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362 Part 3 The Primary Dentition Years: Three to Six Yearsgeneral anesthesia to be the third most acceptable technique after TSD and nitrous oxide. In addition, most parents view sedation as safe and may request sedation for their cooperative child before the dentist has the opportunity to attempt basic behavior guidance techniques.123 However, the dentist must take into account the risks of sedation, the extent of treatment needs, and the cooperation of the patient before deciding to use an advanced behavior guidance technique.Mouth Props in Dentistry for ChildrenMouth props are routinely used in dentistry to improve the quality of dental care and the comfort and safety of the patient. ey can help prevent fatigue from the mouth staying open during long visits, as well as accidental patient closing that may cause trauma or moisture contamination of the area being treated. e AAPD Guidelines on Behavior Guidance1 state that the use of a mouth prop on a compliant child is not considered stabilization. However, the use of a mouth prop on an uncooperative child has been interpreted as protective stabilization that requires informed consent.Multiple types of mouth props are used in pediatric dentistry, as shown in Fig. 24.5, and they all have specic indications, advantages, and disadvantages. e McKesson style of mouth props (Hu-Friedy, Chicago, IL) is a rubber, wedge-shaped device and generally well accepted by patients. Uncooperative patients may easily dislodge this device, and it is not adjustable. Also, these devices typically occlude half of the mouth and can make the approach for an inferior alveolar block dicult. Although unlikely, aspiration of these mouth props is a possibility, and they should be tied with 18 inches of oss and secured extraorally.Molt adjustable mouth props (Hu-Friedy) can also be used. eir appearance may intimidate children, but with TSD they are well accepted. e child can be told that they have a “popcorn popper” in their mouth to explain the clicking noise of opening the mouth prop. e practitioner must use caution because rapid opening of the mouth prop on anterior teeth can luxate or avulse them. Anterior teeth can also be avulsed if the patient reaches up and pulls the appliance out of the mouth before it is released.Soft foam mouth props (Specialized Care Co., Hampton, NH) may be used on children with special needs; they are less rigid and easier to place in a patient who refuses to open, and they are also less likely to damage anterior teeth than rigid mouth props. Caution should be used with these because they are easily deformed. It is advisable to replace these mouth props with McKesson rubber props once adequate opening is obtained, to avoid breaking a mirror or injuring a patient with an instrument.Loose primary teeth can be dislodged and possibly swallowed or aspirated with any type of mouth prop. It is advisable to check the dentition as a precaution before using any mouth prop.Documenting Behavior and Use of Behavior Management Techniquese behavior of the child patient is an important component of the visit that must be documented. A variety of scales for behavior exist, and a commonly used one is the Frankl score, as shown in Table 24.4.124Qualitative comments, in addition to a quantitative score to record behaviors, can help in planning future management strategies for a child. e comments should be objective and nonjudgmental about the child and parents. Words like “overindulged” or “spoiled” injection only.70 It is important to note that in these studies, parents were shown videos of various procedures with little or no explana-tion. Frankel119 found that after the use of a papoose board immobilization device for the treatment of uncooperative children, 90% of mothers approved of its use, 96% thought it was necessary to perform the dentistry, 78% did not think it had a later negative eect on the child, and 86% were willing to use it with their next child. e author pointed out that the technique was positively presented in a warm and caring oce environment, whereas other studies have only shown videos with no personal experience and no explanation.119Separate AAPD guidelines exist for the use of protective stabiliza-tion, and any dentist using this technique should thoroughly review them.115 As with all advanced techniques, the clinician must be trained in its use (beyond the predoctoral dental school curriculum) and specic informed consent should be obtained, documented, and reviewed at each appointment. Use of protective stabilization should be documented including type of device, duration, indica-tion, presence of parent or reason for his or her absence, and untoward outcomes. Contraindications include patients who cannot be immobilized safely due to medical, psychological, or physical conditions.115Sedation and General AnesthesiaSedation is a pharmacologic behavior management technique described in more depth in Chapter 8. As with nitrous oxide, sedation is an adjunct to the child’s innate coping. Children under sedation should be arousable, interactive, and benet from com-municative behavior guidance techniques. Children with no coping skills, such as those who are very young or who have medical or developmental disabilities, may benet from general anesthesia. Studies that look at behavior following these modalities support them as eective ways of protecting the developing psyche of patients. McComb and associates120 concluded that treatment with oral sedation had no signicant eect on future dental behavior at a recall exam performed 2 to 34 months later. Other studies have found more positive behavior in children after treatment under general anesthesia versus conscious sedation.121,122Parents have previously expressed poor acceptance of sedation and general anesthesia for their children’s dental care, but this view has changed dramatically in the last decade.41,72 Lawrence and coworkers found it to be the least acceptable behavior management technique, even with explanation of the need for the procedure.72 More recently, however, Eaton and associates69 found sedation or • Figure 24.4 Medical stabilization with a papoose board. CHAPTER 24 Behavior Guidance of the Pediatric Dental Patient 363 are subjective, should be avoided, and may oend parents on review of the record.Behavior guidance techniques should be documented. Typically communicative techniques do not need to be recorded, but it is helpful to include particularly eective techniques as a reminder for future visits. Pharmacologic and advanced techniques must be recorded specically. e monitoring and recording requirements for nitrous oxide, sedation, and general anesthesia should comply with state regulations. If active immobilization is used, it is important to record who immobilized the patient, what body part was immobilized, for what part of the procedure, and for how long. If passive immobilization is used, the type of device and the approximate time it is used should be recorded.115 It is also prudent to document that an updated verbal consent was obtained in addition to the written consent obtained before use.Role of Behavior Management in SocietyDentists do not care for children in a vacuum. Sheller49 notes that society, parents and their children, the insurance industry, regulatory bodies, legal system, dental sta, and the education, expectations, and choices of dentists all inuence the options available for child patient management.Changes in Society and ParentingMany societal changes in the last two decades have impacted the nature of parenting in America. e changing economic and social ABDC• Figure 24.5 Mouth props. (A) McKesson style mouth prop. (B) Mouth prop with extra oral handle. (C) Molt mouth prop. (D) Disposable foam mouth prop. Behavior Score Classication DescriptionFrankl 4 Denitely positiveGood rapport with the dentistInterested in the dental proceduresLaughing and enjoying the situationFrankl 3 Positive Accepting of treatment but at times cautiousWilling to comply with the dentist, at times with reservation, but patient follows the dentist’s directionsCooperativeFrankl 2 Negative Reluctant to accept treatmentUncooperativeSullen, withdrawnFrankl 1 Denitely negativeRefusal of treatmentCrying forcefullyFearfulaFor children who are too young to cooperate, the term precooperative is preferred.Frankl Behavior Rating ScaleaTABLE 24.4 364 Part 3 The Primary Dentition Years: Three to Six YearsOver the last two decades, aggressive physical manage-ment techniques, specifically hand-over-mouth and passive restraint, have decreased in acceptability, and pharmacologic techniques have increased in acceptability.69 Positive reinforce-ment and TSD are acceptable for nearly all dental procedures. More aversive techniques such as physical restraint during the injection or the use of the papoose board may only be accept-able to parents for certain procedures like the injection or an extraction.70Two areas for further research are the inuences of social class and ethnicity on the acceptability of management techniques. Havelka and coworkers71 found that high social status groups were more accepting than low social status groups of active restraint and TSD but less accepting of using a papoose board and general anesthesia. Scott and Garcia-Godoy73 found that Hispanic parents had favorable attitudes toward verbal techniques, such as TSD and voice control, and unfavorable attitudes toward physical management techniques, such as papoose board, hand-over-mouth, and active restraint.Third-Party ReimbursementA concern for dentists is lack of reimbursement for the time and skill needed to manage the behavior of a child patient eectively. ird-party insurers play an increasingly inuential role on practice decisions and are skeptical about paying for services that cannot be measured.49 How this dynamic will aect dentists’ choices of behavior guidance techniques is unknown. ird-party reimburse-ment for general anesthesia for dental procedures for young children is largely dependent on state regulations. Currently 37 states require medical insurance to cover general anesthesia for dental procedures when deemed medically necessary.128Informed ConsentInformed consent is vital to ensure that the parent is adequately informed about proposed treatment; alerted to risks, benets, and alternatives; and most importantly becomes an active part of the oral care plan. Medical sociologists have noted a shift toward a climate has produced dierent types of families. A trend is for families to live increasingly isolated and disconnected lives. is is due to young families moving away from extended family members, an increased incidence of single parents, and free-time limitations caused by the work schedules of dual-income or single parent families.125 Economic stress has added to the loss of emotional and practical support. Stressed parents have been reported to implement:1. Inconsistent (sometimes lax or overreactive) parenting2. More negative communications3. Decreased monitoring/supervision of children4. Unclear rules and limits on children’s behavior5. More reactive and less proactive behavior6. Increasingly harsh disciplineAll of these factors can contribute to a decline in the quality of the parent-child relationship.125 e rise of violence in the media, both in entertainment and journalism, contributes to a culture that seems to endorse or at least “model” poor behavior control and glamorizes aggression, which may result in more deant behavior in children.67In a survey of the American Academy of Pediatric Dentistry on behavior management techniques, 85% of practitioners indicated that they believed that parenting styles have changed during their years in practice. ey most frequently indicated parents are “less willing to set limits for their children” and are “less willing to use physical discipline.”126 A large majority (88%) of diplomates of the American Board of Pediatric Dentistry reported that parenting styles had “absolutely or probably changed” during their practice time. Ninety-two percent reported that changes were “probably or denitely bad,” and 85% felt that these changes had resulted in “somewhat or much worse” patient behavior.127Changing Parental Perspectives of Behavior ManagementParents have been routinely queried as to their opinions on accept-ability of behavior guidance techniques. Table 24.5 shows the results of past studies in America on parental preference of behavior guidance techniques.Ranking Murphy et al.148 (1984) Lawrence et al.72 (1991) Eaton et al.69 (2005) Patel et al.118 (2016) 1 Tell-show-do Tell-show-do Tell-show-do No basic behavior guidance techniques were surveyed 2 Positive reinforcement Nitrous oxide Nitrous oxide Sedation 3 Mouth prop Voice control GA GA 4 Voice control Active restraint Active restraint Active restraint 5 Physical restraint, dentist Hand-over-mouth Oral premedication Passive restraint 6 Physical restraint, assistant Papoose board Voice control 7 Hand-over-mouth Oral premedication Passive restraint 8 Sedation GA 9 General anesthesia (GA)10 Papoose boardModied from Patel M, McTigue DJ, Thikkurissy S, Fields HW. Parental attitudes toward advanced behavior guidance techniques used in pediatric dentistry. Pediatr Dent. 2016;38(1):30–36.Techniques Ranked by Parental Acceptance in Four Similar StudiesTABLE 24.5 CHAPTER 24 Behavior Guidance of the Pediatric Dental Patient 365 practitioner must comply as soon as possible to safely end the procedure.130Adair and colleagues126 reported that 42% of pediatric dentists give parents a single printed form that describes at least some of the behavior guidance techniques they use. In this study, the majority of practitioners did not obtain consent for the use of most com-municative techniques and obtained only oral consent for passive and active immobilization for unsedated children.126 However, current AAPD guidelines recommend written consent if protective stabilization is used, and this is best obtained on a separate day.115 If unanticipated behavior necessitates use of immobilization, immediate intervention is indicated to ensure safety, and then written informed consent should be obtained, as well as consent for alternative methods such as sedation if further treatment is necessary.1 Box 24.3 shows the method used at the Louisiana State University Department of Pediatric Dentistry to inform parents about various behavior guidance techniques. is form is accom-panied by a separate treatment plan that lists the specic techniques that will be employed. Additional consents are obtained for medical immobilization, sedation, and general anesthesia.Putting It All TogetherBehavior Guidance for the Infant/ToddlerChildren less than 30 months of age can usually only respond to simple commands such as “sit in the chair” or “open your mouth.”37 At this age they are entirely dependent on parents and have little verbal language. Typical fears of the 2-year-old child are strangers, loud sounds, sudden movement, and falling. Having the parents involved is critical because children in this group are typically very consumerist position on health care, and parents are overwhelmed with information, sometimes false, on dentistry.49 It is important that parents fully understand and trust the treatment plan for their child. Allen and coworkers129 found that, compared with video or written presentation, the oral method of delivering information to parents about child behavior guidance techniques was the best method to ensure that the average parent felt informed and was likely to consent.Informed consent should be obtained by the practitioner, and written documentation of informed consent is superior to oral consent only.130 However, one must not mistake the signing of forms for true informed consent. Informed consent is a process of understanding that relies on honest communica-tion from the practitioner and willingness to understand by the parent. Misrepresentations for behavior guidance techniques can cause conict in the parent-dentist relationship and have legal consequences.130It is important that dentists make it clear to parents what level of cooperation is required of their child to be treated and that parents make clear which guidance techniques are acceptable. Clinicians should work to understand the parents’ reasoning behind their decisions to individualize the plan for the patient and family.67 is is an area where the investment of time and patience can prevent future problems, because malpractice complaints have been reported to occur more frequently when a good relationship between the provider and patient is lacking.131Typically only a parent or legal guardian can provide informed consent for a minor patient. Some states, however, provide an exception for emancipated minors, so clinicians must be aware of the laws where they practice. It is also important to note that informed consent can be withdrawn at any time, and a LSU School of Dentistry Pediatric Dental Consent InformationIn order to provide the best dental care of your child, we would like to inform you more about the practice of dentistry for children and risks associated with this practice.Patient ManagementIt is our intent that all professional care provided in our dental clinic shall be of the best possible quality we can provide for each child. Providing high-quality care in a safe manner can be difcult if the child lacks the ability to cooperate. All efforts will be made to obtain the cooperation of the children by the use of warmth, friendliness, kindness, and understanding. There are several behavior management techniques that are used by pediatric dentists to gain the cooperation of children to eliminate disruptive behavior or prevent patients from causing injury to themselves due to uncontrollable movements. This includes:1. Tell-Show-Do: The dentist or assistant explains to the child what is to be done, shows an example on a tooth model or the child’s nger, and then the procedure is done to the child’s tooth.2. Positive Reinforcement: The dentist rewards the child who displays cooperative behavior with compliments, praise, a pat on the shoulder, or a small prize.3. Voice Control: The attention of the disruptive child is redirected by a change in the tone and volume of the dentist’s voice.4. Mouth Props: A device is placed in the child’s mouth to prevent closure of the child’s teeth on dental equipment.5. Hand and/or Head Holding by Dentist, Dental Assistant, or Parent: An adult keeps a child’s body still so the child cannot grab the dentist’s hand or sharp dental tools. This is to ensure patient safety.6. Medical Immobilization: The child is placed in a restraining device made of cloth and Velcro. This is to ensure that the child is not hurt by his or her own movements. Your child’s doctor will discuss the specic consents should medical immobilization be required for dental treatment.7. Nitrous Oxide Sedation: Nitrous oxide (“laughing gas”) is a medication breathed through a nose mask to relax a nervous child and enable him/her to better tolerate dental treatment. The child will remain awake but is expected to be relaxed and calm. The nitrous oxide is breathed out of the child’s body within a few minutes of being turned off. We recommend an adult hold the child’s hand as they leave the clinic.8. Oral Sedation: Sedative drugs may be recommended to help your child receive quality dentistry in a safe manner if other behavior management techniques do not work. Your child will not be orally sedated without you being further informed and obtaining your specic consent for this procedure. Your child’s doctor will discuss the specic instructions and consents should your child need to be sedated for dental treatment.9. General Anesthesia: The dentist performs the dental treatment with the child anesthetized in the hospital operating room. Your child will not be given general anesthesia without you being further informed and obtaining your specic consent for this procedure. Your child’s doctor will discuss the specic instructions and consents should your child need to be sedated for dental treatment.Description of Patient Management Techniques for Informed Consent at Louisiana State University• BOX 24.3 LSU, Louisiana State University.Modied from The LSU Health Sciences Center, School of Dentistry, New Orleans, LA. 366 Part 3 The Primary Dentition Years: Three to Six Yearswith specic tasks such as holding the mirror or cotton rolls can help bring about cooperative behavior through distraction.Behavior Guidance for the School-Aged ChildSchool provides children with the experience of separating from parents, responding to instructions from strangers, and cooperating in a structured environment. However, these new experiences may be a source of stress for the child, which can manifest in the dental environment.132 Nash133 suggests three skills that can be used for eective communication with children: (1) reective listening, (2) self-disclosing assertiveness (i.e., “I cannot see the teeth when the mouth is closed”), and (3) descriptive praise. In addition, this age group is especially receptive to play and humor. Playing games and telling jokes can be useful to build rapport and make the visit more enjoyable.134 ese techniques are appropriate in all age groups but are especially helpful in this age group of patients as they become more sophisticated in their relationships with adults outside the home.Behavior Guidance for the AdolescentAdolescents can be a very enjoyable group to treat. ey are approaching adulthood with unique personalities and are on their way to establishing and achieving goals. However, it is a mistake to view this group as adults. Adolescents have complex pressures regarding peers, personal appearance, and struggles for independence, and the behavior they exhibit in the dental chair is typically inuenced by events outside the oce. Adolescents still have fears of dental procedures and should be managed in a compassionate manner. Listening with empathy is the most eective behavior guidance technique with adolescent patients. Physical techniques such as muscle relaxation, deep breathing, and progressive exposure have been shown to be successful in the treatment of phobic adolescents.112Behavior Guidance for the Child With Previous Negative Dental ExperiencesChildren with previous negative dental experiences present one of the greatest challenges to the practitioner. It is important to gather as much information about the previous experience from the parent as possible. is interview is best conducted out of the child’s hearing to prevent reviving past memories, but this can be dicult, as these children typically need parental support. Parents should be discouraged from reminding the child of previous dicult dental experiences, because Barton and colleagues135 argue that the memories are not always easily recalled by the child. e purpose of this interview is to try to get a sense of the child’s coping skills and temperament and to avoid past triggers.In communicating with the child, it helps to emphasize the oce as a pleasant area for children and that you are interested and condent in treating the child patient. Even if the child has no dental needs, an introductory appointment such as an exam and prophylaxis can help extinguish fears and promote positive memories with this environment. It can help to emphasize that you are doing something new and dierent so the child’s previous experience is distinguished from this one. Again, the previous experience should not be brought up again. e practitioner should not jump to advanced behavior techniques based solely on a previous bad experience at another oce. Sometimes the child can be treated successfully by a compassionate dentist using communicative attached to parents. Older toddlers can be introduced to the oce by letting them see and touch things.105 Examination of children this age typically takes place on the parent’s lap in the “knee-to-knee” position, using gentle active restraint from the dentist and parent (Fig. 24.6). Parents should be informed that patients may not cooperate for treatment, even for a simple examination, at this age. It is important to set appropriate expectations for behavior before any intervention. Patients with dental caries requiring treatment are a challenge at this age because of their poor coping skills, and advanced management techniques are usually indicated. Caries should be stabilized with interim restorative techniques or silver diamine uoride treatment if possible until behavior improves. If severe caries are present, then advanced behavior guidance techniques are indicated.Behavior Guidance for the PreschoolerLanguage improves dramatically during these years (ages 3 to 5), improving the success of basic behavior guidance.37 By age 4 years, all children should be competent in the domain of language, unless an abnormality is present in their psychological development. Musselman132 describes these children as “great talkers,” and they take pride in their clothes and activities.At this age, clear communication by the dentist is critical. ese children may need more time and patience than others, but the outcomes can be the most rewarding. An undemanding, introduc-tory appointment with emphasis on TSD is especially benecial. Younger children in this age group may be startled by the chair moving back, so it is advisable to have the chair in a supine position at the beginning of the appointment or to have the dentist present the experience of the chair going back as a “spaceship ride.” ese patients will respond best to clear, single-step instructions, followed by positive reinforcement. Even though a toothbrush may adequately remove deposit at this age, use of the rotary prophy cup with child’s toothpaste may desensitize the child to the handpiece and give insight into compliance for planned operative treatments. Appointments should be short and ecient so as to not overwhelm the child’s coping abilities.Children in this age group are increasingly seeking to establish independence, and they take pride in their accomplishments. Four-year-olds have been called “bossy” and may try to impose their will on the experience.132 Enlisting the child to assist you • Figure 24.6 Knee-to-knee examination technique with parent control-ling the child’s arms.