Clinical Behavior Guidance for Children in Dentistry

Brent P. Lin, DMD, and Michael I. Lin, MD

ABSTRACT Behavior management is an integral component of pediatric care. It is the ability to guide children through their dental experience to meet their immediate dental needs, to plant seeds for future dental needs and to promote positive dental attitudes. A positive first dental experience paves the way for good oral health practice and success in future dental visits. It is therefore critical to understand children’s behavior and fundamentals for success in clinical pediatric dental care by all providers, including general and family dentists.

Behavior guidance is an integral component of pediatric dental care. It is the ability to guide children through their dental experience to meet their immediate dental needs, to plant seeds for future dental needs and to promote positive dental attitudes. Children of different age groups exhibit general behavior and reaction toward dental procedures corresponding to their developmental stages. In the maturational theory of child development, Gesell described personality characteristics and behavior norms related to specific ages that unfold in a predictable and sequential pattern during growth and development. [1,2] A 3-year-old child typically has a more developed imagination than a 2-year-old toddler. All children undergo the same stages and sequences of development, but each child accomplishes these developmental milestones at their own pace. [1–3] Hence, a child’s developmental age might not coincide with chronological age.

Assessing a child’s development is critical in predicting the ability of a child to cope with dental procedures, and it is imperative to understand that human development is not unitary. The relationship between a provider and a child patient is not linear, and parental factors play a critical role in the care of a child (FIGURE 1 ). Wright and Alpern cited variables and environmental factors that could affect children’s behavior in the dental setting, such as the impact of parental or community influence. [4] Previous health care visits could also potentially instill or alleviate fear and anxiety in a dental visit.

FIGURE 1. Dynamic relationship between provider, child patient and parent in pediatric dental setting. SEE FULL VERSION OF JOURNAL FOR FIGURE.

A child’s visit to the dental office may be the first exposure to oral health, and dental care providers have the opportunity to influence and shape the child’s oral health well-being and dental experience for a lifetime. A positive first dental experience paves the way for good oral health practice and success in future dental visits. It is therefore critical to understand children’s behavior and fundamentals in management for success in clinical pediatric dental care by all providers, including general and family dentists.

Children’s Behavior in Dental Setting

Evaluation of a child’s behavior starts as soon as the child steps into the dental office. Some children are cheerful, giving high-fives to everyone in the office and can’t wait to get their teeth cleaned. Others may hold onto their parents or start crying even before they enter the office. Parents play a key role in determining a child’s dental experience. High parental anxiety can negatively affect a child’s behavior.

Effective communication, cooperation and concurrence with parents on all procedures to be performed are essential. The quality of a child’s previous health care experience is more emotive than the number of visits. Similarly, a child known to have a dental problem tends to display negative behavior in a dental appointment. Hence, a planned wellchild dental visit is invaluable in setting the tone for future dental experiences.

General behavior patterns are observed throughout the age spectrum in healthy children. Prior to age 3, infants and toddlers display undiscerned emotions and, in the absence of developed verbal and communication skills, discomforts or fears are expressed through crying. The world of very young children is more binary than multifaceted. For example, difficulty may present in processing the thought of “pressure” during extraction. It either “hurts” or “not hurts.” Toddlers expand their language skill, and curiosity and the ability to reject a proposed action emerge by age 3, leading to frequent “why” and “no.”

Separation anxiety is observed among this age group, and parental presence may be helpful to ease a child’s fear and anxiety. Toddlers may not want to sit in a dental chair; therefore, dental care providers should be flexible and perform dental examinations in a nontraditional position, such as a lap-to-lap examination ( FIGURE 2). In this position, the child’s head rests on the care provider’s lap and the legs straddle the parent’s waist. While the care provider stabilizes the head of the child, the parent holds the child’s hands and controls body movements.

FIGURE 2. Lap-to-lap examination for toddlers and young children.

Although precooperative behavior is often associated with toddlers prior to age 3, one should never generalize behavior based on chronological age. Each child should be assessed and evaluated and a management strategy should be customized for each child. Due to differential maturation, a 2-year-old toddler may display a more cooperative behavior than an 8-year-old child.

At the preschool age, children develop the processes of self-control and reasoning but continue to have short attention spans. They want to help during dental procedures but may easily become distracted and frustrated. A 4-year-old child, for example, may only have an eight- to 12-minute attention span, thus it is critical to work efficiently as the working time starts to dwindle as soon as the child sits in the dental chair.

According to the Diagnostic and Statistical Manual of Mental Disorders, anxiety is the anticipation of future threat and fear is the emotional response to real or perceived imminent threat. [5] They are often multifactorial, with significant influence from peers and parental figures. At age 5 or 6, a child goes to school and establishes peer relations, self-identity and body image. With increased socialization and exposure to societal norms for rules-based behavior, children this age are more likely to follow instructions and obey orders. They may learn simplified concepts behind medical and dental procedures. With limited understanding and prior adverse experience, a child at this age may exhibit fear toward certain dental procedures.

As children grow, they gain social independence and improve their ability to care for themselves. With maturity and cognitive development, the ability to cope with dental procedures gradually enhances over the years. In uncooperative patients with nonurgent and asymptomatic conditions, definitive treatment could be deferred to a later date when the child is able to better cope with procedures. Treatment options that halt the progression of carious lesions, such as interim therapeutic restoration or silver diamine fluoride, may be considered.

Documentation and classification of behavior are not only helpful in evaluating a child’s cognitive development over the years but also essential in planning appropriate management strategies for future dental visits. One of the most common behavior classification is the Frankl Behavior Rating Scale. [6] It is based on assigned numerical value on behavior, ranging from 1 being definitely negative to 4 being definitely positive (TABLE 1 ). A descriptive evaluation, including tactic or strategy that is helpful in managing the child, should also be noted. For example, if a child loves soccer, it should be documented, and the subjects of interest for the child could enhance rapport during subsequent visits. Symbols such as + and − have also been utilized in behavior classification, with + indicating good behavior and − signifying poor behavior.

TABLE 1 Behavior Classification

Frankl Behavioral Rating Scale

1. Definitely negative (– –)

2. Negative (–)

3. Positive (+)

4. Definitely positive (+ +)

Wright’s Behavioral Clinical Classification

• Cooperative

• Potentially cooperative

• Lacking in cooperative ability

Wright and colleagues distinguished a child’s behavior in three categories based on the ability to cooperate: cooperative, potentially cooperative or lacking in cooperative ability. [7] Children who were potentially cooperative hadn’t yet developed the ability but would likely become cooperative later as they matured. A subset of children who may not fully develop that coping skill, such as special needs children, would be classified as lacking in cooperative ability under the Wright’s behavior assessment.

Fundamentals of Behavior Management

Effective behavior management in children is based on several fundamental principles (TABLE 2 ). A functional inquiry should be obtained through a brief parental interview. Information on the child’s reaction during past medical and dental procedures, the parents' own anxiety, the child's perception of their dental health and parental opinion regarding their child’s behavior and reaction in the dental chair could provide critical background in developing a management approach. A negative response to any question may increase the chance of encountering behavior issues.

TABLE 2 Fundamental Principles for Successful Behavior Management

• Positive approach

• Team attitude

• Organization

• Tolerance

• Flexibility

• Truthfulness

Clinical Guidance Techniques

Behavior management should start with the least invasive and simplest techniques that could accomplish the intended tasks ( TABLE 3). Often a combination of two or more techniques is utilized.

TABLE 3 Behavior Management Techniques

Clinical Management Techniques

• State the goal or task

• Tell-show-do (TSD)

• Distraction n Modeling

• Positive reinforcement n Behavior shaping

• Disregard of minor inappropriate behavior

• Nonverbal communication

Advanced Management Techniques

• Parental presence/absence

• Voice control

• Protective stabilization or medical immobilization

Pharmacological Anxiety Management

• Nitrous oxide and oxygen

• Oral conscious sedation

• Deep sedation/general anesthesia

When working with a child, it is fundamental to have a positive approach. The dental team should be affirmative, validating and supportive. A friendly and encouraging team attitude eases a child’s anxiety, and a great way to build rapport is listening and learning about their interests. Children are observant; any sign of indecisiveness, delays or poor organization could result in apprehension. Tolerance and gentle redirection of misbehaviors of a child are essential while maintaining composure, adaptability and flexibility according to situational demands. Under all circumstance, a dentist should be truthful to the child and their parents to foster a trusting relationship.

The goals or tasks for the visit should be stated simply and to their level of understanding. Tell-show-do (TSD) is a technique that is routinely used and is helpful in introducing a new setting, material or procedure to children. The intended procedures would first be explained in age- or developmentally appropriate phrases (tell), followed by a demonstration of the procedure in a carefully defined, nonthreatening setting (show). The procedure should then be accomplished without much deviation from what is demonstrated (do).

Another strategy to promote good behavior is to show a child the cooperative behavior of another child who is undergoing similar procedures. The intent is to have children model after each other in a positive manner. Positive reinforcements of desired behavior in the form of praise or prize further buttress the behavior via operant conditioning. Positive reinforcements should be specific to the particular behavior or action that is to be promoted. Prize should be used to reward appropriate behavior and positive outcome for the dental visit and should not be given indiscriminately. However, minor inappropriate behavior by the child should be disregarded.

Anxious and fearful children often focus on every task and movement made around them. They may suddenly grab the dentist’s hand or turn their head during the local anesthetic administration process. Coaching

in soothing, child-friendly language or terms, coupled with positive reinforcement, may be helpful in easing anxiety and improve coping ability. Distraction could be an effective method in shifting the child’s focus away from perceived fear and anxiety. Gently tapping on the child’s forehead, telling a story, singing a song or mildly shaking the cheek or lip during administration of local anesthesia are examples of tactics to distract a child from an intended procedure. Watching a movie or listening to a song not only provides comfort and entertainment but also serves as effective visual and auditory distractors. If the root of the problem stems from past dental experiences, progressive exposure and desensitization may be required. For example, treatment could be started with something simple and easy before proceeding to more difficult or extensive procedures. Utilizing nonthreatening or familiar objects, such as a toothbrush, may encourage the child to open their mouth. The ultimate goal is alleviating the anxiety and fear response to optimize treatment outcome.

Children are influenced by their environment and interactions with others. The design of a pediatric dental office should be kid-friendly and a fun place children would enjoy. Asking silly yet appropriate questions and telling age-appropriate jokes could at times be helpful in building rapport. Children have incredible imaginations; hence, storytelling or singing during the dental procedure could keep their minds spellbound and engaged. For very young children, the story can be a fictional customization with characters that capture their imagination, keeping their mind distracted from the procedure. Holding a comforting security object such as a teddy bear or a parent’s hand could keep the child’s hands preoccupied and relaxed. If a child has questions and can’t verbalize due to the ongoing procedure, the practitioner could instruct the child to gently raise their hand on the side that is away from the procedure.

Due to the short attention span among young children, a practitioner should work efficiently and may perform a procedure in short intervals with breaks. Counting backward could be helpful in keeping children occupied and giving them a goal to accomplish.

Not all techniques require spoken words to be effective. Nonverbal communication is the reinforcement and guidance of behavior through appropriate contact, body language, facial expression and posture. One example is to give a thumbs-up gesture for approval, encouragement and acknowledgement for good behavior and a job well done. The purpose is to gain the patient’s attention and to maintain compliance. It should be used in conjunction with other management techniques.

Advanced Management Techniques

With changes in society and a new generation of parenting, the use of some behavior management techniques has become questionable or controversial, especially with the influence of social media. For example, the hand-over-themouth method that was practiced for decades is currently not a standard of care in the profession and is not used in modern pediatric dental practice.

The traditional school of thought was that children behaved the same with or without parental presence. [8–10] However, dentists these days are facing an increasing demand from parents to be in the room with their child. Practitioners have either adapted to parental requests or set up official policy to address this issue. A toddler may exhibit separation anxiety before age 3; therefore, parental presence may comfort the child and ease their fear and anxiety. After the third year of developmental age, parental presence can potentially serve as a reward for good behavior. For example, if the child is cooperative and behaves appropriately, the parents can stay in the operatory at the request of the child. By age 9, parental presence may not matter to most children.

Voice control is another effective technique with the intent to gain immediate attention of a child by sudden and firm commands and can potentially halt an adverse behavior. It should not be presented in an angry voice or give the perception of being mad. For example, a child may place their hands over the mouth to prevent procedural progress despite repeated and gentle requests. The practitioner may consider changing the tone to a firm and commanding voice for a more favorable outcome.

Protective stabilization has generated mostly negative attention from parents and the press. [11] A child may require medical immobilization for immediate medical attention in an urgent situation, such as the extraction of an infected tooth. For children with special needs, a dental examination may not be possible without brief immobilization. There are two general categories of medical immobilization. Active medical immobilization is the personal hold of the child by parents or others, while a stabilization device is considered as passive medical immobilization. Passive medical immobilization could provide stability and protect the child from harmful sudden movement in the setting of a procedure or examination (FI GURE 3 ). Erythema, abrasion and petechiae may be observed in children resisting medical immobilization; therefore, it is essential to obtain informed parental consent covering the rationale, expected outcome, potential complications and risks and benefits of proposed techniques. Mandatory written documentation prior to protective stabilization deployment should include signed informed consents (risks and benefits, potential complications and alternative treatment options), indication and type of restraint, duration and behavior evaluation/rating prior to and during stabilization. This will optimize effective communication and avoid potentially costly and detrimental misunderstandings.

FIGURE 3. Facilitation of pediatric dental treatment utilizing passive medical immobilization.

Pharmacological Anxiety Management

Clinical management techniques may not be effective in the management of all behavior issues. Pharmacological agents may be needed to supplement the clinical management techniques.

The most commonly used pharmacological agent in a dental office is the nitrous oxide and oxygen mixture, which is easily administered with a relatively high margin of safety. When used appropriately, a state of relaxation and enhanced cooperation should be achieved. The patient monitoring requirement for nitrous oxide/ oxygen varies among states, ranging from visual monitoring to pulse oximetry.

Oral anxiolytic agents for oral conscious sedation or intravenous agents for deep sedation are alternative treatment options. [12] These specialty services are usually available in a pediatric dental office. A more controlled setting is provided by general anesthesia with the airway secured via intubation; however, this is only available at selected hospitals or surgery centers with dental service. When encountering difficulty in achieving cooperative behavior for safe dental care delivery, appropriate timely referral for pediatric dental specialty care should be made.

Due to the extensive available literature and page limitation, pharmacological anxiety management is beyond the scope of this article.

Communicating With Children and Use of Child-Friendly Terms

To communicate effectively with children, language and terms should be appropriate for their developmental level. The vocabulary and sentence form, for instance, are different for a 3-year-old compared to a 14-year-old. Children are more receptive to procedures or materials utilizing words or terms that they recognize, understand and can relate to (TABLE 4). For example, a gauze could be referred to as a “tooth towel” and a Dri-Angle cotton roll substitute could be termed as a “sticker” for your cheek.

TABLE 4 Examples of Child-Friendly Terms for Dental Instruments and Materials

Professional terms

• Mouth prop

• Dental explorer

• Local anesthesia

• Topical anesthesia

• Dri-Angle cotton roll substitute

• Gauze

• Suction5 Slow-speed handpiece

• High-speed handpiece

• Rubber-dam clamp

• Rubber dam

Child-friendly terms

• Tooth pillow

• Tooth counter

• Sleepy juice

• Sleepy jelly

• Sticker

• Tooth towel

• Mister thirsty

• Mister bumpy

• Mister whistle

• Tooth ring

• Raincoat

Children like to engage in activities around them. It is appropriate to let children feel empowered. For instance, one should not ask the child, “Do you want to finish?” Instead, the practitioner should rephrase such question to, “Do you want to finish in two minutes or 15 minutes?” Another useful strategy is “don’t ask but give choices.” For example, don’t seek permission for using an explorer by asking, “Let’s use the tooth counter, okay?” A child would be more likely to accept it with simple instruction and choices, such as “Let’s use the tooth counter. Do you want to start on the bottom or the top?” Another common pitfall in communication is that dentists often try to keep the conversation going by asking patients questions during procedures. Between the mouth prop, rubber dam, sharp instruments and handpiece in the mouth, it may be difficult for a child to verbally respond. Hence, it is preferable to make comments, instead of asking questions, during dental procedures.

Summary

A common myth among practitioners is that children under a certain age, those with extensive dental treatment needs and special needs children, require treatment under general anesthesia. Practitioners tend to deploy pharmacological intervention when faced with behavioral challenges. The reality is that a majority of children are cooperative and are able to cope with dental procedures.

All practitioners have their own favorite tools or strategies for managing children. Any behavior management technique utilized should be acceptable and meet the standard of care of the profession. Any advanced or controversial method requires parental informed consent before utilization. If a well behaved child becomes combative or anxious during a procedure, a brief time-out period may alleviate behavioral issues and facilitate a discussion of management strategies with parents.

Detailed documentation of behavior is an integral part of the pediatric dental record at each visit. It provides an overview of a child’s cognitive development, maturation, temperament and ability for cooperation and facilitates behavior management in the subsequent visits. Effective behavior management is essential in achieving a desirable treatment outcome in children. n

REFERENCES

1. Gesell A. Infancy and Human Growth. New York: Macmillan; 1929.

2. Gesell A, Ilg FL. Child development, an introduction to the study of human growth. New York: Harper; 1949.

3. Thelen E, Adolph KE. Arnold L. Gesell: The paradox of nature and nurture. In Parke RD, Ornstein PA, Rieser JJ, et al., eds: A Century of Developmental Psychology. Washington, D.C.: American Psychological Association; 1994:357–388.

4. Wright GZ, Alpern GD. Variables influencing children’s cooperative behavior at the first dental visit. ASDC J Dent Child 1971 Mar–Apr;38(2):124–128.

5. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, D.C.: American Psychiatric Publishing; 2013.

6. Frankl S, Shiere F, Fogels H. Should the parent remain with the child in the dental operatory? J Dent Child 1962 29:150–163.

7. Wright GZ. Behavior management in dentistry for children. Philadelphia: W.B. Saunders Co.; 1975.

8. Lewis TM, Law DB. An investigation of certain anatomic responses of children to a specific dental stress. J Am Dent Assoc 1958 57:769–777.

9. Venham L, Bengston D, Cipes M. Parent’s presence and the child’s response to dental stress. ASDC J Dent Child 1978 May–Jun;45:37–41.

10. Pfefferle JC, Machen JB, Fields HW, Posnick WR. Child behavior in the dental setting relative to parental presence. Pediatr Dent 1982 4(4):311–316. 11. Fields HW, Machen JB, Murphy MG. Acceptability of various behavior management techniques relative to types of dental treatment. Pediatr Dent 1984 Dec;6(4):199–203. PMID: 6596566. 12. 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):211–227.

AUTHORS

Brent P. Lin, DMD, is a clinical professor in the division of pediatric dentistry at the University of California, San Francisco. He obtained his dental degree from Temple University in 1992 and completed his pediatric dentistry residency program at St. Barnabas Hospital. In addition, he did a general practice residency program at Yale-New Haven Hospital and a geriatric fellowship program at the University of Michigan. Conflict of Interest Disclosure: None reported.

Michael I. Lin, MD, is the assistant chief of psychiatry at the Veterans Affairs North Texas Health Care System. He obtained his medical degree from the University of Texas Health Science Center at San Antonio in 1995 and completed his psychiatry residency program at the Texas Tech University Health Sciences Center El Paso, where he served as the chief resident in the department of psychiatry and vice president of the House Staff Association. Conflict of Interest Disclosure: None reported.

THE CORRESPONDING AUTHOR, Brent P. Lin, DMD, can be reached at linb@dentistry.ucsf.edu.