Oral Surgery in Children










CHAPTER 24 Behavior Guidance of the Pediatric Dental Patient 367
communication. For example, distraction techniques that limit
full visibility of surroundings, such as wraparound eyewear, may
be disconcerting for children with hearing impairment.
143
Protective stabilization is often used in the treatment of children
with special needs to prevent untoward movements. Some children
with cerebral palsy nd this comforting because it helps them
control their movements, but caution must be used to not forcefully
extend contracted limbs. Children with ASD have been reported
to nd more comfort and cooperation in the security and weight
of an immobilization device.
144
Parents of children with special
health care needs may be more accepting of medical immobilization
than parents of children without disabilities,
145
although one study
found few dierences between parents of disabled and fully abled
children in their acceptance of management techniques.
146
Parents
are more likely to be accepting of them if they have been used
in the past.
147
As with all children, the decision to use protective stabilization
must be carefully considered, and parents must have all the necessary
information to give informed consent. Pharmacologic management
should be used for uncooperative patients with extensive treatment
needs.
Conclusion
Sheller nicely summarizes the demands of dentistry for children
by stating that “the task of pediatric dentists is the same as it was
a generation ago: to perform precise surgical procedures on children
whose behavior may range from cooperative to hostile to deant.
49
Behavior guidance will remain the art of recognizing the complexities
of childrens and dentists’ temperaments, parental attitudes, and
varying treatment needs and creating an optimal treatment plan
to best address the child’s needs.
References
1. American Academy of Pediatric Dentistry. Guideline on behavior
guidance for the pediatric dental patient. Pediatr Dent. 2016;38(special
issue):185–198.
2. Piaget J. e stages of the intellectual development of the child.
Bull Menninger Clin. 1962;26:120–128.
3. Baghdadi ZD. Principles and application of learning theory in child
patient management. Quintessence Int. 2001;32(2):135–141.
4. Blum MJ, Williams GE, Friman PC, et al. Disciplining young
children: the role of verbal instructions and reasoning. Pediatrics.
1995;96(2):336–341.
5. American Academy of Pediatrics. Committee on Psychosocial
Aspects of child and family health: guidance for eective discipline.
Pediatrics. 1998;101(4):723–728. Rearmed July 2014.
6. omas A, Chess S, Birch H, et al. A longitudinal study of
primary reaction patterns in children. Compr Psychiatry. 1960;1:
103–112.
7. Chess S, omas A. Temperament. In: Lewis M, ed. Child and
Adolescent Psychiatry: A Comprehensive Textbook. 2nd ed. Philadelphia:
Lippincott Williams & Wilkins; 1996:170–181.
8. Aminabadi NP, Puralibaba F, Erfanparast L, et al. Impact of
temperament on child behavior in the dental setting. J Dent Res
Dent Clin Dent Prospects. 2011;5(4):119–122.
9. Arnrup K, Broberg AG, Berggren U, et al. Lack of cooperation in
pediatric dentistry—the role of child personality characteristics.
Pediatr Dent. 2002;24(2):119–129.
10. Arnrup K, Broberg AG, Berggren U, et al. Temperamental reactivity
and negative emotionality in uncooperative children referred to
specialized paediatric dentistry compared to children in ordinary
dental care. In J Paediatr Dent. 2007;17(6):419–429.
techniques in a new environment, and nitrous oxide can be a
helpful adjunct in retraining fearful patients.
Behavior Guidance for the Child With Special
Health Care Needs
Children with special health care needs require additional consid-
eration with behavior guidance. Children with special health care
needs have been excluded from a number of studies evaluating
nonpharmacologic behavior guidance, so evidence in this area is
lacking. Various sources report that predoctoral dental education
is inadequate to prepare dentists to treat patients with special
health care needs.
136,137
Dental fear assessment is challenging in this population, but
one study of adults with a range of cognitive, motor, psychologi-
cal, and medical conditions found that 42% had some level of
dental fear and also found caregivers accurately estimated fear.
138
A
question should be included on the medical history to gauge the
child’s development or education level to let the provider know
if intellectual disability is present. An interview with the primary
caregiver is the best way to predict cooperation, and questions
should include level of cognitive ability (i.e., milestones, grade level),
cooperation in medical settings, triggers for uncooperative behavior,
soothing strategies, adherence to schedule, current therapies, and
other benecial accommodations. When possible, the child should
also be asked about any concerns in the dental setting. Marshall et
al. found that in children with autism spectrum disorders (ASD),
cooperation for dental appointments was predicted by parental
report of toilet training, toothbrushing, haircuts, academic achieve-
ment, and language.
139
Dentists should communicate with children who have special
health care needs at a level appropriate for their cognitive develop-
ment. e dentist should not assume patients with conditions that
impair communication, such as cerebral palsy, are intellectually
disabled. Patients with ASD may be using applied behavior therapy
and may benet from a dental visit “social story” or picture book
that allows them to rehearse procedures in a developmentally
appropriate manner.
140
A sensory-adapted dental environment
that uses relaxing lights and music has been recommended for
children with developmental disabilities.
141
Children with balance
disorders such as Down syndrome may accept the chair more easily
if it is already reclined.
Communicative behavior guidance techniques should be used
with short, one-step instructions for patients with intellectual dis-
abilities (Box 24.4). Applied behavioral therapy using familiarization
and repetitive tasking has been successful in patients with autism.
142
Any physical disabilities should be considered in positioning and
Data from Harper DC, Wadsworth JS. A strategy to train health care professionals to communicate
with persons with mental retardation. Acad Med. 1991;66:495–496.
When an intellectually impaired patient wants to communicate with you:
• Useleveling.
• Removedistractions.
• Usedeclarativesentences.
• Useopen-endedquestions.
• Providecorrectivefeedback.
• Rephrasequestionsifneeded.
Communication With Patients Who Have
Intellectual Disabilities
BOX 24.4

368 Part 3 The Primary Dentition Years: Three to Six Years
35. Aminibadi NA, Deljavan AS, Jamali Z, et al. e inuence of
parenting style and child temperament on child parent dentist
interactions. Pediatr Dent. 2015;37(4):342–347.
36. Krikken JV, van Wijk AJ, ten Cate JM, et al. Child dental anxiety,
parental rearing style and referral status of children. Community
Dent Health. 2012;29(4):289–292.
37. Pinkham JR. Personality development: managing behavior of the coop-
erative preschool child. Dent Clin North Am. 1995;39(4):771–787.
38. Milgrom P, Weinstein P. Dental fears in general practice: new
guidelines for assessment and treatment. Int Dent J. 1993;43(3
suppl 1):288–293.
39. American Academy of Pediatrics, American Pain Society. e
assessment and management of acute pain in infants, children, and
adolescents. Pediatrics. 2001;108(3):793–797.
40. Milgrom P, Weinstein P, Golletz D, et al. Pain management in
school-aged children by private and public clinic practice dentists.
Pediatr Dent. 1994;16(4):294–300.
41. Feigal RJ. Guiding and managing the child dental patient: a fresh
look at old pedagogy. J Dent Educ. 2001;65(12):1369–1377.
42. Lara A, Crgo A, Romero-Maroto M. Emotional contagion of dental
fear to children: the fathers’ mediatring role in parental transfer of
fear. Int J Paediatr Dent. 2012;22(5):324–330.
43. Rouleau J, Ladouceur R, Dufour L. Pre-exposure to the rst dental
treatment. J Dent Res. 1981;60(1):30–34.
44. Feigal R. Pediatric behavior management through nonpharmacologic
methods. Gen Dent. 1995;43(4):327–332.
45. Brill WA. Comparison of the behavior of children undergoing
restorative dental treatment at the rst visit versus the second
visit in a private pediatric dental practice. J Clin Pediatr Dent.
2001;25(4):287–291.
46. Mistry D, Tahmassebi JF. Childrens and parents’ attitudes toward
dentists’ attire. Eur Arch Paediatr Dent. 2009;10(4):237–240.
47. Panda A, Garg I, Bhobe AP. Childrens perspective on the dentist’s
attire. Int J Paediatr Dent. 2014;24(2):98–103.
48. Davis R, McKibben DH, Nazif MM, et al. Child reaction to protec-
tive garb at the rst dental visit. Pediatr Dent. 1993;15(2):86–87.
49. Sheller B. Challenges of managing child behavior in the 21st century
dental setting. Pediatr Dent. 2004;26(2):111–113.
50. Buchanan H, Niven N. Validation of a Facial Image Scale to assess
child dental anxiety. Int J Paediatr Dent. 2002;12(1):47–52.
51. Quinonez R, Santos RG, Boyar R, et al. Temperament and trait
anxiety as predictors of child behavior prior to general anesthesia
for dental surgery. Pediatr Dent. 1997;19(6):427–431.
52. McTigue DJ, Pinkham J. Association between childrens dental
behavior and play behavior. ASDC J Dent Child. 1978;45(3):218–222.
53. Pinkham JR. Observation and interpretation of the child dental
patients’ behavior. Pediatr Dent. 1979;1(1):21–26.
54. Shro S, Hughes C, Mobley C. Attitudes and preferences of
parents about being present in the dental operatory. Pediatr Dent.
2015;37(1):51–55.
55. Peretz B, Zadik D. Attitudes of parents toward their presence in the
operatory during dental treatments to their children. J Clin Pediatr
Dent. 1998;23(1):27–30.
56. Wells M, McTigue D, Casamassimo P, et al. Gender shifts and
eects on behavior guidance. Pediatr Dent. 2014;36(2):102–108.
57. Venham LL, Bengston D, Cipes M. Parents presence and the child’s
response to dental stress. ASDC J Dent Child. 1978;45(3):213–217.
58. Pfeerle JC, Machen JB, Fields HW, et al. Child behavior in
the dental setting relative to parental presence. Pediatr Dent.
1982;4:311–316.
59. Cox IC, Krikken JB, Veerkamp JS. Inuence of parental presence
on the child’s perception of, and behavior during dental treatment.
Eur Arch Paediatr Dent. 2011;12(4):200–204.
60. Vasiliki B, Konstantinos A, Vassilis K, et al. e eect of parental
presence on the child’s perception and co-operation during dental
treatment. Eur Arch Paediatr Dent. 2016;17(5):381–386.
61. Pani SC, AlAnazi GS, AlBaragash A, et al. Objective assessment of
the inuence of the parental presence on the fear and behavior of
11. Hodgins MJ, Lander J. Childrens coping with venipuncture. J Pain
Symptom Manage. 1997;13(5):274–285.
12. Curry SL, Russ SW, Johnsen DC, et al. e role of coping in childrens
adjustment to the dental visit. J Dent Child. 1988;55(3):231–236.
13. Shahnavaz S, Rutley S, Larsson K, et al. Children and parents
experiences of cognitive behavioral therapy for dental anxiety—a
qualitative study. Int J Paediatr Dent. 2015;25(5):317–326.
14. Klingberg G, Broberg AG. Dental fear/anxiety and dental behaviour
management problems in children and adolescents: a review of
prevalence and concomitant psychological factors. Int J Paediatr
Dent. 2007;17(6):391–406.
15. Taylor MH, Moyer IN, Peterson DS. Eect of appointment time,
age, and gender on childrens behavior in a dental setting. ASDC J
Dent Child. 1983;50(2):106–110.
16. Holst A, Crossner C. Direct ratings of acceptance of dental
treatment in Swedish children. Community Dent Oral Epidemiol.
1987;15(5):258–263.
17. Baier K, Milgrom P, Russell S, et al. Childrens fear and
behavior in private pediatric dentistry practices. Pediatr Dent.
2004;26(4):316–321.
18. Cuthbert MI, Melamed BG. A screening device: children at risk
for dental fears and management problems. ASDC J Dent Child.
1982;49(6):432–436.
19. Dogan MC, Seydaoglu G, Uguz S, et al. e eect of age, gender,
and socio-economic factors on perceived dental anxiety deter-
mined by a modied scale in children. Oral Health Prev Dent.
2006;4(4):235–241.
20. Majstorovic M, Veerkamp JS. Relationship between needle
phobia and dental anxiety. J Dent Child (Chic). 2004;71(3):201–205.
21. Tickle M, Jones C, Buchannan K, et al. A prospective study of
dental anxiety in a cohort of children followed from 5 to 9 years
of age. Int J Paediatr Dent. 2009;19(4):225–232.
22. Corkey B, Freeman R. Predictors of dental anxiety in six-year-
old children: ndings from a pilot study. ASDC J Dent Child.
1994;61(4):267–271.
23. Bedi R, Sutclie P, Donnan PT, et al. e prevalence of dental
anxiety in a group of 13- and- 14-year old Scottish children. Int J
Paediatr Dent. 1992;2(1):17–24.
24. Peretz B, Efrat J. Dental anxiety among young adolescent patients
in Israel. Int J Paediatr Dent. 2000;10(2):126–132.
25. Majstorovic M, Morse DE, Do D, et al. Indicators of dental
anxiety in children just prior to treatment. J Clin Pediatr Dent.
2014;39(1):12–17.
26. Torriani DD, Ferro RL, Bonow MLM, et al. Dental caries is associated
with dental fear in childhood: ndings from a birth cohort study.
Caries Res. 2014;48:263–270.
27. Winer GA. A review and analysis of childrens fearful behavior in
dental settings. Child Dev. 1982;43:1111–1133.
28. Shonkof JP, Garner AS, Committee on Psychosocial Aspects of
Child and Family Health; Committee on early Childhood Adoption
and Dependent Care; Section on Developmental and Behavioral
Pediatrics. e lifelong eects of early childhood adversity and toxic
stress. Pediatrics. 2012;129(1):e.232–e.246.
29. Boyce WT. e lifelong eects of early childhood adversity and
toxic stress. Pediatr Dent. 2014;36(2):102–108.
30. Vignehsa H, Chellappah NK, Milgrom P, et al. A clinical evaluation
of high- and low-fear children in Singapore. ASDC J Dent Child.
1990;57(3):224–228.
31. Folayan MO, Idehen EE, Ojo OO. e modulating eect of culture
on the expression of dental anxiety in children: a literature review.
Int J Paediatr Dent. 2004;14(4):241–245.
32. Baumrind D. Current patterns of parental authority. Dev Psychol
Monogr. 1971;4:1–103.
33. Robinson C, Mandleco B, Olsen SF, et al. e parenting styles
and dimensions questionnaire (PSDQ). Handb Fam Meas Tech.
2001;3:319–321.
34. Howenstein J, Kumar A, Casamassimo PS, et al. Correlating parenting
styles with child behavior and careis. Pediatr Dent. 2015;37(1):59–64.

You're Reading a Preview

Become a DentistryKey membership for Full access and enjoy Unlimited articles

Become membership

If you are a member. Log in here

Was this article helpful?

CHAPTER 24 Behavior Guidance of the Pediatric Dental Patient 367 communication. For example, distraction techniques that limit full visibility of surroundings, such as wraparound eyewear, may be disconcerting for children with hearing impairment.143Protective stabilization is often used in the treatment of children with special needs to prevent untoward movements. Some children with cerebral palsy nd this comforting because it helps them control their movements, but caution must be used to not forcefully extend contracted limbs. Children with ASD have been reported to nd more comfort and cooperation in the security and weight of an immobilization device.144 Parents of children with special health care needs may be more accepting of medical immobilization than parents of children without disabilities,145 although one study found few dierences between parents of disabled and fully abled children in their acceptance of management techniques.146 Parents are more likely to be accepting of them if they have been used in the past.147As with all children, the decision to use protective stabilization must be carefully considered, and parents must have all the necessary information to give informed consent. Pharmacologic management should be used for uncooperative patients with extensive treatment needs.ConclusionSheller nicely summarizes the demands of dentistry for children by stating that “the task of pediatric dentists is the same as it was a generation ago: to perform precise surgical procedures on children whose behavior may range from cooperative to hostile to deant.”49 Behavior guidance will remain the art of recognizing the complexities of children’s and dentists’ temperaments, parental attitudes, and varying treatment needs and creating an optimal treatment plan to best address the child’s needs.References1. American Academy of Pediatric Dentistry. Guideline on behavior guidance for the pediatric dental patient. Pediatr Dent. 2016;38(special issue):185–198.2. Piaget J. e stages of the intellectual development of the child. Bull Menninger Clin. 1962;26:120–128.3. Baghdadi ZD. Principles and application of learning theory in child patient management. Quintessence Int. 2001;32(2):135–141.4. Blum MJ, Williams GE, Friman PC, et al. Disciplining young children: the role of verbal instructions and reasoning. Pediatrics. 1995;96(2):336–341.5. American Academy of Pediatrics. Committee on Psychosocial Aspects of child and family health: guidance for eective discipline. Pediatrics. 1998;101(4):723–728. Rearmed July 2014.6. omas A, Chess S, Birch H, et al. A longitudinal study of primary reaction patterns in children. Compr Psychiatry. 1960;1: 103–112.7. Chess S, omas A. Temperament. In: Lewis M, ed. Child and Adolescent Psychiatry: A Comprehensive Textbook. 2nd ed. Philadelphia: Lippincott Williams & Wilkins; 1996:170–181.8. Aminabadi NP, Puralibaba F, Erfanparast L, et al. Impact of temperament on child behavior in the dental setting. J Dent Res Dent Clin Dent Prospects. 2011;5(4):119–122.9. Arnrup K, Broberg AG, Berggren U, et al. Lack of cooperation in pediatric dentistry—the role of child personality characteristics. Pediatr Dent. 2002;24(2):119–129.10. Arnrup K, Broberg AG, Berggren U, et al. Temperamental reactivity and negative emotionality in uncooperative children referred to specialized paediatric dentistry compared to children in ordinary dental care. In J Paediatr Dent. 2007;17(6):419–429.techniques in a new environment, and nitrous oxide can be a helpful adjunct in retraining fearful patients.Behavior Guidance for the Child With Special Health Care NeedsChildren with special health care needs require additional consid-eration with behavior guidance. Children with special health care needs have been excluded from a number of studies evaluating nonpharmacologic behavior guidance, so evidence in this area is lacking. Various sources report that predoctoral dental education is inadequate to prepare dentists to treat patients with special health care needs.136,137Dental fear assessment is challenging in this population, but one study of adults with a range of cognitive, motor, psychologi-cal, and medical conditions found that 42% had some level of dental fear and also found caregivers accurately estimated fear.138 A question should be included on the medical history to gauge the child’s development or education level to let the provider know if intellectual disability is present. An interview with the primary caregiver is the best way to predict cooperation, and questions should include level of cognitive ability (i.e., milestones, grade level), cooperation in medical settings, triggers for uncooperative behavior, soothing strategies, adherence to schedule, current therapies, and other benecial accommodations. When possible, the child should also be asked about any concerns in the dental setting. Marshall et al. found that in children with autism spectrum disorders (ASD), cooperation for dental appointments was predicted by parental report of toilet training, toothbrushing, haircuts, academic achieve-ment, and language.139Dentists should communicate with children who have special health care needs at a level appropriate for their cognitive develop-ment. e dentist should not assume patients with conditions that impair communication, such as cerebral palsy, are intellectually disabled. Patients with ASD may be using applied behavior therapy and may benet from a dental visit “social story” or picture book that allows them to rehearse procedures in a developmentally appropriate manner.140 A sensory-adapted dental environment that uses relaxing lights and music has been recommended for children with developmental disabilities.141 Children with balance disorders such as Down syndrome may accept the chair more easily if it is already reclined.Communicative behavior guidance techniques should be used with short, one-step instructions for patients with intellectual dis-abilities (Box 24.4). Applied behavioral therapy using familiarization and repetitive tasking has been successful in patients with autism.142 Any physical disabilities should be considered in positioning and Data from Harper DC, Wadsworth JS. A strategy to train health care professionals to communicate with persons with mental retardation. Acad Med. 1991;66:495–496.When an intellectually impaired patient wants to communicate with you:• Useleveling.• Removedistractions.• Usedeclarativesentences.• Useopen-endedquestions.• Providecorrectivefeedback.• Rephrasequestionsifneeded.Communication With Patients Who Have Intellectual Disabilities• BOX 24.4 368 Part 3 The Primary Dentition Years: Three to Six Years35. Aminibadi NA, Deljavan AS, Jamali Z, et al. e inuence of parenting style and child temperament on child parent dentist interactions. Pediatr Dent. 2015;37(4):342–347.36. Krikken JV, van Wijk AJ, ten Cate JM, et al. Child dental anxiety, parental rearing style and referral status of children. Community Dent Health. 2012;29(4):289–292.37. Pinkham JR. Personality development: managing behavior of the coop-erative preschool child. Dent Clin North Am. 1995;39(4):771–787.38. Milgrom P, Weinstein P. Dental fears in general practice: new guidelines for assessment and treatment. Int Dent J. 1993;43(3 suppl 1):288–293.39. American Academy of Pediatrics, American Pain Society. e assessment and management of acute pain in infants, children, and adolescents. Pediatrics. 2001;108(3):793–797.40. Milgrom P, Weinstein P, Golletz D, et al. Pain management in school-aged children by private and public clinic practice dentists. Pediatr Dent. 1994;16(4):294–300.41. Feigal RJ. Guiding and managing the child dental patient: a fresh look at old pedagogy. J Dent Educ. 2001;65(12):1369–1377.42. Lara A, Crgo A, Romero-Maroto M. Emotional contagion of dental fear to children: the fathers’ mediatring role in parental transfer of fear. Int J Paediatr Dent. 2012;22(5):324–330.43. Rouleau J, Ladouceur R, Dufour L. Pre-exposure to the rst dental treatment. J Dent Res. 1981;60(1):30–34.44. Feigal R. Pediatric behavior management through nonpharmacologic methods. Gen Dent. 1995;43(4):327–332.45. Brill WA. Comparison of the behavior of children undergoing restorative dental treatment at the rst visit versus the second visit in a private pediatric dental practice. J Clin Pediatr Dent. 2001;25(4):287–291.46. Mistry D, Tahmassebi JF. Children’s and parents’ attitudes toward dentists’ attire. Eur Arch Paediatr Dent. 2009;10(4):237–240.47. Panda A, Garg I, Bhobe AP. Children’s perspective on the dentist’s attire. Int J Paediatr Dent. 2014;24(2):98–103.48. Davis R, McKibben DH, Nazif MM, et al. Child reaction to protec-tive garb at the rst dental visit. Pediatr Dent. 1993;15(2):86–87.49. Sheller B. Challenges of managing child behavior in the 21st century dental setting. Pediatr Dent. 2004;26(2):111–113.50. Buchanan H, Niven N. Validation of a Facial Image Scale to assess child dental anxiety. Int J Paediatr Dent. 2002;12(1):47–52.51. Quinonez R, Santos RG, Boyar R, et al. Temperament and trait anxiety as predictors of child behavior prior to general anesthesia for dental surgery. Pediatr Dent. 1997;19(6):427–431.52. McTigue DJ, Pinkham J. Association between children’s dental behavior and play behavior. ASDC J Dent Child. 1978;45(3):218–222.53. Pinkham JR. Observation and interpretation of the child dental patients’ behavior. Pediatr Dent. 1979;1(1):21–26.54. Shro S, Hughes C, Mobley C. Attitudes and preferences of parents about being present in the dental operatory. Pediatr Dent. 2015;37(1):51–55.55. Peretz B, Zadik D. Attitudes of parents toward their presence in the operatory during dental treatments to their children. J Clin Pediatr Dent. 1998;23(1):27–30.56. Wells M, McTigue D, Casamassimo P, et al. Gender shifts and eects on behavior guidance. Pediatr Dent. 2014;36(2):102–108.57. Venham LL, Bengston D, Cipes M. Parent’s presence and the child’s response to dental stress. ASDC J Dent Child. 1978;45(3):213–217.58. Pfeerle JC, Machen JB, Fields HW, et al. Child behavior in the dental setting relative to parental presence. Pediatr Dent. 1982;4:311–316.59. Cox IC, Krikken JB, Veerkamp JS. Inuence of parental presence on the child’s perception of, and behavior during dental treatment. Eur Arch Paediatr Dent. 2011;12(4):200–204.60. Vasiliki B, Konstantinos A, Vassilis K, et al. e eect of parental presence on the child’s perception and co-operation during dental treatment. Eur Arch Paediatr Dent. 2016;17(5):381–386.61. Pani SC, AlAnazi GS, AlBaragash A, et al. Objective assessment of the inuence of the parental presence on the fear and behavior of 11. Hodgins MJ, Lander J. Children’s coping with venipuncture. J Pain Symptom Manage. 1997;13(5):274–285.12. Curry SL, Russ SW, Johnsen DC, et al. e role of coping in children’s adjustment to the dental visit. J Dent Child. 1988;55(3):231–236.13. Shahnavaz S, Rutley S, Larsson K, et al. Children and parents’ experiences of cognitive behavioral therapy for dental anxiety—a qualitative study. Int J Paediatr Dent. 2015;25(5):317–326.14. Klingberg G, Broberg AG. Dental fear/anxiety and dental behaviour management problems in children and adolescents: a review of prevalence and concomitant psychological factors. Int J Paediatr Dent. 2007;17(6):391–406.15. Taylor MH, Moyer IN, Peterson DS. Eect of appointment time, age, and gender on children’s behavior in a dental setting. ASDC J Dent Child. 1983;50(2):106–110.16. Holst A, Crossner C. Direct ratings of acceptance of dental treatment in Swedish children. Community Dent Oral Epidemiol. 1987;15(5):258–263.17. Baier K, Milgrom P, Russell S, et al. Children’s fear and behavior in private pediatric dentistry practices. Pediatr Dent. 2004;26(4):316–321.18. Cuthbert MI, Melamed BG. A screening device: children at risk for dental fears and management problems. ASDC J Dent Child. 1982;49(6):432–436.19. Dogan MC, Seydaoglu G, Uguz S, et al. e eect of age, gender, and socio-economic factors on perceived dental anxiety deter-mined by a modied scale in children. Oral Health Prev Dent. 2006;4(4):235–241.20. Majstorovic M, Veerkamp JS. Relationship between needle phobia and dental anxiety. J Dent Child (Chic). 2004;71(3):201–205.21. Tickle M, Jones C, Buchannan K, et al. A prospective study of dental anxiety in a cohort of children followed from 5 to 9 years of age. Int J Paediatr Dent. 2009;19(4):225–232.22. Corkey B, Freeman R. Predictors of dental anxiety in six-year-old children: ndings from a pilot study. ASDC J Dent Child. 1994;61(4):267–271.23. Bedi R, Sutclie P, Donnan PT, et al. e prevalence of dental anxiety in a group of 13- and- 14-year old Scottish children. Int J Paediatr Dent. 1992;2(1):17–24.24. Peretz B, Efrat J. Dental anxiety among young adolescent patients in Israel. Int J Paediatr Dent. 2000;10(2):126–132.25. Majstorovic M, Morse DE, Do D, et al. Indicators of dental anxiety in children just prior to treatment. J Clin Pediatr Dent. 2014;39(1):12–17.26. Torriani DD, Ferro RL, Bonow MLM, et al. Dental caries is associated with dental fear in childhood: ndings from a birth cohort study. Caries Res. 2014;48:263–270.27. Winer GA. A review and analysis of children’s fearful behavior in dental settings. Child Dev. 1982;43:1111–1133.28. Shonkof JP, Garner AS, Committee on Psychosocial Aspects of Child and Family Health; Committee on early Childhood Adoption and Dependent Care; Section on Developmental and Behavioral Pediatrics. e lifelong eects of early childhood adversity and toxic stress. Pediatrics. 2012;129(1):e.232–e.246.29. Boyce WT. e lifelong eects of early childhood adversity and toxic stress. Pediatr Dent. 2014;36(2):102–108.30. Vignehsa H, Chellappah NK, Milgrom P, et al. A clinical evaluation of high- and low-fear children in Singapore. ASDC J Dent Child. 1990;57(3):224–228.31. Folayan MO, Idehen EE, Ojo OO. e modulating eect of culture on the expression of dental anxiety in children: a literature review. Int J Paediatr Dent. 2004;14(4):241–245.32. Baumrind D. Current patterns of parental authority. Dev Psychol Monogr. 1971;4:1–103.33. Robinson C, Mandleco B, Olsen SF, et al. e parenting styles and dimensions questionnaire (PSDQ). Handb Fam Meas Tech. 2001;3:319–321.34. Howenstein J, Kumar A, Casamassimo PS, et al. Correlating parenting styles with child behavior and careis. Pediatr Dent. 2015;37(1):59–64. CHAPTER 24 Behavior Guidance of the Pediatric Dental Patient 369 85. Hoge MA, Howard MR, Wallace DP, et al. Use of video eyewear to manage distress in children during restorative dental treatment. Pediatr Dent. 2012;34(5):378–382.86. Ram D, Shapira J, Holan G, et al. Audiovisual video eyeglass distraction during dental treatment in children. Quintessence Int. 2010;41(8):673–679.87. El-Sharkawi HF, El-Housseiny AA, Aly AM. Eectiveness of new distraction technique on pain associated with injection of local anesthesia for children. Pediatr Dent. 2012;34(2):e35–e38.88. Pinkham JR, Paterson JR. Voice control: an old technique re-examined. J Dent Child. 1985;52:199–202.89. Greenbaum PE, Turner C, Cook EW 3rd, et al. Dentist’s voice control: eects on children’s disruptive and aective behavior. Health Psychol. 1990;9(5):546–558.90. Boka V, Arapostathis K, Vretos N, et al. Parental acceptance of behaviour-management techniques used in paediatric dentistry and its relation to parental dental anxiety and experience. Eur Arch Paediatr Dent. 2014;15(5):333–339.91. Kantaputra PN, Chiewcharnvalijkit K, Wairatpanich K, et al. Children’s attitudes toward behavior management techniques used by dentists. J Dent Child (Chic). 2007;74(1):4–9.92. Fox C, Newton JT. A controlled trial of the impact of exposure to positive images of dentistry on anticipatory dental fear in children. Community Dent Oral Epidemiol. 2006;34(6):455–459.93. Gangwal RR, Rameshchandra Badjatia S, Harish Dave B. Eect of exposure to positive images of dentistry on dental anxiety among 7 to 12 years old children. Int J Clin Pediatr Dent. 2014;7(3):176–179.94. Ramos-Jorge ML, Ramos-Jorge J, Vieira de Andrade RG, et al. Impact of exposure to positive images on dental anxiety among children: a controlled trial. Eur Arch Paediatr Dent. 2011;12(4):195–199.95. Greenbaum PE, Melamed BG. Pretreatment modeling. A technique for reducing children’s fear in the dental operatory. Dent Clin North Am. 1988;32(4):693–704.96. Melamed BG, Weinstein D, Katin-Borland M, et al. Reduction of fear-related dental management problems with use of lmed modeling. J Am Dent Assoc. 1975;90(4):822–826.97. Melamed BG, Hawes RR, Heiby E, et al. Use of lmed modeling to reduce uncooperative behavior of children during dental treatment. J Dent Res. 1975;54(4):797–801.98. Paryab M, Arab Z. e eect of Filmed modeling on the anxious and cooperative behavior of 4-6 years old children during dental treatment: a randomized clinical trial study. Dent Res J (Isfahan). 2014;11(4):502–507.99. Farhat-McHayleh N, Harfouche A, Souaid P. Techniques for managing behaviour in pediatric dentistry: comparative study of live modelling and tell-show-do based on children’s heart rates during treatment. J Can Dent Assoc. 2009;75(4):283.100. von Baeyer CL, Marche TA, Rocha EM, et al. Children’s memory for pain: overview and implications for practice. J Pain. 2004;5(5):241–249.101. Pickrell JE, Heima M, Weinstein P, et al. Using memory restructur-ing strategy to enhance dental behaviour. Int J Paediatr Dent. 2007;17(6):439–448.102. Nathan JE, Venham LL, Stewart M, et al. e eects of nitrous oxide on anxious young pediatric patients across sequential visits: a double-blind study. ASDC J Dent. 1988;55(3):220–230.103. Veerkamp JS, Gruythusen RJ, Hoogstraten J, et al. Anxiety reduction with nitrous oxide: a permanent solution? ASDC J Dent Child. 1995;62(1):44–48.104. Nelson TM, Grith TM, Lane KJ, et al. Temperament as a predictor of nitrous oxide inhalation sedation success. Anesth Prog. 2017;64(1):17–21.105. Kuhn BR, Allen KD. Expanding child behavior management technology in pediatric dentistry: a behavioral science perspective. Pediatr Dent. 1994;16(1):13–17.106. Allen KD, Loiben T, Allen SJ, et al. Dentist-implemented contingent escape for management of disruptive child behavior. J Appl Behav Anal. 1992;25(3):629–636.anxious children during their rst restorative dental visit. J Int Soc Prev Community Dent. 2016;6(suppl 2):S148–S152.62. Salmon K, Pereira JK. Predicting children’s response to an invasive medical investigation: the inuence of eortful control and parent behavior. J Pediatr Psychol. 2002;27(3):227–233.63. Jain C, Mathu-Muju KR, Nash DA, et al. Randomized controlled trial: parental compliance with instructions to remain silent in the dental operatory. Pediatr Dent. 2013;35(1):47–51.64. Brill WA. e eect of restorative treatment on children’s behavior at the rst recall visit in a private pediatric dental practice. J Clin Pediatr Dent. 2002;26(4):389–393.65. Chambers DW. Behavior management techniques for pediat-ric dentists: an embarrassment of riches. ASDC J Dent Child. 1977;44(1):30–34.66. Jones RN, Sloane HN, Roberts MW. Limitations of “don’t” instructional control. Behav er. 1992;23:131–140.67. Harper DC, D’Alessandro DM. e child’s voice: understand-ing the contexts of children and families today. Pediatr Dent. 2004;26(2):114–120.68. Brosnan MG, Curzon ME, Fayle S. e use of the local analgesia syringe in children. Should it be kept out of sight? A clinical trial of two methods of presentation. Eur J Paediatr Dent. 2002;3(2):68–72.69. Eaton JJ, McTigue DJ, Fields HW, et al. Attitudes of contemporary parents toward behavior management techniques used in pediatric dentistry. Pediatr Dent. 2005;27(2):107–113.70. Fields HW, Machen JB, Murphy MG. Acceptability of various behavior management techniques relative to types of dental treatment. Pediatr Dent. 1984;6(4):199–203.71. Havelka C, McTigue D, Wilson S, et al. e inuence of social status and prior explanation on parental attitudes toward behavior management techniques. Pediatr Dent. 1992;14(6):376–381.72. Lawrence SM, McTigue DJ, Wilson S, et al. Parental attitudes toward behavior management techniques used in pediatric dentistry. Pediatr Dent. 1991;13(3):151–155.73. Scott S, Garcia-Godoy F. Attitudes of Hispanic parents toward behavior management techniques. ASDC J Dent Child. 1995;65(2):128–131.74. Davies EB, Buchanan H. An exploratory study investigating children’s perceptions of dental behavioural management techniques. Int J Paediatr Dent. 2013;23:297–309.75. Hamzah HS, Gao X, Yiu CKY, et al. Managing dental fear and anxiety in pediatric patients: a qualitative study from the public’s perspective. Pediatr Dent. 2014;36(1):29–33.76. Greenbaum PE, Lumley MA, Turner C, et al. Dentist’s reassuring touch: eects on children’s behavior. Pediatr Dent. 1993;15(1):20–24.77. Wilson S, Flood T, Kramer N, et al. A study of facially expressed emotions as a function of age, exposure time, and sex in children. Pediatr Dent. 1990;12(1):28–32.78. Peretz B, Karouba J, Blumer S. Pattern of parental acceptance of management techniques used in pediatric dentistry. J Clin Pediatr Dent. 2013;38(1):27–30.79. Uman LS, Birnie KA, Noel M, et al. Psychological interventions for needle-related procedural pain and distress in children and adolescents. Cochrane Database Syst Rev. 2013;(10):CD005179.80. Manimala MR, Blount RL. e eects of parental reassurance versus distraction on child distress and coping during immunizations. Child Health Care. 2000;29(3):161–177.81. Stark LJ, Allen KD, Hurst M, et al. Distraction: its utilization and ecacy with children undergoing dental treatment. J Appl Behav Anal. 1989;22(3):297–307.82. Dahlquist LM, Busby SM, Slifer KJ, et al. Distraction for children of dierent ages who undergo repeated needle sticks. J Pediatr Oncol Nurs. 2002;19(1):22–34.83. Aitken JC, Wilson S, Coury D, et al. e eect of music distraction on pain, anxiety, and behavior in pediatric dental patients. Pediatr Dent. 2002;24(2):114–118.84. Venham LL, Goldstein M, Goulin-Kremer E, et al. Eectiveness of a distraction technique in managing young dental patients. Pediatr Dent. 1981;3(1):7–11. 370 Part 3 The Primary Dentition Years: Three to Six Years129. Allen KD, Hodges ED, Knudsen SK. Comparing four methods to inform parents about child behavior management: how to inform for consent. Pediatr Dent. 1995;17(3):180–186.130. Seale NS. Behavior Management Conference Panel III Report—legal issues associated with managing children’s behavior in the dental oce. Pediatr Dent. 2004;26(2):175–179.131. Bross DC. Managing pediatric dental patients: issues raised by the law and changing views of proper child care. Pediatr Dent. 2004;26(2):125–130.132. Musselman RJ. Considerations in behavior management of the pediatric dental patient. Helping children cope with dental treatment. Pediatr Clin North Am. 1991;38(5):1309–1324.133. Nash DA. Engaging children’s cooperation in the dental environ-ment through eective communication. Pediatr Dent. 2006;28(5): 455–459.134. Wright GZ, Kupietzky A. Non-pharmacologic approaches in behavior management. In: Wright GZ, Kupietzky A, eds. Behavior Management in Dentistry for Children. 2nd ed. Ames, IA: John Wiley & Sons; 2014:81.135. Barton DH, Hatcher E, Potter R, et al. Dental attitudes and memories: a study of the eects of hand over mouth/restraint. Pediatr Dent. 1993;15(1):13–19.136. Weil TN, Inglehart MR. Dental education and dentists’ attitudes and behavior concerning patients with autism. J Dent Educ. 2010;74(12):1294–1307.137. Rutkauskas J, Seale NS, Casamassimo P, et al. Preparedness of entering pediatric dentistry residents: advanced pediatric program directors’ and rst-year residents’ perspectives. J Dent Educ. 2015;79(11):1265–1271.138. Martin MD, Kinoshita-Byrne J, Getz T. Dental fear in a special needs clinic population of persons with disabilities. Spec Care Dentist. 2002;22(3):99–102.139. Marshall J, Sheller B, Williams BJ, et al. Cooperation predic-tors for dental patients with autism. Pediatr Dent. 2007;29(5): 369–376.140. Charles JM. Dental care in children with developmental disabilities: attention decit disorder, intellectual disabilities, and autism. J Dent Child. 2010;77:84–91.141. Shapiro M, Melmed RN, Sgan-Cohen HD, et al. Eect of sensory adaptation on anxiety of children with developmental disabilities: a new approach. Pediatr Dent. 2009;31(3):222–228.142. Al Humaid J, Tesini D, Finkelman M, et al. Eectiveness of the D-TERMINED program of repetitive tasking for children with autism spectrum disorder. J Dent Child. 2016;83(1): 16–21.143. Fakruddin KS, Gorduysus MO, El Batawi H. Eectiveness of behavioral modication techniques with visual distraction using intrasulcular local anesthesia in hearing disabled children during pulp therapy. Eur J Dent. 2016;10(4):551–555.144. Romer M. Consent, restraint, and people with special needs: a review. Spec Care Dent. 2009;29(1):58–66.145. De Castro AM, de Oliveira FS, de Paiva Novaes MS, et al. Behavior guidance techniques in Pediatric Dentistry: attitudes of parents of children with disabilities and without disabilities. Spec Care Dentist. 2013;33(5):213–217.146. Brandes DA, Wilson S, Preisch JW, et al. A Comparison of opinions from parents of disabled and non-disabled children on behavior management techniques used in dentistry. Spec Care Dentist. 1995;15(3):119–123.147. Marshall J, Sheller B, Mancl L, et al. Parental attitudes regarding behavior guidance of dental patients with autism. Pediatr Dent. 2008;30(5):400–407.148. Murphy MG, Fields HW, Machen JB. Parental acceptance of pediatric dentistry behavior management techniques. Pediatr Dent. 1984;6:193–198.107. Allen KD, Stokes TF. Use of escape and reward in the management of young children during dental treatment. J Appl Behav Anal. 1987;20(4):381–390.108. O’Callaghan PM, Allen KD, Powell S, et al. e ecacy of noncontingent escape for decreasing children’s disruptive behavior during restorative dental treatment. J Appl Behav Anal. 2006;39(2): 161–171.109. Wolpe J. Reciprocal inhibition as the main basis of psychotherapeutic eects. AMA Arch Neurol Psychiatry. 1954;72(2):205–226.110. Hakeberg M, Berggren U, Carlsson SG. A 10-year follow-up of patients treated for dental fear. Scand J Dent Res. 1990;98(1):53–59.111. Coldwell SE, Getz T, Milgrom P, et al. CARL: a LabVIEW 3 computer program for conducting exposure therapy for the treatment of dental injection fear. Behav Res er. 1998;36(4): 429–441.112. Levitt J, Mcgoldrick P, Evans D. e management of severe dental phobia in an adolescent boy: a case report. Int J Paediatr Dent. 2000;10(4):348–353.113. Fetner M, Cascio CJ, Essick G. Nonverbal patient with autism spec-trum disorder and obstructive sleep apnea: use of desensitization to acclimatize to a dental appliance. Pediatr Dent. 2014;36(7):499–501.114. Oce of the Federal Register. Code of Federal Regulations. 42 Public Health, 482.13. 2010.115. American Academy of Pediatric Dentistry. Guideline on protective sta-bilization for pediatric dental patients. Pediatr Dent. 2016;38(special issue):199–203.116. Spreat S, Lipinski D, Hill J, et al. Safety indices associated with the use of contingent restraint procedures. Appl Res Ment Retard. 1986;7(4):475–481.117. Nunn J, Foster M, Master S, et al. British Society of Paediatric Dentistry: a policy document on consent and the use of physical intervention in the dental care of children. Int J Paediatr Dent. 2008;18(suppl 1):39–46.118. Patel M, McTigue DJ, ikkurissy S, et al. Parental attitudes toward advanced behavior guidance techniques used in pediatric dentistry. Pediatr Dent. 2016;38(1):30–36.119. Frankel RI. e Papoose Board and mothers’ attitudes following its use. Pediatr Dent. 1991;13(5):284–288.120. McComb M, Koenigsberg SR, Broder HL, et al. e eects of oral conscious sedation on future behavior and anxiety in pediatric dental patients. Pediatr Dent. 2002;24(3):207–211.121. Fuhrer CT 3rd, Weddell JA, Sanders BJ, et al. Eect of behavior of dental treatment rendered under conscious sedation and general anesthesia in pediatric patients. Pediatr Dent. 2009;31(7):492–497.122. Klaassen MA, Veerkamp JS, Hoogstraten J. Changes in children’s dental fear: a longitudinal study. Eur Arch Paediatr Dent. 2008;9(suppl 1):29–35.123. White J, Wells M, Arheart KL, et al. A questionnaire of parental perceptions of conscious sedation in pediatric dentistry. Pediatr Dent. 2016;38(2):116–121.124. Frankl SN, Shiere FR, Fogels HR. Should the parent remain with the child in the dental operatory? ASDC J Dent Child. 1962;29(2):150–163.125. Long N. e changing nature of parenting in America. Pediatr Dent. 2004;26(2):121–124.126. Adair SM, Waller JL, Schafer TE, et al. A survey of members of the American Academy of Pediatric Dentistry on their use of behavior management techniques. Pediatr Dent. 2004;26(2):150–166.127. Casamassimo PS, Wilson S, Gross L. Eects of changing U.S. parent-ing styles on dental practice: perceptions of diplomats of the American Board of Pediatric Dentistry. Pediatr Dent. 2002;24(1):18–22.128. Pediatric Oral Health Research and Policy Center. An essential health benet: general anesthesia for treatment of early childhood caries. http://www.aapd.org/assets/1/7/POHRPCTechBrief2.pdf. Accessed April 21, 2016. CHAPTER 24 Behavior Guidance of the Pediatric Dental Patient 370.e1 Case Study: Protective StabilizationPaul AndrewsMaria, a 6-year-old girl, is coming to see you for an initial appointment. Her parents heard from her neighbors that you are good with children. Maria has a history of well-controlled insulin-dependent diabetes mellitus. The pediatrician also informed them that she was born with a patent ductus arteriosus that closed at age 2 years. She had her tonsils and adenoids removed a year ago without incident. Maria is otherwise in good health and participates fully in all activities.Her mother called your ofce this morning to conrm the appointment time and informed your receptionist that Maria, whom you have not seen yet, went to bed last night after complaining that her teeth hurt while eating dinner the night before. She slept through the night but awoke with the right side of her face swollen, although reporting she is not in any pain (Fig. E24.1). Her parents rst noticed that Maria had cavities approximately 6 months ago; they have not insisted that she see a dentist because Maria said she did not want to. She brushes her teeth only when she feels like it.Maria reluctantly accompanies her parents into the ofce, and she actively resists her parents’ attempts to move her into the operatory. She responds to your attempts to engage in conversation by repeatedly saying “I want to go home NOW!” Her parents react angrily and nally pick her up and carry her into the operatory. After reviewing her medical, dental, social, and family history, you discuss with the parents how they want to proceed with her care.Maria’s mother states that she does not want to use any sedation and she denitely does not want her child to have a general anesthetic after hearing in the news about the tragic incidents when other kids were put asleep for dentistry. You then have a discussion of various behavior management techniques, including tell-show-do, distraction, suggestion, extinction, positive reinforcement, modeling, voice control, passive protective stabilization, and active protective stabilization. Maria’s parents are interested only in the use of active protective stabilization. Your discussion includes indications and contraindications (Table E24.1), as well as pros, cons, fees, and consent.Protective stabilization is the term used in dentistry for the physical limitation of a patient’s movement by a person or restrictive equipment, materials, or devices for a nite period of time1–4 to safely provide examination, diagnosis, and/or treatment. Active immobilization involves restraint by another person, such as the parent, dentist, or dental auxiliary; passive immobilization uses a restraining device.5 Informed consent must be obtained and documented in the patient’s record prior to performing protective stabilization.6–9The patient’s record must include indication for stabilization, type of stabilization, informed consent for protective stabilization, reason for parental exclusion during protective stabilization (when applicable), the duration of application of stabilization, behavior evaluation/rating during stabilization, any untoward outcomes such as skin markings, and management implications for future appointments.10• Figure E24.1 Facial swelling. Indications ContraindicationsPatients who require immediate diagnosis and/or urgent limited treatment and cannot cooperate due to emotional and cognitive developmental levels, or lack of maturity, or medical and physical conditionsCooperative nonsedated patientsPatients for whom emergent urgent care is needed and uncontrolled movements risk the safety of the patient, staff, dentist, or parent without the use of protective stabilizationPatients who cannot be immobilized safely due to associated medical, psychological, or physical conditionsPreviously cooperative patients who quickly become uncooperative during the appointment to protect the patient’s safety and help to expedite completion of treatmentSedated patients who may become uncooperative during treatment; patients who require limited stabilization to help reduce untoward movements during treatmentPatients with special health care needs who may experience/exhibit uncontrolled movements that would be harmful or signicantly interfere with the quality of careData from American Academy of Pediatric Dentistry. Guideline on protective stabilization for pediatric dental patients. http://www.aapd.org/assets/1/7/1Q._Protective_Stabilization_for_Pediatric_Dental_Patients2.PDF. Accessed September 13, 2017.Indications and Contraindications for Protective StabilizationTABLE E24.1 Continued 370.e2 Part 3 The Primary Dentition Years: Three to Six YearsQuestions1. Which is the least controversial nonpharmacologic behavior management approach? a. Tell-sho w-do b. Positive reinforcement c. Voice control d. Distraction e. ModelingAnswer: a2. True or False: When providing passive protective stabilization, verbal consent is adequate.Answer: FalseReferences1. Ofce of the Federal Register. Code of Federal Regulations. 42 Public Health, 482.13; 20102011. http://www.gpo.gov/fdsys/pkg/CFR-2011-title42-vol15/pdf/CFR-2011-329-title42vol15.pdf. Accessed January 28, 2017.2. Royal College of Nursing. Restrictive physical intervention and therapeutic holding for children and young people. Guidance for nursing staff; 2010. London: RCN. http://www.rcn.org.uk/__data/assets/pdf_le/0016/312613/003573.pdf. Accessed January 28, 2017.3. Newton JT. Restrictive behavior management procedures with people with intellectual disabilities who require dental treatment. J Appl Res Intellect Disabil. 2009;22:118–125.4. Tesini DA. Providing comprehensive quality dental care to children with autism spectrum disorder. Inside Dental Assisting. 2014;March/April:22–27.5. Adair SM, Schafer TE, Rockman RA, et al. Survey of behavior management teaching in predoctoral pediatric dentistry programs. Pediatr Dent. 2004;26(2):143–150.6. NYS Ofce for People with Developmental Disabilities. Administrative Memorandum—#2010-02. Medical immobilization/protective stabilization (MIPS) and sedation for medical/dental appointments; 2010; 1-7. http://www.opwdd.ny.gov/node/961. Accessed January 28, 2017.7. State of Colorado Department of Regulatory Agencies. Board of Dental Examiners. 3CCR709-1. Rules and Regulations; Medical immobilization/protective stabilization; 2011; page 37-38. http://www.nasddds.org/uploads/documents/CO_Dental_Restraints_Policy.pdf. Accessed January 28, 2017.8. American Academy of Pediatric Dentistry. Guideline on informed consent. Pediatr Dent. 2016;38(6):351–353.9. American Academy of Pediatrics Committee on Bioethics. Informed consent in decision-making in pediatric practices. Pediatrics. 2016;138(2):e20161484.10. American Academy of Pediatric Dentistry. Guideline on protective stabilization for pediatric dental patients. http://www.aapd.org/assets/1/7/1Q._Protective_Stabilization_for_Pediatric_Dental_Patients2.PDF. Accessed September 13, 2017. 37125 Periodontal Problems in Children and AdolescentsWILLIAM V. STENBERG, JR.CHAPTER OUTLINEGingivitisGingival EnlargementChronic Inammatory Gingival EnlargementDrug-Induced Gingival EnlargementAnatomic ProblemsDevelopment and Defects of the Attached GingivaFrenaPeriodontitisAggressive PeriodontitisLocalized Aggressive Periodontitis in the Permanent DentitionGeneralized Aggressive PeriodontitisLocalized Aggressive Periodontitis in the Primary DentitionNecrotizing Ulcerative Gingivitis/PeriodontitisSystemic Diseases and Conditions With Associated Periodontal ProblemsDiabetesDown SyndromeHypophosphatasiaLeukocyte Adhesion DeciencyNeutropeniaPapillon-Lefèvre SyndromeHistiocytosisLeukemiaPeriodontal Examination of Childrenbacteria that live in biolms at the gingival margin and in the sulcus.1 e clinical signs of gingivitis include erythema, bleeding on probing, and edema. In the early primary dentition, gingivitis is uncommon. Younger children have less plaque than adults do and appear to be less reactive to the same amount of plaque. is can be explained both by dierences in bacterial composition of plaque and by developmental changes in the inammatory response. Gingivitis occurs in half the population by the age of 4 or 5 years, and the incidence continues to increase with age. e prevalence of gingivitis peaks at close to 100% at puberty, but after puberty it declines slightly and stays constant into adulthood.2 Some children exhibit severe gingivitis at puberty, as shown in Fig. 25.1. Puberty-associated gingivitis is related to increases in steroid hormones.3 e gingiva may be enlarged with granulomatous changes similar to those occurring in pregnancy. e peak prevalence of puberty-associated gingivitis is at age 10 years in girls and age 13 years in boys. Extensive gingivitis in 12-year-olds, as indicated by bleeding upon probing in more than 15% of sites, has been shown to negatively aect children in how they perceive their oral health as well as their daily lives.4Certain local factors may be important contributors to gingivitis in children. Crowded teeth and orthodontic appliances may make oral hygiene more dicult and predispose to gingivitis. Mouth breathing may cause chronically dehydrated gingiva in the maxillary labial area and lead to a characteristic localized gingivitis as shown in Fig. 25.2. Inammation, especially erythema, often occurs around erupting primary and permanent teeth.Gingivitis is reversible and can be managed with improved oral hygiene. Appropriately sized toothbrushes, as well as toothpaste and oss avored to appeal to children, may enhance compliance. Young children, especially those younger than 6 years of age, will require some parental assistance with their oral hygiene care. Older children and even some adolescents can benet from some degree of parental supervision.Gingival EnlargementChronic Inammatory Gingival EnlargementLongstanding gingivitis in young patients sometimes results in chronic inammatory gingival enlargement, which may be localized or generalized. It commonly occurs when plaque is allowed to accumulate around orthodontic appliances, as shown in Fig. 25.3, or in areas chronically dried by mouth breathing. e interdental Children and adolescents are aected by a variety of peri-odontal diseases and conditions. Gingivitis is common, especially around puberty. Signicant loss of periodontal attachment or alveolar bone is more unusual in young patients and can result from systemic disease or occur as isolated dental disease. In addition, gingival anatomic problems, such as lack of attached gingiva, can arise during development and may necessitate early management.GingivitisGingivitis is characterized by inammation of the gingival tissues with no loss of attachment or bone. It occurs in response to the 372 Part 3 The Primary Dentition Years: Three to Six YearsDrug-Induced Gingival EnlargementLong-term therapy with certain systemic medications can produce an overgrowth of gingival tissue (Fig. 25.4).5 It can occur after therapy with the anticonvulsant phenytoin (Dilantin), the immu-nosuppressant cyclosporine, or calcium channel blockers. e overgrowth is painless and diers from chronic inammatory enlargement in that it is brous, rm, and pale pink, often with little tendency to bleed. The enlargement occurs first in the interdental region and may appear lobular. It gradually spreads to the gingival margin. e condition can become extreme, sometimes covering the crowns of the teeth and interfering with eruption or occlusion.Drug-inuenced gingival enlargement occurs slowly and may resolve to some degree when medication is discontinued. ere appears to be a genetic component to susceptibility to gingival enlargement. e severity of the enlargement is also aected by both the adequacy of oral hygiene and the gingival concentration of the medication. If medication cannot be discontinued or changed, the enlargement can be surgically removed, but it will recur. Surgery is indicated when the appearance of the gingiva is unacceptable to the patient, when the enlargement interferes with comfortable functioning, or when enlargement produces periodontal pockets that cannot be maintained in a healthy state. Postoperative dis-comfort after gingivectomy can be considerable and should be • Figure 25.1 Puberty-associated gingivitis in a 13-year-old African-American boy. The dark pigmentation of the gingiva is a normal racial characteristic. BA• Figure 25.2 (A) The typical oral posture of mouth breathing. (B) The resultant gingivitis of the maxillary facial gingiva. BA• Figure 25.3 (A) Gingival enlargement (noted between lateral incisors and canines) in response to longstanding plaque accumulation on the mandibular incisors secondary to orthodontic appliances. Note uneven gingival margin and narrow gingiva on left mandibular central incisor, without root exposure (“pseudorecession”). (B) Gingival enlargement secondary to orthodontic appliances. papillae and the marginal gingiva become enlarged, and the tissue is usually erythematous and bleeds easily. It may be soft and friable with a smooth, shiny surface (see Fig. 25.3A), or dense and brotic with a matted surface (see Fig. 25.3B). Inammatory gingival enlargement often slowly resolves when adequate plaque control is instituted, unless the tissues are brotic; in such cases, gingivec-tomy is often required. CHAPTER 25 Periodontal Problems in Children and Adolescents 373 A free gingival graft or connective tissue graft is indicated to stabilize and repair the gingiva of teeth with signicant recession. Such grafts commonly use allogenic material or donor tissue from the patient’s own palate. Surgical repair of lingual recession due to oral piercings can be performed but requires more complex treatment than typical labial gingival grafts.7 Orthodontic movement of a labially malpositioned tooth in the direction of the alveolar ridge may produce a small increase in attached gingiva and place the tooth in a periodontally more stable position.FrenaPeriodontal examination of the pediatric patient should include evaluation of the frena. ese are mucosal folds with enclosed muscle tissue that serve as attachments for the lips and tongue to the immobile tissue of the mandible and premaxilla. e three primary frena are the maxillary labial, mandibular labial, and lingual frena. Aberrant frena can be related to various problems at dierent stages of growth and development.Abnormal frena can also be associated with various syndromic and nonsyndromic conditions. erefore the clinician is advised to carefully evaluate the frena of pediatric patients. Hyperplastic frena have been associated with the Ellis-van Creveld syndrome, and multiple hyperplastic frena in females can be associated with the oral-facial-digital syndrome. e congenital absence of frena may indicate Ehlers-Danlos syndrome. It has also been associated with infantile hypertrophic pyloric stenosis. Even in otherwise healthy patients, the appearance of the frena can be variable. erefore the clinician is advised not to use a frenum as the sole criteria in a diagnosis but correlate the presentation with other signs and symptoms.Maxillary Midline FrenumA prominent maxillary frenum, often accompanied by a large midline diastema, is a common nding in children (Fig. 25.6). It is often a cause for concern by parents and health care providers. In general, surgical treatment of this condition should be delayed until the maxillary canines have fully erupted, because they will often cause spontaneous closure of the diastema. If orthodontic therapy is necessary, consideration for surgery can usually be delayed until the completion of active treatment and is only necessary if the diastema presents an esthetic or functional problem at that time. Treatment has traditionally consisted of a Z-plasty procedure, but lasers are eective and are increasingly being used to provide this treatment.carefully weighed against potential benets for special needs patients who may not be able to give fully informed consent.Anatomic ProblemsDevelopment and Defects of the Attached GingivaWhen teeth erupt, they pierce through an existing band of keratin-ized gingiva, and the width of this band and its relationship to the teeth change very little during subsequent growth and develop-ment. Deections in the path of eruption, such as those due to crowding or overretention of primary teeth, may result in a narrowed band of attached gingiva.6 is is particularly common when mandibular incisors erupt labial to the alveolar ridge, as shown in Fig. 25.5. If the band of attached gingiva is very narrow, even a small subsequent loss of attachment can result in a mucogingival defect (which occurs when the pocket depth exceeds the width of keratinized gingiva), and recession may occur, as shown in Fig. 25.5 (left central incisor). e loss of attachment and recession that occurs with a labially malpositioned tooth is often referred to as stripping. Other factors that may contribute to recession in children and adolescents are habit-related self-inicted injury, oral piercings, and the use of smokeless tobacco.• Figure 25.4 Severe gingival enlargement, secondary to cyclosporine and nifedipine therapy, in a teenaged kidney transplant patient. • Figure 25.5 A reduction in the width of gingiva resulting from labial eruption of the mandibular central incisors. Localized recession has occurred on the left central incisor as the result of plaque accumulation in an area that was difcult to clean and had inadequate attached gingiva. The dark pigmentation of the gingiva is a normal racial characteristic. • Figure 25.6 Prominent midline maxillary labial frenum in a child. 374 Part 3 The Primary Dentition Years: Three to Six Yearsoften begins in adolescence. Chronic periodontitis responds well to oral hygiene measures and can easily be arrested in its early stages when attachment loss is minimal and deep pockets have not developed.Smoking is a major risk factor for periodontitis, and smoking among children and adolescents is no longer limited to traditional tobacco cigarettes. e use of e-cigarettes, which consists of inhaling noncombusted, electrically vaporized chemicals including nicotine, is known as “vaping.” E-cigarette, hookah, and pipe tobacco use is increasing faster in younger age groups than use of traditional cigarettes. E-cigarettes are currently the most commonly used tobacco product among middle and high school students.12 Candy-avored electronic cigarettes have been shown to elicit a strong interest in smoking among children, and adolescents who begin with e-cigarettes are much more likely to start using traditional cigarettes and become heavy smokers. e misconception that e-cigarettes are a harmless alternative to smoking is common, but recent studies have demonstrated a causal link to periodontal destruction.13 e eect of secondhand aerosol from e-cigarettes on infants and small children is unknown, but studies suggest that such exposure may also be harmful. e actual components of electronic cigarettes are toxic if ingested by small children, and calls to poison control centers have skyrocketed since their popularity has increased. More than 50% of such calls involved children aged 5 years and younger.14Smoking is not limited to tobacco. With the recent legalization of medical marijuana in many states, the availability to children and adolescents has increased. e frequent use of cannabis (marijuana and hashish) is associated with deeper periodontal probing depths, more clinical attachment loss, and increased risk of developing severe periodontitis.15 Smoking crack cocaine and other illicit drugs is also linked to periodontal destruction.16 e potential for periodontal destruction, as well as the long-term eects of tobacco and other psychoactive compounds on the developing adolescent brain and body, are of great concern. Current and past smoking status should be determined as part of a periodontal assessment for young patients, including detailed questioning about nontraditional smoking and other tobacco use. Appropriate cessation counseling and/or referrals should be provided.Aggressive PeriodontitisRare, rapidly progressing forms of periodontitis also aect children and adolescents who are otherwise healthy. Aggressive periodontitis has localized and generalized forms and can occur in the permanent or the primary dentition.Localized Aggressive Periodontitis in the Permanent DentitionLocalized aggressive periodontitis (LAP), formerly called localized juvenile periodontitis, is characterized by the loss of attachment and bone around the permanent incisors and rst permanent molars. e radiographic appearance is distinctive (Fig. 25.8). e attach-ment loss is rapid, occurring at three times the rate of chronic disease. Inammation in LAP is not as extreme as that occurring in periodontitis associated with systemic disease such as neutropenia, but both inammation and plaque accumulation are often greater than those found in the typical teenager. e disease is usually detected in early adolescence but may begin as LAP of the primary dentition (discussed later). e prevalence of LAP is estimated to be approximately 1%, and in the United States it most commonly e maxillary midline frenum can also present problems in nursing infants, a condition known as “lip tie.” Studies have shown dramatic improvements in nursing ability in infants after surgical release of the maxillary midline frenum.8Mandibular Labial Frenume mandibular labial frenum should normally attach between the mandibular central incisors at a level below the attached gingiva. A hypertrophic frenum, or one with an aberrant attachment near the free gingival margin, may be associated with gingival recession. In these cases, treatment is directed at the reconstruction of the attached gingiva and not at the frenum per se. Treatment options consist of periodontal plastic surgery, such as a free gingival graft with vestibular extension or a connective tissue graft. e frenum is relocated to a more apical position as a consequence of these procedures. is is very eective at providing root coverage and gingival stability, in addition to preventing reattachment of the frenum to the free gingival margin.Lingual FrenumA restrictive lingual frenum (“tongue tie”) is often seen in children (Fig. 25.7). In approximately 3% of children, the attachment may limit normal tongue mobility (ankyloglossia), which can lead to discomfort or diculties while nursing and can also impact the development of speech. Some studies have shown marked improve-ment in speech and language assessment in children who were treated for ankyloglossia and had preexisting speech diculties.9 Although lingual frenotomies may be indicated for infants with feeding issues, there are insucient data to recommend prophylactic surgery in asymptomatic patients. Consultation with a speech pathologist is recommended if problems are suspected. Occasionally, the restrictive lingual frenum may impact the lingual gingiva (see Fig. 25.7). Treatment generally consists of a simple frenotomy, which can be performed with scissors or with lasers.PeriodontitisSignicant loss of periodontal attachment is common in adults, with chronic periodontitis (formerly called “adult-onset” periodontitis) aecting the majority of the population. When epidemiologic observations have been made, 20% of 14- to 17-year-olds in the United States are found to have attachment loss of at least 2 mm at one or more sites.10,11 e number and severity of aected sites increase steadily with age, demonstrating that chronic periodontitis • Figure 25.7 Restrictive lingual frenum in a child. Note the relationship of the frenum to the tip of the tongue and the lingual gingiva of the central incisors. CHAPTER 25 Periodontal Problems in Children and Adolescents 375 periodontitis.18 GAP may aect the entire dentition and is not self-limiting. Heavy accumulations of plaque and calculus are found in GAP, and inammation may be severe. GAP is not associated with high levels of A. actinomycetemcomitans but instead has a microbiologic prole closer to that of chronic disease. It should be managed aggressively with local therapy as well as systemic antibiotics.Localized Aggressive Periodontitis in the Primary DentitionLAP in the primary dentition (formerly called localized prepubertal periodontitis [LPP]) is characterized by localized loss of attachment in the primary dentition. It occurs in children without evidence of systemic disease. e disease is most commonly manifested in the molar area, where localized, usually bilaterally symmetric loss of attachment occurs (Fig. 25.9). In the United States LAP of the primary dentition occurs most commonly in the African-American population. It is usually accompanied by mild to moderate inam-mation, and heavier than average plaque deposits may be visible. occurs in the African-American population. Some cases appear to be inherited as an autosomal dominant trait, and LAP has been linked to a neutrophil chemotactic defect. LAP may progress to generalized aggressive periodontitis (GAP).Despite the genetic component, LAP is clearly linked to the presence of high numbers of Aggregatibacter actinomycetemcomitans, and successful treatment outcomes correlate well with eradication of the bacteria. Treatment consists of local débridement in combination with systemic antibiotic therapy and microbiologic monitoring. Localized surgical intervention is often necessary to manage the residual defects. Systemic tetracyclines have been used with some success but should not be used in children under 9 years of age due to the potential for delayed bone growth and permanent tooth discoloration. Metronidazole alone or in combination with amoxicillin appears to be eective in arresting disease progression.17Generalized Aggressive PeriodontitisGAP sometimes occurs in adolescents and teenagers. In young adults the same disease was formerly called rapidly progressive • Figure 25.8 Radiographic appearance of localized aggressive periodontitis showing the typical bone loss pattern around rst permanent molars and central incisors. Note the root canal treatment of the central incisor. Luxation injuries are common in these patients because of mobility of the incisors. • Figure 25.9 Radiographic appearance of localized aggressive periodontitis showing the characteristic loss of bone around the primary molars. In this patient the disease has not progressed to include the permanent teeth, as sometimes occurs. 376 Part 3 The Primary Dentition Years: Three to Six Yearsperiodontitis are important for the overall health of patients with diabetes.Down SyndromeDown syndrome is accompanied by an increased susceptibility to periodontitis. Most Down syndrome patients develop periodontitis by 30 years of age, and it may rst occur in the primary denti-tion.20 Plaque levels are high in these patients, but the severity of periodontal destruction exceeds that attributable to local factors alone. Various minor immune decits in patients with Down syndrome may be responsible for the increased susceptibility to periodontitis. Severe recession in the mandibular anterior region associated with a high frenum attachment is also common in Down syndrome.HypophosphatasiaHypophosphatasia is a genetic disorder in which the enzyme bone alkaline phosphatase is deficient or defective. Phenotypes of hypophosphatasia can vary from premature loss of deciduous teeth to severe bone abnormalities leading to neonatal death.21 In general, the earlier the presentation of symptoms, the more severe the disease. In mild forms the early loss of primary teeth may be the rst and only clinical sign, as shown in Fig. 25.10. e early loss of teeth is the result of defective cementum formation, which aects attachment of tooth to bone. ere currently is no treatment for the disease, but the dental prognosis for the permanent teeth is good. Typically, the primary incisors are exfoliated before the age of 4 years, the other primary teeth are aected to varying degrees, and the permanent dentition is normal. Hypophosphatasia can be diagnosed by a nding of low alkaline phosphatase levels in a serum sample.Leukocyte Adhesion DeciencyLAD, also called generalized prepubertal periodontitis,22 is a rare, recessive genetic disease that leaves patients susceptible to bacterial infections, including periodontitis. Because of the high incidence of skin abscesses, recurrent otitis media, pneumonitis, and other bacterial infections of soft tissues, a diagnosis is usually made before dental symptoms appear. Dental symptoms are manifested early in the primary dentition. Bone loss is rapid around nearly all teeth, and inammation is marked. Scrupulous oral hygiene measures are necessary to control the periodontitis associated with LAD.It is commonly rst diagnosed during the late primary dentition or early transitional dentition. LAP of the primary dentition may progress to LAP in the permanent dentition.LAP in the primary dentition is associated with a bacterial infection and a specic, but minor, host immunologic decit. Some cases are associated with systemic (genetic) diseases. Anti-biotic therapy combined with local débridement appears to be an eective treatment regimen. Metronidazole is the antibiotic of choice for LAP of the primary dentition. Tetracyclines are contraindicated.Necrotizing Ulcerative Gingivitis/PeriodontitisNecrotizing ulcerative gingivitis/periodontitis is characterized by the rapid onset of painful gingivitis with interproximal and marginal necrosis and ulceration. e incidence peaks in the late teens and early 20s in North America and Europe, but in less developed countries it is common in young children. Malnutrition, viral infections, stress, lack of sleep, and smoking have been reported as predisposing factors. Necrotizing ulcerative gingivitis/periodontitis is associated with high levels of spirochetes and Prevotella intermedia. Local débridement usually produces rapid resolution of the disease, but antibiotic therapy with penicillin or metronidazole may be indicated in patients with elevated body temperature.Systemic Diseases and Conditions With Associated Periodontal ProblemsEarly loss of periodontal attachment in children is often a sign of systemic disease. Periodontitis may occur in the presence of defects in the immune system that result in susceptibility to infection such as leukocyte adhesion deciency (LAD) or neutropenia,1 developmental defects in the attachment apparatus as in hypophosphatasia, or from the invasion of neoplastic cells as in leukemia.DiabetesAn increased risk and earlier onset of periodontitis occur in both insulin-dependent and non–insulin-dependent diabetes mellitus.19 As many as 10% to 15% of teenagers with insulin-dependent diabetes mellitus have significant periodontal disease. Poor metabolic control increases the risk of periodontitis, and untreated periodontitis in turn worsens metabolic control of diabetes. Eec-tive preventive regimens and early diagnosis and treatment of BA• Figure 25.10 (A) The dentition of a 4-year-old child with early loss of upper and lower central incisors due to hypophosphatasia. (B) The lower incisors, exfoliated at 13 months of age. Note the incomplete root development at the time the teeth were exfoliated.

Related Articles

Leave A Comment?