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Guideline on Behavior Guidance for the Pediatric
Dental Patient
Review Council
Council on Clinical Affairs
Latest Revision
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 this guideline to educate
health care providers, parents, and other interested parties about
influences on thebehavior 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
This guideline was originally 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 be-
havior 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.
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
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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