes and feelings.
Children are increasingly inuenced by culture once they reach
the formal operations stage of cognitive development. Although
uncooperative dental behavior and high scores on temperament
subscales of anger, irritability, fear, reaction, reactivity, and shyness.
Impulsivity and negative emotionality have also been more com-
monly found in children with behavior management problems.
ese temperament proles (impulsivity and negative emotionality)
are a poor t with the demands and formal structure of a dental
visit. Patients with dental behavior management problems are less
likely to have a balanced temperament prole than control groups.
Coping is the ability to manage threatening, challenging, or
potentially harmful situations and is crucial for well-being. Coping
strategies may be behavioral or cognitive. Behavioral coping eorts
are overt physical or verbal activities, whereas cognitive eorts
involve the conscious manipulation of one’s thoughts or emotions.
An example of behavioral coping is the use of self-statements
focusing on competence, such as “I am a brave boy,” which can
help children tolerate uncomfortable situations for a longer period
Eective coping strategies enable the individual to perceive
some sense of control over the stressful event. Typically, older
children have a more extensive coping repertoire than younger
children. Girls have also been reported to use more emotional and
comfort-seeking strategies when faced with a stressful event, but
boys use more physical aggression and stalling techniques. However,
coping skills vary greatly among individuals. Studies involving
venipuncture show that lower pain scores were associated with
children who reported using behavioral coping strategies.
skills in patients with dental anxiety can be improved through
cognitive behavioral therapy.
Factors Inuencing Child Behavior
Child behavior in pediatric dentistry is typically studied in terms
of dental fear and/or anxiety and dental behavior management
Data from Chess S, Thomas A. Temperament. In: Lewis M, ed. Child and Adolescent Psychiatry: A
Comprehensive Textbook. 2nd ed. Philadelphia: Lippincott Williams and Wilkins; 1996:170–181.
1. Activity level
3. Approach or withdrawal
5. Threshold of responsiveness
6. Intensity of reaction
7. Quality of mood
9. Attention span and persistence
1. Easy temperament: biological regularity, quick adaptability to change,
tendency to approach new situations versus withdraw, predominantly
positive mood of mild or moderate intensity.
2. Difcult temperament: biological irregularity, withdrawal tendencies to the
new, slow adaptability to change, frequent negative emotional expressions
of high intensity.
3. Slow-to-warm-up temperament: this category comprises withdrawal
tendencies to the new, slow adaptability to change, and frequent negative
emotional reactions of low intensity. Such individuals are often labeled
Temperament• BOX 24.2
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354 Part 3 The Primary Dentition Years: Three to Six Yearsproblems. Dental fear and/or anxiety is the feeling the patient has regarding dentistry, whereas behavior management problems are the experiences the dentist has treating the patient.14 Pediatric dental behavior management problems and fear are dierent entities, but because of their signicant association, they will be discussed together as we explore variables related to uncooperative behavior.DemographicsMost studies nd that negative behavior in the dental oce is most intense in younger children and decreases as children grow older.15–17 Dental anxiety also decreases as the child grows older, as does needle phobia,14,18–21 most likely due to maturing com-munication and coping skills. However, it is important to assess the patient’s degree of psychological development because that may be more important than chronologic age when predicting disruptive behavior.22e role of gender in dental anxiety and misbehavior is not as clear. e majority of studies found increased anxiety in females, particularly after children pass early school age,15,21,23–25 while others found no dierence.16,18,19,22,26 Klingberg and Broberg14 concluded in a 2007 review of the literature that a clear trend exists, with girls being both more dentally anxious and exhibiting more behavior management problems, which was in contrast with an early 1982 review where no clear dierence in gender was found.27 is may be in part due to increased willingness for females to verbalize fears because of cultural norms for gender.Environmente inuence of environment on health or social determinants of health has been an area of recent interest. Toxic stress is the “result of strong, frequent, or prolonged activation of the body’s stress response systems in the absence of the buering protection of a supportive adult relationship.”28 is type of stress may be a result of child abuse and neglect, exposure to violence, poverty, or maternal depression.28 Exposure can begin prenatally and can result in lasting changes to the neural architecture, resulting in persistent devel-opmental and physiologic harm and increasing risks for lifelong chronic diseases.28,29 Evidence suggests individual dierences are present in physiologic reactivity to stress, as measured by the amount of corticotropin hormone released in stressful situations.29 Some children, dubbed dandelion children, are low reactors and exhibit little physiologic change when presented with toxic stress, but other children, dubbed orchid children, exhibit extreme physiologic changes (i.e., high reactors).29Studies have linked dental anxiety and resultant behavior management problems to socioeconomic status and household characteristics.9,19,23 Explanations for this behavior may include increased caries history and resultant invasive treatment and/or lack of access to dentists with experience treating children.30 Behavior management problems have also been linked to single parent homes,9 possibly due to increased economic and social pressures in these environments. Emerging areas of study are the correlation between dental behavior and residence in an area at high risk for toxic stressors such as violence and low socioeconomic status.Culture may be dened as a system of shared beliefs, values, customs, and behaviors that members of society use to cope with their world; it is a shared system of attitudes and feelings.31 Children are increasingly inuenced by culture once they reach the formal operations stage of cognitive development. Although uncooperative dental behavior and high scores on temperament subscales of anger, irritability, fear, reaction, reactivity, and shyness.8 Impulsivity and negative emotionality have also been more com-monly found in children with behavior management problems.9 ese temperament proles (impulsivity and negative emotionality) are a poor t with the demands and formal structure of a dental visit. Patients with dental behavior management problems are less likely to have a balanced temperament prole than control groups.10CopingCoping is the ability to manage threatening, challenging, or potentially harmful situations and is crucial for well-being. Coping strategies may be behavioral or cognitive. Behavioral coping eorts are overt physical or verbal activities, whereas cognitive eorts involve the conscious manipulation of one’s thoughts or emotions.11 An example of behavioral coping is the use of self-statements focusing on competence, such as “I am a brave boy,” which can help children tolerate uncomfortable situations for a longer period of time.12 Eective coping strategies enable the individual to perceive some sense of control over the stressful event. Typically, older children have a more extensive coping repertoire than younger children. Girls have also been reported to use more emotional and comfort-seeking strategies when faced with a stressful event, but boys use more physical aggression and stalling techniques. However, coping skills vary greatly among individuals. Studies involving venipuncture show that lower pain scores were associated with children who reported using behavioral coping strategies.11 Coping skills in patients with dental anxiety can be improved through cognitive behavioral therapy.13Factors Inuencing Child BehaviorChild behavior in pediatric dentistry is typically studied in terms of dental fear and/or anxiety and dental behavior management Data from Chess S, Thomas A. Temperament. In: Lewis M, ed. Child and Adolescent Psychiatry: A Comprehensive Textbook. 2nd ed. Philadelphia: Lippincott Williams and Wilkins; 1996:170–181.Temperament Categories1. Activity level2. Rhythmicity3. Approach or withdrawal4. Adaptability5. Threshold of responsiveness6. Intensity of reaction7. Quality of mood8. Distractability9. Attention span and persistenceTemperament Classication1. Easy temperament: biological regularity, quick adaptability to change, tendency to approach new situations versus withdraw, predominantly positive mood of mild or moderate intensity.2. Difcult temperament: biological irregularity, withdrawal tendencies to the new, slow adaptability to change, frequent negative emotional expressions of high intensity.3. Slow-to-warm-up temperament: this category comprises withdrawal tendencies to the new, slow adaptability to change, and frequent negative emotional reactions of low intensity. Such individuals are often labeled “shy.”Temperament• BOX 24.2 CHAPTER 24 Behavior Guidance of the Pediatric Dental Patient 355 from siblings and peers, and the fear of the needle, while an example of a theorized fear is the fear of being electrocuted by the x-ray tube.17 Dental fear is a worldwide problem and a universal barrier to oral health services; fears acquired in childhood through direct experience with painful treatment or vicariously through parents, friends, and siblings may persist into adulthood.38Dental fear has been attributed to lack of trust in the dentist and lack of control over a traumatic event.38 Dental techniques that help the patient regain trust and control, such as use of signal-ing, may prevent or alleviate these fears. Regarding specic pro-cedures, the dental injection is the most feared procedure, followed by “drilling” and “tooth scaling.”23 Other common fears are “feeling the needle” and “seeing the needle.”24 Needle phobia, however, does not imply a high level of children’s dental anxiety and diminishes with increasing age.20Dental fear and anxiety have also been linked to increased general fears.23 Dental fear itself may be a manifestation of another disorder, such as fear of heights and ying, claustrophobia, and other fears.38 Dental fear and anxiety may also be linked to general behavioral problems, and children at risk of developing internalizing disorders (i.e., separation anxiety disorder, generalized anxiety disorder, obsessive-compulsive disorder) are more likely to exhibit dental fear.14Irregular dental visits and increased length of time since the last dental visit are signicantly associated with increased dental anxiety.21,23 Unfortunately, the cycle of avoiding dental care, having increased need for invasive and emergent dental needs, and having a painful experience that reinforces avoidance can be observed in childhood and adolescence.Paine child in pain will almost always exhibit behavior guidance challenges. Pain is an inherently subjective experience and should be assessed and treated as such. Pain has sensory, emotional, cognitive, and behavioral components that are interrelated with environmental, developmental, sociocultural, and contextual factors.39 Tissue damage is not required to provoke pain, and reports of pain should not be casually dismissed. It is counter-productive to argue with the child that a sensation is “uncomfort-able but does not hurt,” especially in young children who are unable to describe levels of pain and experience noxious stimuli dichotomously (i.e., either “yes, it hurts” or “no, it does not hurt”). Introduction to new experiences through the tell-show-do (TSD) technique can prevent patients from interpreting new sensations as painful.Although adequate management of pain is considered funda-mental in providing dentistry for children, this has not always been the case. Historically, childhood pain has routinely been denied and undertreated.39 Milgrom and coworkers40 found in a 1994 survey that “many dentists believe dental care for children is not particularly painful but only unpleasant, and a substantial proportion denies the reality of child dental pain. Some dentists tend to believe children confuse pressure with pain or knowingly present false or exaggerated responses, possibly in an attempt to escape the dental environment.”One advantage to the highly uid nature of pain is that, just as anxiety can upregulate pain perception, many of our behavior management strategies such as relaxation and distraction can downregulate pain. Hypnosis and mental imagery strategies can help patients modulate their own pain.41 is topic is discussed in more detail in Chapter 7.cooperation may be greater in cultures that place great stress on obedience, dental anxiety (typically based on behavior) may be overlooked.31Parenting styles may also aect child behavior. Baumrind dened three specic parenting styles—(1) authoritative, (2) authoritarian, and (3) permissive—and a fourth, neglecting, has since been added (Table 24.1).32,33 Positive behavior has been associated with children of authoritative parents compared with children of authoritarian and permissive parents.34 Aminabadi et al. found a positive cor-relation between authoritative parenting style and positive child behavior and a correlation between permissive parenting and negative behaviors.35 Most likely, this parenting style is associated with improved behavior because it reinforces adult authority so that a child will follow commands of the dentist, but the style also oers parental nurturing and support for any anxiety the child may have about the dental visit. Krikken et al. did not nd an impact on child behavior and anxiety associated with parenting style, although for one group of children, they did nd increased anxiety with authoritarian parenting style.36Dental Feare relationship between dental fear and negative behavior is not straightforward, and it would be an oversimplication to attribute all misbehavior to dental fear. e etiology of dental fear in children is multifactorial and a product of previous experience, generalized fear, and familial anxiety.17Between 9% and 20% of children and adolescents exhibit dental fear and anxiety,14 although Baier et al. found a 20% prevalence.17 Dental fear has been found in most but not all children with behavior management problems.9 While the odds are increased that children who exhibit negative behavior have dental fear, and children who have dental fear may exhibit negative behavior, not all uncooperative children report dental fear.17 Children who report being fearful by various measurement tools are twice as likely to behave negatively than children who are not fearful.17Pinkham classies fears of dentistry as realistic and theorized fears.37 Realistic fears are previous bad experiences, fears acquired Parenting Style DescriptionAuthoritative High parental responsiveness/affection and high parental demand for obedience; warmth and involvement, reasoning/induction, democratic participationAuthoritarian Low parental responsiveness/affection but high parental demand for obedience; clear parental authority, unquestioning obedience and punitive strategiesPermissive High parental responsiveness/affection but low parental demand for obedience; tolerance, tendencies to ignore child’s misbehavior; child shares in the decision-making process with parent generally accepting child’s decisionsNeglecting Low parental responsiveness and low parental demandParenting StylesTABLE 24.1 356 Part 3 The Primary Dentition Years: Three to Six YearsThe Dentist and the Dental Teame successful behavior guidance of a child is dependent on the dentist’s ability to communicate with the parent, child, and sta.26 Dentists who treat children can have a variety of personalities and still be eective. Some are very extroverted and emotive, providing an energetic atmosphere that makes children feel included and special. Other dentists tend to be quiet and gentle to put patients at ease. is exibility is benecial because some children need upbeat encounters, and others need quiet ones.41 As long as the underlying message is kindness and regard for the child’s well-being, dentists with almost any personality type can be successful at treating children.The dentist’s appearance should be neat and professional. Traditional attire such as a white coat need not be avoided, because a few studies have shown parents and children to prefer it.46,47 In addition, protective gear required for universal precautions has not been shown to increase fear in children.48e dental team should be a reection of the oce philosophy. e entire team should display a positive, friendly attitude toward the patient. Training in communication, multicultural awareness, child development, behavior guidance, and informed consent for auxiliaries can help them become an integral part of successful behavior guidance.49 Using the same euphemisms and terms by sta can help provide stability for the child.Patient AssessmentTo improve the child’s experience, it is important that the dentist gain familiarity with the child before treatment. At a minimum, the dentist should inquire about previous dental visits and the patient’s behavior at these visits. Previous disruptive behavior in the dental situation and previous extraction is signicantly associated with dental anxiety status.21,22 Generally, it is helpful to ask parents how they feel the child will cooperate today, and it may also be helpful to ask how the patient copes with medical visits. Although this assessment is not always correct, it can help the dentist get a better sense of the child and parental expectations.A number of questionnaires and surveys that can help the dentist gather more information about the fear, anxiety, and temperament of the child patient are available, although their clinical ecacy is unknown. A simple facial images scale with smiling, neutral, and frowning faces has been validated in children as young as 3 years to assess dental anxiety.50 e dental subset of the Children’s Fear Survey Schedule has been used to determine fear in younger children,18 and the Emotionality, Activity, and Sociability (EAS) Temperament Survey can gauge for temperament types more prone to distress, particularly shyness.51Often much can be learned from observing patients as they play in the waiting room, interact with parents, and respond to the initial approach of dental personnel.52,53Parents in the OperatoryContemporary parents overwhelmingly would like to accompany their children in the operatory.54,55 e most recent survey of AAPD members found that the majority of respondents had parents back for all procedures except for sedations.56Having parents in the operatory provides an opportunity for immediate communication on changes in treatment plan, oral hygiene instructions, and postoperative instructions from the dentist rather than an intermediary. Also, it reduces the possibility of a Parental Anxietye dental anxiety of children is inuenced by their family and peers.23 Parental anxiety, especially maternal anxiety, is inuential on the child’s development of anxiety.20,21 Corkey and Freeman22 found the mother’s dental anxiety status, the length of time since the mother’s last dental visit, her regularity of dental attendance, and her dislike of restorations were all signicantly related to child dental anxiety status. e study concluded that maternal dental anxiety status and maternal psychiatric morbidity were both closely related to child dental anxiety status.22 Although the mother is the primary source of fear, recent studies have suggested fathers can also aect their children.42Setting the Stage for Successful Behavior GuidanceThe Dental OceOces that exclusively treat children have a wide array of décor, from a child-friendly theme to oce artwork or the presence of video games. Creating the child-friendly environment in an oce that treats both children and adults can be more challenging, but a poster on the ceiling of the operatory or a few stued animals can make the child patient more at ease. It is important to send the message that this is a place that children have come before and are welcome.Many oces have new patient packets or websites that familiarize parents with oce policies and set expectations that may include letters directly to the children or activities for the children to prepare them for the visit. Parents should be encouraged not to put too much emphasis on the visit, because this may lead to negative stress. A preexposure visit to the oce for healthy children may provide little benet43 but should be considered for patients with special health care needs such as autism spectrum who benet from familiarity and routine.SchedulingConventional wisdom states that very young children are usually at their best early in the day. ey may be able to tolerate a prophylaxis visit that is minimally demanding in the afternoon, but may be too tired later in the day for an operative appointment with higher levels of stress. Studies have not veried this and have actually found decreased negative behavior for restorative treatment in afternoon visits versus morning.15 However, the dentist may want to schedule these patients when sta have the most energy, and if a patient does have a dicult operative visit, reappointing for a morning visit might be benecial before resorting to advanced behavior guidance techniques.Typically dentists believe that a child needs an introductory visit to the oce before performing an invasive procedure. Feigal refers to this examination or examination and prophylaxis only appointment as a “preconditioning appointment” and claims it helps ease children into the dental experience with as little stress as possible.44 However, Brill45 showed no dierence in behavior between children who had an initial nonthreatening dental visit and those who had a rst restorative treatment visit. us emergent or urgent treatment should not be delayed on these grounds alone. CHAPTER 24 Behavior Guidance of the Pediatric Dental Patient 357 dentist and responses from the child. Requests and commands for the child patient are best when they are direct, brief, literal, and appropriate for the child’s level of understanding. Avoid “don’t” commands in toddlers and preschoolers as they have less developed language processing skills and are more likely to make impulse errors in communication.4,66 ese commands may prompt the unwanted behavior they are intended to avoid.4,66 Extensive explanations are ineective and can erode the authority of the dentist. Sarcasm and belittling of the patient have no place in dentistry for children.In order to achieve cooperation and success, the dentist should establish open lines of communication with the child and preserve them throughout the appointment. When communicating with children it is important to use a relaxed tone of voice, acknowledge their interests, and talk to them at an appropriate developmental level.67Communication should come primarily from the dentist who must establish a relationship of trust through verbal and nonverbal techniques. e dentist must be aware of any o-putting nonverbal habits they have, such as sighing or avoiding eye contact, because patients and parents quickly perceive and interpret them negatively.49 e exercise of video recording oneself during patient interactions can alert the practitioner to undesired habits that may interfere with the message.To achieve success, it is important that the dentist phrase requests in a manner that encourages compliance and gives the child choices when possible. For example, the dentist may not give the child the choice of whether they want topical anesthetic but can ask if the patient wants strawberry or bubble gum avor to preserve a sense of control.23 If a patient does not comply with a request, then it is often necessary to rephrase the request in a manner that encourages compliance. e behavior guidance technique of voice control and nonverbal communication is eective in rephrasing requests.In providing dentistry for the child patient, the focus of all conversation should be the child. A discussion with the dental assistant or parent does nothing to encourage cooperation from the child and may provoke undesired behavior for attention. A child-focused conversation provides distraction for the child.One question often asked is how truthful to be with the child patient when the dentist is fearful that the truth may cause the child to object to a procedure that is otherwise tolerated. e obvious example of this is when the child patient asks, “Am I getting a shot?” One way to cope with a dicult question like this may be to use a euphemism, such as “We don’t have shots here, but I am going to use some sleepy juice so your tooth doesn’t hurt.” Other dentists are more direct in explaining the need for the local anesthetic, and in one study, showing the syringe was associated with similar behavior outcomes as concealing it.68 Clinicians must use their best judgment to honor the trust of the child while helping the child cope with the procedure as much as possible.Tell-Show-Doe technique known as tell-show-do (TSD) is one of the most intuitive yet essential behavior management techniques. In TSD, the patient is introduced to the dental environment in a nonthreaten-ing way that can be comprehended. First the child is told about the procedure or instrument in a child-friendly manner. For example, the rubber dam may be called a “trampoline.” Next the child is shown what will happen or what will be used, and allowed to see, touch, or smell the material or instrument, or watch a demonstration of the procedure. For example, once the child is told about the explorer, the dentist may use it to feel the child’s ngernail (Fig. parental misunderstanding or disagreement regarding how the child was treated. Finally, some dentists feel that the relationship with the parents is as important as the relationship with the children to establish trust. In historic studies, no increase in negative behavior was noted when parents were present as passive observers.57,58 Recent studies suggest either no dierence in behavior59 or improved behavior and reduced anxiety when parents are present.60,61If parents are to remain in the operatory, then the dentist should prepare them to best assist with treatment. A dentist may ask a parent to be a “silent observer” so that the child can focus on the dentist’s voice and requests. Moreover, parents should be informed that natural parent behaviors such as reassurance can contribute to child distress behavior and should be avoided.62 Jain et al.63 found the majority of parents were compliant with written and verbal instructions to remain a silent observer during dental procedures. However, most dentists report that they do use parental help with basic communication, reinforcement, and occasional stabilization.56 Dentists must have clear policies that are com-municated to parents before treatment about their presence in the operatory and their role. Parents can use this information to decide if the practice is best for their needs.e dentist should use caution in determining if siblings should observe an operative visit, especially one with local anesthesia. Also, it is best to have only one parent in the operatory to reduce distraction and the occasional disagreement between parents.Setting Parent ExpectationsBefore any procedure, the dentist should inform the parent of reasonable expectations of the child’s behavior based on their assessment and discuss how this behavior will be managed. Gaining a valid informed consent from the parents before treatment is critical. Parents should also be warned that behavior at the examina-tion visit may deteriorate with the added demands of restorative procedures. Positive acceptance of operative treatment by preschool children tends to decrease over the appointments, indicating a negative “appointment eect” in younger children.18 is means that sometimes more urgent needs should be treated rst instead of starting with simple procedures and completing complex procedures at subsequent visits. In addition, children who have invasive procedures may exhibit more negative behavior at recall visits than those who do not receive restorative treatment in between recall visits.64Review of Behavior Guidance TechniquesDiscrete behavior guidance techniques have been described in the literature and are listed in the AAPD guidelines1 but are rarely used in isolation. e experienced practitioner weaves almost all of them into a visit to help guide the patient through challenges and to reward cooperative behavior. Although these techniques seem intuitive and may be used by the dentist not instructed in behavior guidance, consciously practicing them can help improve skills and success with children. e dentist should formulate a behavior guidance treatment plan for the total patient’s well-being, including short-term and long-term goals of this treatment.65Basic Behavior GuidanceCommunication and Communicative Guidancee foundation for all basic behavior guidance is communication. e dental appointment involves a series of requests from the 358 Part 3 The Primary Dentition Years: Three to Six YearsA common mistake that novice clinicians make is showing the child a number of dierent instruments and materials before starting any procedure. is can overwhelm the patient, increase anxiety, and delay treatment. It is best for the practitioner to apply TSD to one procedure at a time and work through the various steps of the procedure.TSD is the foundation for a new technique in the AAPD guidelines, ask-tell-ask.1 In this technique, the patient is asked about feelings toward planned procedures and informed about the procedure using appropriate language. After this TSD component is completed, the patient is once again asked how he or she feels about the procedure. If the patient continues to have concerns, the dentist should attempt to address them or reconsider his or her behavior guidance plan.Nonverbal Behavior GuidanceNonverbal communication is the reinforcement and guidance of behavior through appropriate contact, posture, facial expressions, and body language.1 Children constantly receive nonverbal cues to interpret the world around them, and these cues work synergisti-cally with words and style to communicate with children.e conscientious practitioner can use this form of communica-tion to help shape ideal behavior in the child patient.75 Smiling, making eye contact, and an upbeat tone of voice convey to the child that the practitioner is condent that the child will enjoy the visit. A practitioner must remember that personal protective equipment (PPE) such as a mask and eye protection may hide the practitioner’s facial expressions and should not walk into the operatory to greet a patient in PPE. Nonverbal cues are important for the young child, and smiles and a friendly pat on the arm may help the toddler with limited verbal skills feel more comfortable. Children between the ages of 7 and 10 years who were patted on the upper arm or shoulder displayed less dgeting behavior than their counterparts who did not receive this touch; they also reported greater enjoyment of the visit.76e dentist may choose to sit down and have the preschool patient approach him or her, versus running the risk of being intimidating through height. is technique is called “leveling.” If a child is misbehaving, a stern facial expression and more upright posture can convey authority and regain the child’s attention and compliance.One must recognize that very young patients may misinterpret nonverbal cues. Wilson and associates77 found that 3-year-old 24.2). Finally, the child experiences the procedure, instrument, or material. is technique works best with children capable of communication and is very successful in all but very young toddlers. e dentist would be advised to not overlook this useful technique in older children and adolescents to help allay fear. is technique is almost universally acceptable to children, parents, and dentists.69–73 However, some children have expressed concern it could increase anxiety, and they were concerned about seeing the tools.74 One way to avoid anxiety over seeing the instruments is to cover all of the tools with the patient napkin, except nonthreatening items like the mirror and a toothbrush.Many of a dentist’s actions are psychologically neutral. e sensation is present but their pain- or fear-inducing qualities are interpretations added onto the sensation, usually through previous experience or by inuencing gures such as parents and siblings. TSD and euphemisms, such as those shown in Table 24.2, allow the dentist to dene new sensations.A B• Figure 24.2 Tell-show-do. (A) The patient is told about the explorer and shown how it will be used on the teeth in a nonthreatening manner. (B) The explorer is immediately introduced into the mouth and the teeth are examined. Device EuphemismRubber dam Trampoline, raincoatHigh-speed handpiece Mr. WhistleSlow-speed handpiece Mr. BumpyRubber dam clamp Tooth ring, tooth huggerHigh volume suction Mr. ThirstySaliva ejector StrawAmalgam restoration Silver starStainless steel crown Princess hatCuring light FlashlightEtch Blue shampooSealant or composite Tooth paintCement Tooth glueNitrous hood Astronaut maskCommon Euphemisms for Tell-Show-DoTABLE 24.2 CHAPTER 24 Behavior Guidance of the Pediatric Dental Patient 359 large rewards, such as going to a fast food restaurant and getting a prize at a toy store. e notion that the ordeal they are going to experience merits these rewards can increase the anxiety of the children and cause them to view the upcoming treatment as threatening. Preparing the parent prior to the operative appointment and asking him or her not to make large promises to the child before the visit can avoid this situation. If the child indeed displays adequate cooperation, the parent can surprise the child with such a treat, providing irregular reinforcement.DistractionOf all the pediatric behavior guidance techniques, distraction has the most research to support its ecacy. A Cochrane review of psychological interventions for needle-related procedural pain in children found strong evidence supporting distraction.79 Dental visits are challenging, and distraction is an eective technique to promote coping. e nursing literature has shown that parental reassurance during immunizations was related to increased need for restraint, increased verbal pain, and increased information-seeking, whereas children with parental-assisted distraction exhibited better behavior and less fear.80e most basic form of distraction is conversation with the dentist. Storytelling can be related to the procedure, such as telling a child you are chasing “sugar bugs” while using the high-speed handpiece. One former student would chase away all the dierent colors of sugar bugs and then knock down their house. Other stories may be totally unrelated to dentistry to take them away from the experience, such a shopping trip with a cartoon character or a story about pets. Counting is also a very popular form of distraction for some children.75 Physical distraction such as asking a child to rotate dierent feet during the injection can be helpful, and games such as guessing favorite colors or teachers’ names are a fun way to take a child’s mind o of the procedure. e dentist may enlist the help of an auxiliary in distracting the patient, either by telling a story or playing a game. One study that used a poster and a story by the auxiliary during dental treatment found decreased anxious or disruptive behavior.81 Parents may also be utilized during distraction, and when trained properly to avoid distress-promoting behavior, they can make a strong contribution to coping strategies, as shown in Table 24.3.41,62,80,82Early studies using television program or music distraction did not show a signicant impact on behavior.83,84 In recent years a number of quality studies have shown that wraparound eyewear is eective in reducing uncooperative behavior.85–87 is increase in success may be due to the ability of this type of eyewear to block out upsetting stimuli and to use popular and engaging programs.Voice ControlVoice control is a means of obtaining compliance from a child patient, with the dentist modulating tone and/or volume to gain the patient’s attention and cooperation.88 e term voice control is unique to pediatric dentistry. In voice control, instructions should be rm, denite, and convincing; to be most successful, the facial expression must mirror the message.88Typically the practitioner of voice control will make a request in a normal tone. If this request is not honored, the dentist can rephrase it in a rmer tone. e volume may become louder, or sometimes reduced to a whisper to get the patient’s attention. More importantly, the command should be repeated slowly and clearly. is technique is most acceptable to the child, dentist, and parent when it is followed by positive reinforcement for improved patients were signicantly less accurate than 6- and 9-year-olds at correctly identifying emotions associated with facial expressions depicted in photographs. ree-year-old patients were signicantly more likely to confuse happy and angry for sad.77 e dentist should be especially careful with patients of this age to make verbal and nonverbal communication as clear as possible.Positive ReinforcementPositive reinforcement is a way to recognize the cooperation of the child patient and promote future positive behavior through rewards. Positive reinforcement is universally accepted69,74,75,78 and contributes to the child’s overall sense of accomplishment with successfully completing a dental procedure. Social positive reinforce-ment is most eective and best when it is specic to the behavior that is cooperative. e patient will be pleased by a comment such as “You are being such a great patient today.” However, children are more likely to continue the desired behavior if the praise is more specic, such as “ank you for sitting so still and opening your mouth so wide.” Such a focused comment often motivates a child to continue to sit still and open a bit wider. Complimenting the child in front of parents and dental assistants, again being specic to the positive behaviors the child exhibits, is a great way to boost the child’s self-esteem and memories of the visit.Rewards such as a small toy or sticker also provide positive reinforcement, as shown in Fig. 24.3. ese items are concrete, and the child can take them home and show them o as a source of pride and accomplishment. It should be noted that these prizes will not have the same meaning or reinforcement of positive dental behavior without accompanying social reinforcement.Some question whether positive reinforcement is appropriate in all circumstances. For example, should children receive a reward if they do not exhibit cooperative behavior, or will this reinforce bad behavior? is is determined by the individual philosophy of the practitioner and should be consistently enforced. A practitioner may nd one positive aspect of the child’s behavior during the appointment and give a sticker for that aspect. For example, “ank you for coming to see me today. I appreciate you sitting in the chair and opening your mouth wide for me, and this sticker is for being so good at that. I think next time if you can sit still the entire time, you’ll get two stickers.”Sometimes what parents intend to be positive reinforcement becomes negative. ey may preemptively oer children multiple, • Figure 24.3 Social and tangible positive reinforcement at the end of the appointment. 360 Part 3 The Primary Dentition Years: Three to Six YearsDirect ObservationDirect observation uses social learning theory and the concept of modeling to improve behavior by allowing a child to observe a cooperative patient undergoing dental treatment.1 Modeling refers to learning by observation. In addition to helping children acquire new behaviors, it can help extinguish fear behavior through the process of “vicarious extinction,” where children observe other children undergoing experiences that they fear and become less afraid. For example, a younger or fearful patient typically watches a cooperative sibling undergo a procedure to extinguish fears. Greenbaum and Melamed note that it is particularly ecacious as a preventive measure to use with children who have had no prior exposure to dental treatment.95 is observation can be live or in video form, and Melamed et al. found signicantly less disrup-tive behavior when children watched a video of a child who displays coping and cooperative behavior during a dental appointment and is rewarded,96,97 but Paryab and Arab found no dierence.98 In addition, a parent can be the model, as Farhat-McHayleh et al. found lower heart rates in children if they observed their mother as the live model.99Memory RestructuringA child’s memory of an event is inuenced by the information he or she receives after the event.100 If a parent reminds the child of an unpleasant dental experience, memories of the visit can become more negative. Memory restructuring has been suggested as a tool to prevent dental fear after an aversive experience.101 is technique has four specic elements. First, a visual reminder such as a happy picture of the child at a dental appointment is shown to the child, and second, the child is asked if the parent was told how brave the child was during the dental visit. e child is enlisted in role-play to tell the dentist what the parent was told. is is the verbalization component where the child reports behaving well. en the dentist praises the child with specic, concrete examples of the cooperative behavior, such as sitting very still. Finally, the child is asked to demonstrate the behaviors again to satisfy the sense of accomplishment. Pickrell et al., in a study of 6- to 9-year-old behavior and the previously positive tenor of the appointment is reestablished. is reinforces the dentist as the coach who helps guide the patient to proper behavior.Voice control can be considered an aversive technique because parents may interpret this as punishing the child by “yelling at him or her.” is is not an accurate reection of the true intent of voice control. Human nature values the approval of others, and a change to a negative tone signals disapproval. erefore the benet of voice control may be the withdrawal of positive reinforce-ment as much as the introduction of an aversive technique. Others argue that voice control is still in the linguistic domain of behavior guidance and simply a way of rephrasing the previous request in a way that gets the patient’s attention.53 Although voice control can be eective at normal and reduced volume, Greenbaum and colleagues89 found that the loud voice was most eective at minimiz-ing disruptiveness. Furthermore, the children reported a more positive experience when loud voice control was used.89 Voice control may not be eective for a child who is constantly verbally chastised.Parents 69,78,90 and children74,91 may nd voice control objection-able, and parents should be informed of the possibility of its use before the appointment. One explanation might be “I would like to keep your child as safe as possible and provide the best quality dentistry. If your child begins behavior that will interfere with this and does not comply with requests, I will change my tone to sound more rm to get his attention, just like you would if he were about to do something that would hurt him.” Most parents will consent with proper explanation.71Positive Previsit ImageryPositive previsit imagery is a new technique added to the AAPD guidelines.1 is technique has its foundation in social learning theory and involves showing children positive images of dentistry prior to the visit.92 Two studies have shown that exposing children to positive images of dentistry significantly reduced anxiety compared to neutral pictures,92,93 while one other study failed to nd a signicant dierence.94Distress-Promoting Behavior Example AlternativeUninformative reassuring “Don’t worry, Billy. Everything will be okay.” “You are a brave boy! Going to the dentist will be easy for such a brave boy.”Giving control to the child when there really is not a choice“Are you ready to start now?” “It is time to get your teeth counted!”Apologizing “I’m sorry this is taking so long, honey.” Use distraction:“What do you want to do when we leave? Would you like to go to the park? I know the slide is your favorite!”Displaying empathy “I know it hurts.” Reframe it: “Let’s play a game! It’s called the tooth dance. Your tooth is going to wiggle, wiggle, wiggle—look, its dancing!”Making confusing statements “Bonnie, you can do anything but move.” Use clear directions:“Bonnie, keep your hands in your lap.”Making demands to the provider “Johnny does better if you give him choices. Don’t just tell him what to do.”“Don’t lie to my child; he knows he’s going to get a shot.”The parent may need to be a silent observer.Distress-Promoting Behaviors Often Employed by ParentsTABLE 24.3 CHAPTER 24 Behavior Guidance of the Pediatric Dental Patient 361 their fears, are taught relaxation techniques, and are gradually exposed to the situations that they identify. Studies in adult patients with small sample sizes show that this technique is eective long term in reducing dental fear.110,111 Case reports have described successful desensitization of adolescents with dental fear and patients with special health care needs.112,113Deferred TreatmentAn often overlooked alternative is to simply defer treatment. When behavior is an obstacle to safe, high-quality care, and treatment needs are not urgent, deferring treatment is an alternative to advanced behavior guidance.1 Treatment of patients with pain, infection, or advanced carious lesions should not be deferred, but care of small carious lesions, application of sealants, and space maintenance can often wait until patient cooperation improves. Parents must be aware that ideal treatment is being deferred because of patient behavior, and they must understand the potential consequences. ere must also be a designated plan of observation so that treatment can be implemented if the condition worsens. is is often termed “active surveillance.”Advanced Behavior Guidance TechniquesFor some children, basic behavior guidance is inadequate to permit safe, high-quality dental care. is may be due to the young age of the child, special health care needs, extreme deance, or fearful-ness. In these cases it is important to engage the parents to discuss risks, benets, and alternatives of advanced behavior guidance so that they can make an informed decision for their child.Protective StabilizationProtective stabilization is dened as “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.”114 It is used to decrease risk of injury during treat-ment and may be classied as either active or passive.115 In active stabilization, the parent, dentist, or assistant helps stabilize the patient; typically this is carried out only for a very short period of time or in times of unexpected, physically uncooperative behavior. is type of stabilization is less eective in preventing untoward movement and has been associated with more injuries compared with passive immobilization in adult patients with intellectual disability.116Passive protective stabilization is the use of a device to restrict patient movement for patient safety. Devices used commonly are Papoose Boards (Olympic Medical Corporation, Seattle, WA) or Rainbow Wraps (Specialized Care Co Inc., Hampton, NH), as shown in Fig. 24.4. ese devices have fabric wraps to help reduce the movement of arms and legs. Often this technique is employed when patient behavior unexpectedly deteriorates during an appoint-ment, and the appointment must be brought to a safe conclusion or in emergency settings.115 Protective stabilization may also be used during a sedation appointment to prevent untoward movements by the sedated child. e risks of protective stabilization are physical or psychological harm, loss of dignity, and violation of patient’s rights.117Protective stabilization is among the most controversial of behavior guidance techniques. Parents tend to rate both active and passive immobilization as unacceptable,69,70,73,118 and many pediatric dentists nd its use rarely acceptable for routine dental treatment.56 Parents did rank active immobilization more favorable if the dental assistant performed it or if it was performed by the dentist for the patients, found this technique improved child behavior and changed memories of fear.101Parental Presence/Absencee child’s desire for parental presence can become an important adjunct to behavior management. If a child is behaving poorly, then the dentist can request that the parent leave until the child becomes cooperative. is is an eective way to encourage com-munication for the child unwilling to interact with the dentist. For this technique to work properly, parents must be willing to comply when they are asked to leave, and parents should consent in advance to leave the operatory if asked. Parents may feel more comfortable with this is if they are told that they do not have to leave the room; moving just out of the line of vision of the child is sucient. When the child cooperates, the dentist should oer praise, and the parent should return promptly.Nitrous Oxidee use of nitrous oxide/oxygen (N2O/O2) is a form of pharma-cologic behavior management that is discussed in detail in Chapter 8. It has been found to have a signicant eect on reducing mild to moderately anxious and uncooperative child behavior, and does facilitate coping at subsequent visits, even if it is not used at those visits.102,103 It is important to understand that the use of N2O/O2 is only effective if accompanied by communicative behavior management techniques. N2O/O2 is used to improve the child’s ability to cope so that he or she is more receptive to techniques such as TSD, positive reinforcement, and distraction. e child must have some coping skills and an appropriate temperament to be receptive to nitrous oxide sedation. Nelson et al. found that children with high eortful control (the ability to inhibit negative reactions and focus on a task and persist even if it is dicult) were more successfully sedated with nitrous oxide.104 Generally N2O/O2 is readily accepted by parents.69,71Alternative Communicative TechniquesEscapeEscape gives children the ability to take a break from the demands of the dental visit. Typically escape is the cessation of activity in the mouth, not getting up from the chair. Two dierent types of escape have been discussed: contingent and noncontingent. Escape from unpleasant or undesirable events is one of the most common and powerful sources of motivation, and plays a major role in behavior management problems such as temper tantrums.105 Contingent escape is given when a patient complies with a request or exhibits cooperative behavior. One often used form of this is “If you can hold still until I count to 10, we can take a break.” Allen and associates106,107 have demonstrated success with this procedure in preschool-aged disruptive children. Advantages of this technique are its nonaversive nature, and it generally takes no more time than other behavior guidance techniques.106,107Noncontingent escape is given regardless of behavior; it is granted at a predetermined interval. Studies have shown similar improve-ments in behavior with contingent and noncontingent escape.108 Practically, noncontingent escape is dicult to carry out consistently, but the concept of breaks is very eective with children. If the handpiece is stopped for any reason, it can be rephrased as a break.DesensitizationDesensitization is exposure to fear-invoking stimuli in a progressive manner, beginning with the least disturbing.109 Patients self-identify