OFFICIAL BUT UNFORMATTED
Methods
Recommendations on behavior guidance were developed by the Clinical Affairs Committee, Behavior
Management Subcommittee and adopted in 1990.
7
This document by the Council of Clinical Affairs is a revision
of the previous version, last revised in 2020.
8
This update reflects a review of proceedings from the most recent
AAPD conferences on behavior guidance
9,10
, 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.
11(pg25-
26)
In addition, a search of the PubMed
®
/MEDLINE electronic database was performed (see Appendix 1). Articles
were screened by viewing titles and abstracts. A narrative review was performed to extract the data and used to
summarize research on behavior guidance for infants and children through adolescents, including those with
special healthcare needs. An additional 50 articles on mind-body therapies were hand-searched, and a proportion
of them were reviewed by the workgroup for inclusion in this document. The information presented in this best
practice document aligns with the recent AAPD clinical practice guideline Nonpharmacological Behavior
Guidance for the Pediatric Dental Patient
12
which offers evidence for the efficacy of various nonpharmacological
behavior guidance techniques. This document extends the discussion of behavior guidance to include objectives,
indications, and contraindications of both nonpharmacological and pharmacological techniques. 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
scope of knowledge and skills acquired during their professional education. Safe and effective treatment of these
diseases requires an understanding of modifying the child’s and family’s response to care and an ability to modify
treatment approaches accordingly. Behavior guidance is a continuum of interaction involving the dental team
(i.e., dentist and staff), the patient, and parent directed toward communication and education before and during
the delivery of care. Goals of behavior guidance are to: 1) establish communication, 2) alleviate the child’s dental
fear and anxiety, 3) promote patient’s and parents’ awareness of the need for good oral health and the process by
which it is achieved, 4) promote the child’s positive attitude toward oral health care, 5) build a trusting
relationship between the dental team and the child/parent, and 6) provide quality oral health care in a comfortable,
minimally-restrictive, safe, and effective manner. Behavior guidance techniques range from establishing or
maintaining communication to stopping unwanted or unsafe behaviors.
13
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 is never meant to be punishment for misbehavior, power
assertion, or any strategy that hurts, shames, or belittles a patient. General considerations for use of any behavior
guidance technique include alternative behavior guidance modalities, the oral health needs of the patient, the
effect on the quality of dental care and the patient’s well-being, the patient’s emotional and cognitive
development, medical and physical status, and the safety of the patient, parent, and dental team.
Predictors of child behaviors
Patient attributes
The ability to assess the child’s developmental level, dental attitudes, and temperament allows a provider to
anticipate the child’s reaction to care. The response to the demands of oral health care is complex and determined
by many factors. Factors that may contribute to noncompliance during the dental appointment include fears,
general or situational anxiety, a previous unpleasant and/or painful dental/medical experience, pain, inadequate
preparation for the encounter, and parenting practices.
13-18
In addition, cognitive age, developmental delay,
inadequate coping skills, general behavioral considerations, negative emotionality, maladaptive behaviors,
physical/mental disability, and acute illness or chronic disease are potential reasons for noncompliance during
the dental appointment.
13-18
Behavioral challenges often are more readily recognized than dental fear/anxiety due to associations with general
behavioral considerations (e.g., activity, impulsivity) versus temperamental traits (e.g., shyness, negative
emotionality).
19(pg345)
Only a minority of children with uncooperative behavior have dental fears, and not all
fearful children present with disruptive behavior in the dental setting.
14,20,21
Dental anxiety in children is an
expected occurrence due to unfamiliar environment and expectations. Apprehension to dental care may range