Purpose

The American Academy of Pediatric Dentistry (AAPD) recognizes that dental care is medically necessary for the purpose of preventing and eliminating orofacial disease, infection, and pain, restoring the form and function of the dentition, and correcting facial disfiguration or dysfunction.1  Behavior guidance techniques, both nonpharmalogical and pharmalogical, are used to alleviate anxiety, nurture a positive dental attitude, and perform quality oral health care safely and efficiently for infants, children, adolescents, and persons with special health care needs. Selection of techniques must be tailored to the needs of the individual patient and the skills of the practitioner. The AAPD offers these recommendations to educate health care providers, parents, and other interested parties about influences on the behavior of pediatric dental patients and the many behavior guidance techniques used in contemporary pediatric dentistry. Information regarding protective stabilization and pharmacological behavior management for pediatric dental patients is provided in greater detail in additional AAPD clinical practice guidelines.2-4

Methods

Recommendations on behavior guidance were developed by the Clinical Affairs Committe, Behavior Management Subcommittee and adopted in 1990. This document is a revision of the previous version, last revised in 2011. This document was developed subsequent to the AAPD’s 1988 conference on behavior management and modified following the AAPD’s symposia on behavior guidance in 2003 and 2013.5,6  This update reflects a review of the most recent proceedings, other dental and medical literature related to behavior guidance of the pediatric patient, and sources of recognized professional expertise and stature including both the academic and practicing pediatric dental communities and the standards of the Commission on Dental Accreditation.7 In addition, a search of the PubMed® electronic database was performed using the terms: behavior management in children, behavior management in dentistry, child behavior and dentistry, child and dental anxiety, child preschool and dental anxiety, child personality and test, child preschool personality and test, patient cooperation, dentists and personality, dentist-patient relations, dentist-parent relations, attitudes of parents to behavior management in dentistry, patient assessment in dentistry, pain in dentistry, treatment deferral in dentistry, toxic stress, cultural factors affecting behavior in dentistry, culture of poverty, cultural factors affecting family compliance in dentistry, poverty and stress and effects on dental care, social risks and determinants of health in dentistry, gender shifts in dentistry, protective stabilization and dentistry, medical immobilization, restraint and dentistry, and patient restraint for treatment; fields: all; limits: within the last 10 years, humans, English, birth through age 18. There were 5,843 articles matching these criteria. Papers for review were chosen from this list and from references within selected articles. When data did not appear sufficient or were inconclusive, recommendations were based upon expert and/or consensus opinion by experienced researchers and clinicians. 

Background

Dental practitioners are expected to recognize and effectively treat childhood dental diseases that are within the knowledge and skills acquired during their professional education. Safe and effective treatment of these diseases requires an understanding of and, at times, modifying the child’s and family’s response to care. Behavior guidance is the process by which practitioners help patients identify appropriate and inappropriate behavior, learn problem solving strategies, and develop impulse control, empathy, and self-esteem. This process is a continuum of interaction involving the dentist and dental team, the patient, and the parent; its goals are to establish communication, alleviate fear and anxiety, deliver quality dental care, build a trusting relationship between dentist/staff and child/parent, and promote the child’s positive attitude toward oral health care. Knowledge of the scientific basis of behavior guidance and skills in communication, empathy, tolerance, cultural sensitivity, and flexibility are requisite to proper implementation. Behavior guidance should never be punishment for misbehavior, power assertion, or use of any strategy that hurts, shames, or belittles a patient.

Predictors of child behaviors
Patient attributes
A dentist who treats children should be able to accurately assess the child’s developmental level, dental attitudes, and temperament and to anticipate the child’s reaction to care. The response to the demands of oral health care is complex and determined by many factors. Developmental delay, physical/ mental disability, and acute or chronic disease are potential reasons for noncompliance during the dental appointment. In the healthy communicating child, behavioral influences often are more subtle and difficult to identify. Contributing factors can include fears, general or situational anxiety, a previous unpleasant and/or painful dental/medical experience, inadequate preparation for the encounter, and parenting practices.8-10,22-24  Only a minority of children with uncooperative behavior have dental fears, and not all fearful children present dental behavior guidance problems.8,11,12  Fears may occur when there is a perceived lack of control or potential for pain, especially when a child is aware of a dental problem or has had a painful health care experience. If the level of fear is incongruent with the circumstances and the patient is not able to control impulses, disruptive behavior is likely.

Cultural and linguistic factors also may play a role in attitudes and cooperation and behavior guidance of the child.13-16  Since every culture has its own beliefs, values, and practices, it is important to understand how to interact with patients from different cultures and to develop tools to help navigate their encounters. Qualified interpreters may be required for those families who have limited English proficiency.15,17  The dentist/staff must listen actively and address the patient’s/ parents’ concerns in a sensitive and respectful manner.13 

Parental influences
Parents influence their child’s behavior at the dental office in several ways. Positive attitudes toward oral health care may lead to the early establishment of a dental home. Early preventive care leads to less dental disease, decreased treatment needs, and fewer opportunities for negative experiences.18,19  Parents who have had negative dental experiences8,20,21 as a patient may transmit their own dental anxiety or fear to the child thereby adversely affecting her attitude and response to care.8,20-22  Long term economic hardship and inequality can lead to parental adjustment problems such as depression, anxiety, irritability, substance abuse, and violence.13  Parental depression may result in decreased protection, caregiving, and discipline for the child, thereby placing the child at risk for a wide variety of emotional and behavior problems.13  In America, evolving parenting styles22,23 and parental behaviors influenced by economic hardship have left practitioners challenged by an increasing number of children ill-equipped with the coping skills and self-discipline necessary to contend with new experiences.13-15  Frequently, parental expectations for the child’s response to care (e.g., no tears) are unrealistic, while expectations for the dentist who guides their behavior are great.24

Orientation to dental environment
The non-clinical office staff plays an important role in behavior guidance. The scheduling coordinator or receptionist will have the first contact with a prospective parent, usually through a telephone conversation. The tone of the call should be welcoming and pleasant. The scheduling coordinator should actively engage the parent to determine the primary patient concerns, including special health care or cultural/linguistic needs. The conversation can provide insights into parental anxiety or stress. The staff should help set expectations for the initial visit by providing relevant information and may suggest a preappointment visit to the office to meet the doctor and staff and tour the facility.25  Before the call ends, staff should offer the office’s website and directions and ask if there are any further questions. Such encounters serve as educational tools that help to allay fears and better prepare the parent and child for the first visit.

The receptionist is usually the first staff member the child meets upon arrival at the office. The caring and assuring manner in which the child is welcomed into the practice at the first and subsequent visits is important.24,26  A child-friendly reception area (e.g., age-appropriate toys and games) can both provide a distraction and indicate that the staff has a genuine concern for young patients. These first impressions may influence future behaviors.

Patient assessment
An evaluation of the child’s cooperative potential is essential for treatment planning. No single assessment method or tool is completely accurate in predicting a patient’s behavior, but awareness of the multiple influences on a child’s response to care can aid in treatment planning. Initially, information can be gathered from the parent through questions regarding the child’s cognitive level, temperament/personality characteristics,9,12,27-29 anxiety and fear,8,12,30 reaction to strangers,31 and behavior at previous medical/dental visits, as well as how the parent anticipates the child will respond to future dental treatment. Later, the dentist can evaluate cooperative potential by observation of and interaction with the patient. Whether the child is approachable, somewhat shy, or definitely shy and/or withdrawn may influence the success of various communicative techniques. Assessing the child’s development, past experiences, and current emotional state allows the dentist to develop a behavior guidance plan to accomplish the necessary oral health care.32  During delivery of care, the dentist must remain attentive to physical and/or emotional indicators of stress.13-16,33  Changes in adaptive behaviors may require alterations to the behavioral treatment plan.

Dentist/dental team behaviors
The behaviors of the dentist and dental staff members are the primary tools used to guide the behavior of the pediatric patient. The dentist’s attitude, body language, and communication skills are critical to creating a positive dental visit for the child and to gain trust from the child and parent.18  Dentist/ staff behaviors that help reduce anxiety and encourage patient cooperation are giving clear and specific instructions, an empathetic communication style, and an appropriate level of physical contact accompanied by verbal reassurance.34  While a health professional may be inattentive to communication style, patients/parents are very attentive.35

Communication (i.e., imparting or interchange of thoughts, opinions, or information) may occur by a number of means but, in the dental setting, it is accomplished primarily through dialogue, tone of voice, facial expression, and body language.36  Communication between the doctor/staff and the child and parent is vital to successful outcomes in the dental office.

The four essential ingredients of communication are:

  1. the sender.
  2. the message, including the facial expression and body language of the sender.
  3. the context or setting in which the message is sent; and 
  4. the receiver.47

For successful communication to take place, all four elements must be present and consistent. Without consistency, there may be a poor fit between the intended message and what is understood.36

Communicating with children poses special challenges for the dentist and the dental team. A child’s cognitive development will dictate the level and amount of information interchange that can take place.15  It is impossible for a child to perceive an idea for which she has no conceptual framework and it is unrealistic to expect a child patient to adopt the dentist’s frame of reference. With a basic understanding of the cognitive development of children, the dentist can use appropriate vocabulary and body language to send messages consistent with the receiver’s intellectual development.15,36

Communication may be impaired when the sender’s expression and body language are not consistent with the intended message. When body language conveys uncertainty, anxiety, or urgency, the dentist cannot effectively communicate confidence in her clinical skills.36

The importance of the context in which messages are delivered cannot be overstated. The operatory may contain distractions (e.g., another child crying) that, for the patient, produce anxiety and interfere with communication. Dentists and other members of the dental team may find it advantageous to provide certain information (e.g., post-operative instructions, preventive counseling) away from the operatory and its many distractions.24

The communicative behavior of dentists is a major factor in patient satisfaction.37,38  Dentist actions that are reported to correlate with low parent satisfaction include rushing through appointments, not taking time to explain procedures, barring parents from the examination room, and generally being impatient.27,34  However, when a provider offers compassion, empathy, and genuine concern, there may be better acceptance of care.34  While some patients may express a preference for a provider of a specific gender, female and male practitioners have been found to treat patients and parents in a similar manner.39

The clinical staff is an extension of the dentist in behavior guidance of the patient and communication with the parent. A collaborative approach helps assure that both the patient and parent have a positive dental experience. All dental team members are encouraged to expand their skills and knowledge through dental literature, video presentations, and/or continuing education courses.40

Informed consent
All behavior guidance decisions must be based on a review of the patient’s medical, dental, and social history followed by an evaluation of current behavior. Decisions regarding the use of behavior guidance techniques other than communicative management cannot be made solely by the dentist. They must involve a parent and, if appropriate, the child. The practitioner, as the expert on dental care (i.e., the timing and techniques by which treatment can be delivered), should effectively communicate behavior and treatment options, including potential benefits and risks, and help the parent decide what is in the child’s best interests.18  Successful completion of diagnostic and therapeutic services is viewed as a partnership of dentist, parent, and child.18,41,42

Communicative management, by virtue of being a basic element of communication, requires no specific consent. All other behavior guidance techniques require informed consent consistent with the AAPD’s Guideline on Informed Consent43 and applicable state laws. If the parent refuses the proposed and alternative treatment, other than noncommunicative behavior guidance procedures, it is prudent to have an informed refusal form signed by the parent and retained in the patient’s record.44

In the event of an unanticipated behavioral reaction to dental treatment, it is incumbent upon the practitioner to protect the patient and staff from harm. Following immediate intervention to assure safety, if techniques must be altered to continue delivery of care, the dentist must obtain informed consent for the alternative methods.43,45

Pain assessment and management during treatment
Pain has a direct influence on behavior.46  Findings of pain or a painful past health care visit are important considerations in the patient’s medical/dental history that will help the dentist anticipate possible behavior problems.32,44,46  Likewise, pain assessment and management during pediatric dental procedures are critical as pain has a direct influence on behavior.36  Prevention or reduction of pain during treatment can nurture the relationship between the dentist and the patient, build trust, allay fear and anxiety, and enhance positive dental attitudes for future visits.47-51  The subjective nature of pain perception, varying patient responses to painful stimuli, and lack of use of accurate pain assessment scales may hinder the dentist’s attempts to diagnose and intervene during procedures.20,47,49,52-54  Observing changes in patient behavior (e.g., facial expressions, crying, complaining, body movement during treatment) is important in pain evaluation.47,51  The patient is the best reporter of her pain.20,49,52,55  Listening to the child at the first sign of distress will facilitate assessment and any needed procedural modifications.49  At times, dental providers may underestimate a patient’s level of pain or may develop pain blindness as a defense mechanism and continue to treat a child who really is in pain.20,47,55-58  Misinterpreted or ignored changes in behavior due to painful stimuli can cause sensitization for future appointments as well as psychological trauma.59

Documentation of patient hehaviors
Recording the child’s behavior serves as an aid for future appointments.53  One of the more reliable and frequently used behavior rating systems in both clinical dentistry and research is the Frankl Scale.25,53  This scale (see Appendix 1 in PDF) separates observed behaviors into four categories ranging from definitely negative to definitely positive.25,55 In addition to the rating scale, an accompanying descriptor (e.g., “+, non-verbal”) will help practitioners better plan for subsequent visits.

Treatment deferral
Dental disease usually is not life-threatening and the type and timing of dental treatment can be deferred in certain circumstances. When a child’s cognitive abilities or behavior prevents routine delivery of oral health care using communicative guidance techniques, the dentist must consider the urgency of dental need when determining a plan of treatment.45,60  In some cases, treatment deferral may be considered as an alternative to treating the patient under sedation or general anesthesia. However, rapidly advancing disease, trauma, pain, or infection usually dictates prompt treatment. Deferring some or all treatment or employing therapeutic interventions [e.g., interim therapeutic restoration (ITR)],61,62 fluoride varnish, antibiotics for infection control] until the child is able to cooperate may be appropriate when based upon an individualized assessment of the risks and benefits of that option. The dentist must explain the risks and benefits of deferred or alternative treatments clearly and informed consent must be obtained from the parent.43-45

Treatment deferral also should be considered in cases when treatment is in progress and the patient’s behavior becomes hysterical or uncontrollable. In such cases, the dentist should halt the procedure as soon as possible, discuss the situation with the patient/parent, and either select another approach for treatment or defer treatment based upon the dental needs of the patient. If the decision is made to defer treatment, the practitioner immediately should complete the necessary steps to bring the procedure to a safe conclusion before ending the appointment.60-62

Caries risk should be reevaluated when treatment options are compromised due to child behavior.63  An individualized preventive program, including appropriate parent education and a dental recall schedule, should be recommended after evaluation of the patient’s caries risk, oral health needs, and abilities. Topical fluorides (e.g., brush-on gels, fluoride varnish, professional application during prophylaxis) may be indicated.64  ITR may be useful as both preventive and therapeutic approaches.61,62

Behavior guidance techniques
Since children exhibit a broad range of physical, intellectual, emotional, and social development and a diversity of attitudes and temperament, it is important that dentists have a wide range of behavior guidance techniques to meet the needs of the individual child and be tolerant and flexible in their implementation.18,25  Behavior guidance is not an application of individual techniques created to deal with children, but rather a comprehensive, continuous method meant to develop and nurture the relationship between the patient and doctor, which ultimately builds trust and allays fear and anxiety. Some of the behavior guidance techniques in this document are intended to maintain communication, while others are intended to extinguish inappropriate behavior and establish communication. As such, these techniques cannot be evaluated on an individual basis as to validity, but must be assessed within the context of the child’s total dental experience. Techniques must be integrated into an overall behavior guidance approach individualized for each child. Consequently, behavior guidance is as much an art as it is a science.

 

 

Recommendations

Basic behavior guidance
Communication and communicative guidance
Communicative management and appropriate use of commands are applied universally in pediatric dentistry with both the cooperative and uncooperative child. At the beginning of a dental appointment, asking questions and active/reflective listening can help establish rapport and trust.65  The dentist may establish teacher/student roles in order to develop an educated patient and deliver quality dental treatment safely.18,25  Once a procedure begins, the dentist’s ability to guide and shape behavior becomes paramount, and information sharing becomes secondary. The two-way interchange of information often gives way to one-way guidance of behavior through directives. Use of self-disclosing assertiveness techniques (e.g., “I need you to open your mouth so I can check your teeth”, “I need you to sit still so we can take an X-ray”) tells the child exactly what is required to be cooperative.65  Observation of the child’s body language is necessary to confirm the message is received and to assess comfort and pain level.47,48,65  Communicative management comprises a host of specific techniques that, when integrated, enhance the evolution of a cooperative patient. Rather than being a collection of singular techniques, communicative management is an ongoing subjective process that becomes an extension of the personality of the dentist. Associated with this process are the specific techniques of pre-visit imagery, direct observation, tell-show-do, ask-tellask, voice control, nonverbal communication, positive reinforcement, distraction, and memory restructuring. The dentist should consider the cognitive development of the patient, as well as the presence of other communication deficits (e.g., hearing disorder), when choosing specific communicative management techniques.

Positive pre-visit imagery 

  • Description: Patients are shown positive photographs or images of dentistry and dental treatment in the waiting area before the dental appointment.66
  • Objectives: The objectives of positive pre-visit imagery are to:
    — provide children and parents with visual information on what to expect during the dental visit, and 
    — provide children with context to be able to ask providers relevant questions before dental procedures are initiated.
  • Indications: May be used with any patient.
  • Contraindication: None.

Direct observation 

  • Description: Patients are shown a video or are permitted to directly observe a young cooperative patient undergoing dental treatment.67,68 
  • Objectives: The objectives of direct observation are to:
    — familiarize the patient with the dental setting and specific steps involved in a dental procedure, and
    — give the patient and parent an opportunity to ask questions about the dental procedure in a safe environment.
  • Indications: May be used with any patient.
  • Contraindications: None.

Tell-show-do

  • Description: The technique involves verbal explanations of procedures in phrases appropriate to the developmental level of the patient (tell); demonstrations for the patient of the visual, auditory, olfactory, and tactile aspects of the procedure in a carefully defined, nonthreatening setting (show); and then, without deviating from the explanation and demonstration, completion of the procedure (do). The tell-show-do technique is used with communication skills (verbal and nonverbal) and positive reinforcement.18,26,69 
  • Objectives: The objectives of tell-show-do are to:
    — teach the patient important aspects of the dental visit and familiarize the patient with the dental setting, and
    — shape the patient’s response to procedures through de- sensitization and well-described expectations. 
  • Indications: May be used with any patient.
  • Contraindications: None.

Ask-tell-ask

  • Description: This technique involves inquiring about the patient’s visit and feelings toward or about any planned procedures (ask); explaining the procedures through demonstrations and non-threatening language appropriate to the cognitive level of the patient (tell); and again inquiring if the patient understands and how she feels about the impending treatment (ask). If the patient continues to have concerns, the dentist can address them, assess the situation, and modify the procedures or behavior guidance techniques if necessary.15 
  • Objective: The objectives of ask-tell-ask are to:
    — assess anxiety that may lead to noncompliant behavior during treatment;
    — teach the patient about the procedures and how they are going to be accomplished; and
    — confirm the patient is comfortable with the treatment before proceeding.
  • Indications: May be used with any patient able to dialogue.
  • Contraindications: None.

Voice control

  • Description: Voice control is a deliberate alteration of voice volume, tone, or pace to influence and direct the patient’s behavior. While a change in cadence may be readily accepted, use of an assertive voice may be considered aversive to some parents unfamiliar with this technique. An explanation prior to its use may prevent misunderstanding.18,25,26,69 
  • Objectives: The objectives of voice control are to:
    — gain the patient’s attention and compliance;
    — avert negative or avoidance behavior; and
    — establish appropriate adult-child roles.
  • Indications: May be used with any patient.
  • Contraindications: Patients who are hearing impaired.

Nonverbal communication 

  • Description: Nonverbal communication is the reinforcement and guidance of behavior through appropriate contact, posture, facial expression, and body language.18,26,42,69 
  • Objectives: The objectives of nonverbal communication are to:
    — enhance the effectiveness of other communicative management techniques, and
    — gain or maintain the patient’s attention and compliance. 
  • Indications: May be used with any patient. 
  • Contraindications: None.

Positive reinforcement and descriptive praise 

  • Description: In the process of establishing desirable patient behavior, it is essential to give appropriate feedback. Positive reinforcement rewards desired behaviors thereby strengthening the likelihood of recurrence of those behaviors. Social reinforcers include positive voice modulation, facial expression, verbal praise, and appropriate physical demonstrations of affection by all members of the dental team. Descriptive praise emphasizes specific cooperative behaviors (e.g., “Thank you for sitting still”, “You are doing a great job keeping your hands in your lap”) rather than a generalized praise (e.g., “Good job”).65  Nonsocial reinforcers include tokens and toys.
  • Objective: The objective of positive reinforcement and descriptive praise is to reinforce desired behavior.25,36,69,70 
  • Indications: May be used with any patient.
  • Contraindications: None.

Distraction

  •  Description: Distraction is the technique of diverting the patient’s attention from what may be perceived as an unpleasant procedure. Giving the patient a short break during a stressful procedure can be an effective use of distraction prior to consideering more advanced behavior guidance techniques.25,36,70
  •  Objectives: The objectives of distraction are to:
    — decrease the perception of unpleasantness, and
    — avert negative or avoidance behavior. 
  • Indications: May be used with any patient.
  • Contraindications: None.

Memory restructuring 

  • Description: Memory restructuring is a behavioral approach in which memories associated with a negative or difficult event (e.g., first dental visit, local anesthesia, restorative procedure, extraction) are restructured into positive memories using information suggested after the event has taken place.71 This approach been tested with children who received local anesthesia at an initial restorative dental visit and has been shown to change local anesthesia-related fears and improve behaviors at subsequent treatment visits.71,72 Restructuring involves four components: (1) visual reminders; (2) positive reinforcement through verbalization; (3) concrete examples to encode sensory details; and (4) sense of accomplishment. A visual reminder could be a photograph of the child smiling at the initial visit (i.e., prior to the difficult experience). Positive reinforcement through verbalization could be asking if the child had told her parent what a good job she had done at the last appointment. The child is asked to role-play and to tell the dentist what she had told the parent. Concrete examples to encode sensory details include praising the child for specific positive behavior such as keeping her hands on her lap or opening her mouth wide when asked. The child then is asked to demonstrate these behaviors, which leads to a sense of accomplishment. 
  • Objectives: The objectives of memory restructuring are to:
    — restructure difficult or negative past dental experiences, and
    — improve patient behaviors at subsequent dental visits.
  • Indications: May be used with patients who had a negative or difficult dental visits.
  • Contraindications: None

Parental presence/absence 

  • Description: The presence or absence of the parent sometimes can be used to gain cooperation for treatment. A wide diversity exists in practitioner philosophy and parental attitude regarding parents’ presence or absence during pediatric dental treatment. As establishment of a dental home by 12 months of age continues to grow in acceptance, parents will expect to be with their infants and young children during examinations as well as during treatment. Parental involvement, especially in their children’s health care, has changed dramatically in recent years.18,73  Parents’ desire to be present during their child’s treatment does not mean they intellectually distrust the dentist; it might mean they are uncomfortable if they visually cannot verify their child’s safety. It is important to understand the changing emotional needs of parents because of the growth of a latent but natural sense to be protective of their children.74  Practitioners should become accustomed to this added involvement of parents and welcome the questions and concerns for their children. Practitioners must consider parents’ desires and wishes and be open to a paradigm shift in their own thinking.5,18,24,74,75 
  • Objectives: The objectives of parental presence/absence are:
    For parents to:
    — participate in infant examinations and/or treatment;
    — offer very young children physical and psychological support; and
    — observe the reality of their child’s treatment.
    For practitioners to:
    — gain the patient’s attention and improve compliance;
    — avert negative or avoidance behaviors;
    — establish appropriate dentist-child roles;
    — enhance effective communication among the dentist, child, and parent;
    — minimize anxiety and achieve a positive dental experience; and
    — facilitate rapid informed consent for changes in treatment or behavior guidance.
  • Indications: May be used with any patient.
  • Contraindications: Parents who are unwilling or unable to extend effective support.

Communication techniques for parents (and age appropriate patients)
Because parents are the legal guardians of minors, successful bi-directional communication between the dentist/staff and the parent is essential to assure effective guidance of the child’s behavior.43  Socioeconomic status, stress level, marital discord, dental attitudes aligned with a different cultural heritage, and linguistic skills may present challenges to open and clear communication.13,15,76  Communication techniques such as ask-tell-ask, teach back, and motivational interviewing can reflect the dentist/staff’s caring for and engaging in a patient/ parent centered-approach.15  These techniques are presented in Appendix 2 (see PDF).

Nitrous oxide/oxygen inhalation 

  • Description: Nitrous oxide/oxygen inhalation is a safe and effective technique to reduce anxiety and enhance effective communication. Its onset of action is rapid, the effects easily are titrated and reversible, and recovery is rapid and complete. Additionally, nitrous oxide/oxygen inhalation mediates a variable degree of analgesia, amnesia, and gag reflex reduction. The need to diagnose and treat, as well as the safety of the patient and practitioner, should be considered before the use of nitrous oxide/oxygen analgesia/ anxiolysis. If nitrous oxide/oxygen inhalation is used in concentrations greater than 50 percent or in combination with other sedating medications (e.g., midazolam, an opioid), the likelihood for moderate or deep sedation increases.77,78  In these situations, the clinician must be prepared to institute the guidelines for moderate or deep sedation.3  Detailed information concerning the indications, contraindications, and additional clinical considerations may be found in the Guideline on Use of Nitrous Oxide for Pediatric Dental Patients and Guidelines for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures: An Update.2,3
  • Objectives: The objectives of nitrous oxide/oxygen inhalation include to:
    — reduce or eliminate anxiety;
    — reduce untoward movement and reaction to dental treatment;
    — enhance communication and patient cooperation;
    — raise the pain reaction threshold;
    — increase tolerance for longer appointments;
    — aid in treatment of the mentally/physically disabled or medically compromised patient;
    — reduce gagging; and
    — potentiate the effect of sedatives.
  • Indications: Indications for use of nitrous oxide/oxygen inhalation analgesia/anxiolysis include:
    — a fearful, anxious, or obstreperous patient;
    — certain patients with special health care needs;
    — a patient whose gag reflex interferes with dental care;
    — a patient for whom profound local anesthesia cannot be obtained; and
    — a cooperative child undergoing a lengthy dental procedure.
  • Contraindications: Contraindications for use of nitrous oxide/oxygen inhalation may include:
    — some chronic obstructive pulmonary diseases;79
    — severe emotional disturbances or drug-related dependencies;79
    — first trimester of pregnancy;79,80
    — methylenetetrahydrofolate reductase deficiency;81 and
    — recent illnesses (e.g., cold or congestion) that may compromise the airway.

Advanced behavior guidance
Most children can be managed effectively using the techniques outlined in basic behavior guidance. Such techniques should form the foundation for all of the management activities provided by the dentist. Children, however, occasionally present with behavioral considerations that require more advanced techniques. These children often cannot cooperate due to lack of psychological or emotional maturity and/or mental, physical, or medical disability. The advanced behavior guidance techniques commonly used and taught in advanced pediatric dental training programs include protective stabilization, sedation, and general anesthesia.82  They are extensions of the overall behavior guidance continuum with the intent to facilitate the goals of communication, cooperation, and delivery of quality oral health care in the non-compliant patient. Skillful diagnosis of behavior and safe and effective implementation of these techniques necessitate knowledge and experience that are generally beyond the core knowledge students receive during predoctoral dental education. While most predoctoral programs provide didactic exposure to treatment of very young children (i.e., aged birth through two years), patients with special health care needs, and patients requiring advanced behavior guidance techniques, hands-on experience is lacking.82  A minority of programs provides educational experiences with these patient populations, while few provide hands-on exposure to advanced behavior guidance techniques.82  “On average, predoctoral pediatric dentistry programs teach students to treat children four years of age and older, who are generally well behaved and have low levels of caries.”82  Dentists considering the use of these advanced behavior guidance techniques should seek additional training through a residency program, a graduate program, and/or an extensive continuing education course that involves both didactic and experiential mentored training.

Protective stabilization

  • Description: The use of any type of protective stabilization in the treatment of infants, children, adolescents, or patients with special health care needs is a topic that concerns health care providers, care givers, and the public.26,45,84-91  The broad definition of protective stabilization is the restriction of patient’s freedom of movement, with or without the patient’s permission, to decrease risk of injury while allowing safe completion of treatment. The restriction may involve another person(s), a patient stabilization device, or a combination thereof. The use of protective stabilization has the potential to produce serious consequences, such as physical or psychological harm, loss of dignity, and violation of a patient’s rights. Stabilization devices placed around the chest may restrict respirations; they must be used with caution, especially for patients with respiratory compromise (e.g., asthma) and/or for patients who will receive medications (i.e., local anesthetics, sedatives) that can depress respirations. Because of the associated risks and possible consequences of use, the dentist is encouraged to evaluate thoroughly its use on each patient and possible alternatives.45,92  Careful, continuous monitoring of the patient is mandatory during protective stabilization.45,92

    Partial or complete stabilization of the patient sometimes is necessary to protect the patient, practitioner, staff, or the parent from injury while providing dental care. Protective stabilization can be performed by the dentist, staff, or parent with or without the aid of a restrictive device.45,92  The dentist always should use the least restrictive, but safe and effective, protective stabilization.45,92  The use of a mouth prop in a compliant child is not considered protective stabilization.

    The need to diagnose, treat, and protect the safety of the patient, practitioner, staff, and parent should be considered prior to the use of protective stabilization. The decision to use protective stabilization must take into consideration:
    — alternative behavior guidance modalities;
    — dental needs of the patient;
    — the effect on the quality of dental care;
    — the patient’s emotional development; and
    — the patient’s medical and physical considerations.

    Protective stabilization, with or without a restrictive device, led by the dentist and performed by the dental team requires informed consent from a parent. Informed consent must be obtained and documented in the patient’s record prior to use of protective stabilization. Furthermore, when appropriate, an explanation to the patient regarding the need for restraint, with an opportunity for the patient to respond, should occur.43,45,93

    In the event of an unanticipated reaction to dental treatment, it is incumbent upon the practitioner to protect the patient and staff from harm. Following immediate intervention to assure safety, if techniques must be altered to continue delivery of care, the dentist must have informed consent for the alternative methods.43,60
  • Objectives: The objectives of patient stabilization are to:
    — reduce or eliminate untoward movement;
    — protect patient, staff, dentist, or parent from injury; and
    — facilitate delivery of quality dental treatment.
  • Indications: Patient stabilization is indicated for:
    — a patient who requires immediate diagnosis, urgent care, and/or limited treatment and cannot cooperate due to emotional or cognitive developmental levels, lack of maturity, or mental or physical conditions;
    — a patient who requires immediate diagnosis, urgent care, and/or limited treatment and uncontrolled movements risk the safety of the patient, staff, dentist, or parent without the use of protective stabilization; and
    — sedated patients to help reduce untoward movement.
  • Contraindications: Patient stabilization is contraindicated for: 
    — cooperative non-sedated patients;
    — patients who cannot be immobilized safely due to asso- ciated medical, psychological, or physical conditions;
    — patients with a history of physical or psychological trauma due to immobilization (unless no other alternatives are available);
    — patients with non-emergent treatment needs in order to accomplish full mouth or multiple quadrant dental rehabilitation; and
    — practitioner’s convenience.
  • Precautions: The following precautions should be taken:
    — the patient’s medical history must be reviewed carefully to ascertain if there are any medical conditions (e.g., asthma) which may compromise respiratory function;
    — tightness and duration of the stabilization must be monitored and reassessed at regular intervals;
    — stabilization around extremities or the chest must not actively restrict circulation or respiration;
    — observation of body language and pain assessment must be continuous to allow for procedural modifications at the first sign of distress; and
    — stabilization should be terminated as soon as possible in a patient who is experiencing severe stress or hysterics to prevent possible physical or psychological trauma.
  • Documentation: The 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 implication for future appointments.

Sedation 

  • Description: Sedation can be used safely and effectively with patients who are unable to cooperate due to lack of psychological or emotional maturity and/or mental, physical, or medical disability. Background information and documentation for the use of sedation is detailed in the Guideline for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures.3

    The need to diagnose and treat, as well as the safety of the patient, practitioner, and staff, should be considered for the use of sedation. The decision to use sedation must take into consideration:
    — alternative behavioral guidance modalities; 
    —dental needs of the patient;
    — the effect on the quality of dental care;
    — the patient’s emotional development; and
    — the patient’s medical and physical considerations.
  • Objectives: The goals of sedation are to:
    — guard the patient’s safety and welfare;
    — minimize physical discomfort and pain;
    — control anxiety, minimize psychological trauma, and maximize the potential for amnesia;
    — control behavior and/or movement so as to allow the safe completion of the procedure; and
    — return the patient to a state in which safe discharge from medical supervision, as determined by recognized criteria, is possible.
  • Indications: Sedation is indicated for:
    — fearful, anxious patients for whom basic behavior guidance techniques have not been successful;
    — patients who cannot cooperate due to a lack of psycho- logical or emotional maturity and/or mental, physical, or medical disability; and
    — patients for whom the use of sedation may protect the developing psyche and/or reduce medical risk.
  • Contraindications: The use of sedation is contraindicated for:
    — the cooperative patient with minimal dental needs; and
    — predisposing medical and/or physical conditions which would make sedation inadvisable.
  • Documentation: The patient’s record shall include:2
    — informed consent. Informed consent must be obtained from the parent and documented prior to the use of sedation;
    — instructions and information provided to the parent;
    — health evaluation;
    — a time-based record that includes the name, route, site, time, dosage, and patient effect of administered drugs;
    — the patient’s level of consciousness, responsiveness, heart rate, blood pressure, respiratory rate, and oxygen satura tion at the time of treatment and until predetermined discharge criteria have been attained;
    — adverse events (if any) and their treatment; and
    — time and condition of the patient at discharge.

General anesthesia 

  • Description: General anesthesia is a controlled state of unconsciousness accompanied by a loss of protective reflexes, including the ability to maintain an airway independently and respond purposefully to physical stimulation or verbal command. The use of general anesthesia sometimes is necessary to provide quality dental care for the child. Depending on the patient, this can be done in a hospital or an ambulatory setting, including the dental office. Additional background information may be found in the Guideline on Use of Anesthesia Care Personnel in the Administration of Office-based Deep Sedation/General Anesthesia to the Pediatric Dental Patient. 4 The need to diagnose and treat, as well as the safety of the patient, practitioner, and staff, should be considered for the use of general anesthesia. Anesthetic and sedative drugs are used to help ensure the safety, health, and comfort of children undergoing procedures. Increasing evidence from research studies suggests the benefits of these agents should be considered in the context of their potential to cause harmful effects.94 Additional research is needed to identify any possible risks to young children. “In the absence of conclusive evidence, it would be unethical to withhold sedation and anesthesia when necessary”.95 The decision to use general anesthesia must take into consideration:
    — alternative modalities;
    — age of the patient;
    — risk benefit analysis;
    — treatment deferral;
    — dental needs of the patient;
    — the effect on the quality of dental care;
    — the patient’s emotional development; and
    — the patient’s medical status. 
  • Objectives: The goals of general anesthesia are to:

    — provide safe, efficient, and effective dental care;
    — eliminate anxiety;
    — reduce untoward movement and reaction to dental treatment;
    — aid in treatment of the mentally, physically, or medi- cally compromised patient; and
    — eliminate the patient’s pain response.
  • Indications: General anesthesia is indicated for:
    — patients who cannot cooperate due to a lack of psychological or emotional maturity and/or mental, physical, or medical disability;
    — patients for whom local anesthesia is ineffective because of acute infection, anatomic variations, or allergy;
    — the extremely uncooperative, fearful, anxious, or uncommunicative child or adolescent;
    — patients requiring significant surgical procedures;
    — patients for whom the use of general anesthesia may protect the developing psyche and/or reduce medical risk; and
    — patients requiring immediate, comprehensive oral/ dental care.
  • Contraindications: The use of general anesthesia is contraindicated for:
    — a healthy, cooperative patient with minimal dental needs;
    — a very young patient with minimal dental needs that can be addressed with therapeutic interventions (e.g., ITR, fluoride varnish) and/or treatment deferral;
    — patient/practitioner convenience; and
    — predisposing medical conditions which would make general anesthesia inadvisable.
  • Documentation: Prior to the delivery of general anesthesia, appropriate documentation shall address the rationale for use of general anesthesia, informed consent, instructions provided to the parent, dietary precautions, and preoperative health evaluation. Because laws and codes vary from state to state, each practitioner must be familiar with her state guidelines. Minimal requirements for a time-based anesthesia record should include:
    — the patient’s heart rate, blood pressure, respiratory rate, and oxygen saturation at specific intervals throughout the procedure and until predetermined discharge criteria have been attained;
    — the name, route, site, time, dosage, and patient effect of administered drugs, including local anesthesia;
    — adverse events (if any) and their treatment; and
    — that discharge criteria have been met, the time and condition of the patient at discharge, and into whose care the discharge occurred.

References

  1. American Academy of Pediatric Dentistry. Policy on medically necessary care. Pediatr Dent 2015;37(special issue):18-22. 
  2. American Academy of Pediatric Dentistry. Guideline on use of nitrous oxide for pediatric dental patients. Pediatr Dent 2015;37(special issue):206-10.
  3. American Academy of Pediatrics, American Academy of Pediatric Dentistry. Guideline for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures. Pediatr Dent 2014;36(special issue):209-25.
  4. American Academy of Pediatric Dentistry. Guideline on use of anesthesia personnel in the administration of office-based deep sedation/general anesthesia to the pediatric dental patient. Pediatr Dent 2015;37(special issue):211-27. 
  5. American Academy of Pediatric Dentistry. Proceedings of the consensus conference: Behavior management for the pediatric dental patient. American Academy of Pediatric Dentistry. Chicago, Ill.; 1989. 
  6. American Academy of Pediatric Dentistry. Special issue: Proceedings of the conference on behavior management for the pediatric dental patient. Pediatr Dent 2004;26(2):110-83. 
  7. American Dental Association Commission on Dental Accreditation. Accreditation Standards for Advanced Specialty Education Programs in Pediatric Dentistry. American Dental Association. Chicago, Ill.; 2013. Available at: “http://www.ada.org/~/media/CODA/Files/ped.ashx”. Accessed August 26, 2015.
  8. Baier K, Milgrom P, Russell S, Mancl L, Yoshida T. Children’s fear and behavior in private pediatric dentistry practices. Pediatr Dent 2004;26(4):316-21.
  9. Rud B, Kisling E. The influence of mental development on children’s acceptance of dental treatment. Scand J Dent Res 1973;81(5):343-52.
  10. Brill WA. The effect of restorative treatment on children’s behavior at the first recall visit in a private pediatric dental practice. J Clin Pediatr Dent 2002;26(4):389-94.
  11. Klingberg G, Broberg AG. Temperament and child dental fear. Pediatr Dent 1998;20(4):237-43.
  12. Arnup K, Broberg AG, Berggren U, Bodin L. Lack of cooperation in pediatric dentistry: The role of child personality characteristics. Pediatr Dent 2002;24(2):119-28.
  13. Long N. Stress and economic hardship: The impact on children and parents. Pediatr Dent 2014;36(2):109-14. 
  14. Boyce TW. The lifelong effects of early childhood adversity and toxic stress. Pediatr Dent 2014;36(2):102-7.
  15. Goleman J. Cultural factors affecting behavior guidance and family compliance. Pediatr Dent 2014;36(2):121-7.
  16. da Fonseca MA. Eat or heat? The effects of poverty on children’s behavior. Pediatr Dent 2014;36(2):132-7.
  17. Chen AH, Youdelman MK, Brooks J. The legal framework for language access in healthcare settings: Title VI and beyond. J Gen Intern Med 2007;22(suppl 2):362-7.
  18. Feigal RJ. Guiding and managing the child dental patient: A fresh look at old pedagogy. J Dent Educ 2001;65(12):1369-77.
  19. American Academy of Pediatric Dentistry. Policy on the dental home. Pediatr Dent 2015;37(special issue):24-5.
  20. Versloot J, Craig KD. The communication of pain in paediatric dentistry. Eur Arch Paediatr Dent 2009;10(2);61-6.
  21. Klingberg G, Berggren U. Dental problem behaviors in children of parents with severe dental fear. Swed Dent J 1992;16(1-2):27-32, 39. 
  22. Long N. The changing nature of parenting in America. Pediatr Dent 2004;26(2):121-4. 
  23. Howenstein J, Kumar A, Casamassimo PS, McTigue D, Coury D, Yin H. Correlating parenting styles with child behavior and caries. Pediatr Dent 2015;37(1):59-64.
  24. Sheller B. Challenges of managing child behavior in the 21st century dental setting. Pediatr Dent 2004;26(2):111-3.
  25. Wright GZ, Stigers JI. Nonpharmacologic management of children’s behaviors. In: Dean JA, Avery DR, McDonald RE, eds. McDonald and Avery’s Dentistry for the Child and Adolescent. 9th ed. Maryland Heights, Mo.: Mosby-Elsevier; 2011:27-40. 
  26. Law CS, Blain S. Approaching the pediatric dental patient: A review of nonpharmacologic behavior management strategies. J Calif Dent Assoc 2003;31(9):703-13.
  27. Radis FG, Wilson S, Griffen AL, Coury DL. Temperament as a predictor of behavior during initial dental examination in children. Pediatr Dent 1994;16(2):121-7.
  28. Lochary ME, Wilson S, Griffen AL, Coury DL. Temperament as a predictor of behavior for conscious sedation in dentistry. Pediatr Dent 1993;15(5):348-52.
  29. Jensen B, Stjernqvist K. Temperament and acceptance of dental treatment under sedation in preschool children. Acta Odontol Scand 2002;60(4):231-6.
  30. Arnup K, Broberg AG, Berggren U, Bodin L. Treatment outcome in subgroups of uncooperative child dental patients: An exploratory study. Int J Paediatr Dent 2003;13(5):304-19.
  31. Holst A, Hallonsten AL, Schroder U, Ek L, Edlund K. Prediction of behavior-management problems in 3- year-old children. Scand J Dent Res 1993;101(2):110-4.
  32. American Academy of Pediatric Dentistry. Policy on pediatric pain management. Pediatr Dent 2015;37(special issue):82-3.
  33. Shonkoff JP, Garner AS. The lifelong effects of early childhood adversity and toxic stress. Pediatrics 2012;129:e232-46. 
  34. Zhou Y, Cameron E, Forbes, G, Humphris G. Systematic review of the effect of dental staff behavior on child dental patient anxiety and behavior. Patient Educ Couns 2011;85(1):4-13. 
  35. Hall JA, Roter DL, Katz NR. Task versus socio-emotional behaviors in physicians. Med Care 1987;25(5):399-412.
  36.  Chambers DW. Communicating with the young dental patient. J Am Dent Assoc 1976;93(4):793-9. 
  37. Gale EN, Carlsson SG, Eriksson A, Jontell M. Effects of dentists’ behavior on patients’ attitudes. J Am Dent Assoc 1984;109(3):444-6. 
  38. Schouten BC, Eijkman MA, Hoogstraten J. Dentists’ and patients’ communicative behavior and their satisfaction with the dental encounter. Community Dent Health 2003;20(1):11-5.
  39. Wells M, McTigue DJ, Casamassimo PS, Adair S. Gender shifts and effects on behavior guidance. Pediatr Dent 2014;36(2):138-44.
  40. Adair SM, Schafer TE, Rockman RA, Waller JL. Survey of behavior management teaching in predoctoral pediatric dentistry programs. Pediatr Dent 2004;26(2):143-50.
  41. Freeman R. Communicating with children and parents: Recommendations for a child-parent-centered approach for paediatric dentistry. Eur Arch Paediatr Dent 2008;9(1):16-22.
  42. Eaton JJ, McTigue DJ, Fields HW Jr, Beck M. Attitudes of contemporary parents toward behavior management techniques used in pediatric dentistry. Pediatr Dent 2005;27(2):107-13. 
  43. American Academy of Pediatric Dentistry. Guideline on informed consent. Pediatr Dent 2015;37(special issue):315-7.
  44. American Dental Association Division of Legal Affairs. Dental Records. Chicago, Ill.: American Dental Association; 2007:16. 
  45. Nunn J, Foster M, Master S, Greening S. 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. 
  46. Burgess J, Meyers A. Pain management in dentistry. Available at: “http://emedicine.medscape.com/article 2066114-overview”. Accessed February 17, 2015. 
  47. Nutter DP. Good clinical pain practice for pediatric procedure pain: Iatrogenic considerations. J Calif Dent Assoc 2009;37(10):713-8.
  48. Nutter DP. Good clinical pain practice for pediatric procedure pain: Target considerations. J Calif Dent Assoc 2009;37(10):719-22.
  49. Nutter DP. Good clinical pain practice for pediatric procedure pain: Neurobiologic considerations. J Calif Dent Assoc 2009;37(10):705-10.
  50. Nakai Y, Milgrom P, Mancl L, Coldwell SE, Domoto PK, Ramsay DS. Effectiveness of local anesthesia in pediatric dental practice. J Am Dent Assoc 2000;131(12):1699-705.
  51. American Academy of Pediatric Dentistry. Guideline on Use of local anesthesia for pediatric dental patients. Pediatr Dent 2015;37(special issue):199-205.
  52. Versloot J, Veerkamp JS, Hoogstraten J. Children’s selfreported pain at the dentist. Pain 2008;137(2):389-94. 
  53. Klingberg G. Dental anxiety and behaviour management problems in paediatric dentistry: A review of background factors and diagnostics. Eur Arch Paediatr Dent 2007;8(4):11-5.
  54. Stinson JN, Kavanagh T, Yamada J, Gill N, Stevens B. Systematic review of the psychometric properties, interpretability and feasibility of self-reporting pain intensity measures for use in clinical trials in children and adolescents. Pain 2006;125(1):143-57. 
  55. Versloot J, Veerkamp JS, Hoogstraten J. Assessment of pain by the child, dentist, and independent observers. Pediatr Dent 2004;26(5):445-9.
  56. Rasmussen JK, Fredeniksen JA, Hallonsten AL, Poulsen S. Danish dentists’ knowledge, attitudes and management of procedural dental pain in children: Association with demographic characteristics, structural factors, perceived stress during the administration of local analgesia and their tolerance towards pain. Int J Paediatr Dent 2005;15(3):159-68.
  57. Wondimu B, Dahllöf G. Attitudes of Swedish dentists to pain and pain management during dental treatment of children and adolescents. Euro J Paediatr Dent 2005;6(2):66-72. 
  58. Murtomaa H, Milgrom P, Weinstein P, Vuopio T. Dentists’ perceptions and management of pain experienced by children during treatment: A survey of groups of dentists in the USA and Finland. Int J Paediatr Dent 1966;6(1):25-30. 
  59. American Academy of Pediatric Dentistry. Behavior symposium Workshop A report – Current guidelines/ revisions. Pediatr Dent 2014;36(2):152-3. 
  60. Seale NS. Behavior management conference panel III report: Legal issues associated with managing children’s behavior in the dental office. Pediatr Dent 2004;26(2):175-9.
  61. American Academy of Pediatric Dentistry. Guideline on restorative dentistry. Pediatr Dent 2015;37(special issue):232-43.
  62. American Academy of Pediatric Dentistry. Policy on interim therapeutic restorations (ITR). Pediatr Dent 2015;37(special issue):48-9. 
  63. American Academy of Pediatric Dentistry. Guideline on caries-risk assessment and management for infants, children, and adolescents. Pediatr Dent 2015;37(special issue):132-9. 
  64. American Academy of Pediatric Dentistry. Guideline on fluoride therapy. Pediatr Dent 2015;37(special issue):176-9.
  65. Nash DA. Engaging children’s cooperation in the dental environment through effective communication. Pediatr Dent 2006;28(5):455-9.
  66. 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):455-9.
  67. Melamed BG, Hawes RR, Heiby E, Glick J. Use of filmed modeling to reduce uncooperative behavior of children during dental treatment. J Dent Res 1975;54(4):797-801.
  68. Williams JA, Hurst MK, Stokes TF. Peer observation in decreasing uncooperative behavior in young dental patients. Behav Modif 1983;7(2):225-42.
  69. Townsend JA. Behavior guidance in the pediatric patient. In: Casamassimo PS, Fields HW Jr, McTigue DJ, Nowak AJ, eds. Pediatric Dentistry - Infancy through Adolescence. 5th ed. St Louis, Mo., Elsevier-Saunders Co.; 2013:352-70.
  70. Pinkham JR. The roles of requests and promises in child patient management. J Dent Child 1993;60(3):169-74.
  71. Kamath PS. A novel distraction technique for pain management during local anesthesia administration in pediatric patients. J Clin Pediatr Dent 2013;38(1):45-7.
  72. Pickrell JE, Heima M, Weinstein P, et al. Using memory restructuring strategy to enhance dental behaviour. Int J Paediatr Dent 2007;17(6):439-48.
  73. La Rosa-Nash PA, Murphy JM. A clinical case study: Parent-present induction of anesthesia in children. Pediatr Nursing 1996;22(2):109-11.
  74. Pinkham JR. An analysis of the phenomenon of increased parental participation during the child’s dental experience. J Dent Child 1991;58(6):458-63.
  75. Shroff S, Hughes C, Mobley C. Attitudes and preferences of parents about being present in the dental operatory. Pediatr Dent 2015;37(1):51-5.
  76. Fisher-Owens S. Broadening perspectives on pediatric oral health care provision: Social determinants of health and behavioral management. Pediatr Dent 2014;36(2):115-20.
  77. Litman RS, Kottra JA, Berkowitz RJ, Ward DS. Breathing patterns and levels of consciousness in children during administration of nitrous oxide after oral midazolam premedication. J Oral Maxillofac Surg 1997;55(12):1372-7, discussion 1378-9.
  78. Litman RS, Kottra JA, Verga KA, Berkowitz RJ, Ward DS. Chloral hydrate sedation: The additive sedative and respiratory depressant effects of nitrous oxide. Anesth Analg 1998;86(4):724-8.
  79. Becker DE, Rosenberg M. Nitrous oxide and the inhalation anesthetics. Anesth Prog 2008;55(4):124-31.
  80. American Academy of Pediatric Dentistry. Guideline on oral health care for the pregnant adolescent. Pediatr Dent 2015;37(special issue):159-65.
  81. Wyatt SS, Gill RS. An absolute contraindication to nitrous oxide. Anaesthesia 1999;54(3):307.
  82. Adair SM, Rockman RA, Schafer TE, Waller JL. Survey of behavior management teaching in pediatric dentistry advanced education programs. Pediatr Dent 2004;26(2):151-8.
  83. Seale NS, Casamassimo PS. US predoctoral education in pediatric dentistry: Its impact on access to dental care. J Dent Educ 2003;67(1):23-30.
  84. Connick C, Palat M, Puagliese S. The appropriate use of physical restraint: Considerations. ASDC J Dent Child 2000;67(4):231, 256-62. 
  85. Crossley ML, Joshi G. An investigation of pediatric dentists’ attitudes towards parent accompaniment and behavioral management techniques in the UK. Br Dent J 2002;192(9):517-21. 
  86. Peretz B, Zadik D. Parents’ attitudes toward behavior management techniques during dental treatment. Pediatr Dent 1999;2(3):201-4.
  87. Peretz B, Gluck GM. The use of restraint in the treatment of pediatric dental patients: Old and new insights. Int J Paediatr Dent 2002;12(6):392-7.
  88. Brill WA. Parents’ assessment and children’s reactions to a passive restraint device used for behavior control in a private pediatric dental practice. ASDC J Dent Child 2002;69(3):236, 310-3.
  89. Kupietzky A. Strap him down or knock him out: Is conscious sedation with restraint an alternative to general anesthesia? Br Dent J 2004;196(3):133-8. 
  90. Manley MCG. A UK perspective. Br Dent J 2004;196(3):138-9.
  91. Morris CDN. A commentary on the legal issues. Br Dent J 2004;196(3):139-40. 
  92. Joint Commission on Accreditation of Healthcare Organizations. Comprehensive Accreditation Manual for Hospitals 2011. Oakbrook Terrace, Ill.: Joint Commission on Accreditation of Healthcare Organizations; 2011:pc30-pc66. 
  93. American Academy of Pediatrics Committee on Pediatric Emergency Medicine. The use of physical restraint inter-ventions for children and adolescents in the acute care setting. Pediatrics 1997;99(3):497-8.
  94. American Academy of Pediatrics. The pediatrician’s role in the evaluation and preparation of pediatric patients undergoing anesthesia. Pediatrics 2014;134(3):634-41.
  95. SmartTots. Consensus statement regarding anesthesia safety in children. Available at: “http://www.smarttots.org/media/smarttots-releases-consensus-statementregarding-anesthesia-safety-in-children”. Accessed August 15, 2015