Module 5: Behavior Guidance
Special Care- Behavior Guidance

5.3 Basic Behavior Guidance

Communication and Communicative Guidance

Note: Much of the information in this section is based on American Academy of Pediatric Dentistry, Council on Clinical Affairs—Committee on Behavior Guidance. 2015. Guideline on Behavior Guidance for the Pediatric Dental Patient3

Communicative management and appropriate use of commands are used universally in dentistry with both cooperative and uncooperative children. It is the most fundamental form of behavior guidance.

Communication and communicative guidance includes a host of communication techniques, including positive pre-visit imagery, direct observation, tell-show-do, ask-tell-do, voice control, nonverbal communication, positive reinforcement and descriptive praise, distraction, memory restructuring, and parent presence or absence. Since these comprise the elements of usual and customary communication, they are appropriate for all children and have few contraindications.

Communicative management comprises a host of specific techniques that, when integrated, enhance the evolution of a cooperative patient. Rather than being a collection of individual techniques, communicative management is an ongoing subjective process that becomes an extension of the personality of the oral health professional.

Communication and Communicative Guidance—Positive Pre-Visit Imagery

Positive pre-visit imagery is an approach where children are shown positive photographs or images of the oral health team and the dental operatory environment while they are in the waiting area before a dental appointment. For example, social stories (pictures of what will happen step by step) and picture books can be used to share information with the child.


  1. Provide children and parents with visual information about what to expect during the dental visit
  2. Provide children and parents with context to help them ask dental staff relevant questions before dental procedures begin

Communication and Communicative Guidance—Direct Observation

Direct observation is a technique where children are shown a video or are permitted to directly observe a cooperative child undergoing dental treatment.


  1. Familiarize the child with the dental setting and specific steps involved in procedures to be undertaken
  2. Give the child and parents an opportunity to ask questions about dental procedures in a non-threatening environment

Communication and Communicative Guidance—Tell-Show-Do

Tell-show-do involves verbal explanations of procedures in phrases appropriate to the developmental level of the child (tell); demonstrations 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. For certain procedures, another step is to have the child reproduce the behavior on themselves or on a doll (reciprocal demonstration) (e.g., brush the doll’s teeth, open their mouth). Adaptations will need to be made depending on whether the child has communication disorders or impairments. Using social stories (pictures of what will happen step by step) can also help. This can work especially well for children with autism.


  1. Teach the child about important aspects of the dental visit and familiarize the child with the dental setting
  2. Shape the child’s response to procedures through desensitization and well-described expectations and reciprocal demonstrations

Communication and Communicative Guidance—Ask-Tell-Ask

The ask-tell-ask technique involves asking about a child’s upcoming dental visit and their feelings about any planned procedures (ask), explaining the procedures through demonstrations and non-threatening language appropriate for the child’s age and cognitive level (tell), and again asking if the child understands and how they feel about the impending treatment (ask). If the child continues to have concerns, the dentist can address them, assess the situation, and modify the procedures or use other behavior guidance techniques, if necessary.


  1. Assess anxiety that may lead to noncompliant behavior during treatment
  2. Inform the child about the procedures that will be undertaken
  3. Confirm that the child is comfortable with the procedures before proceeding

Communication and Communicative Guidance—Voice Control

Voice control is a controlled alteration of voice volume, tone, or pace to influence and direct the child’s behavior. This technique is ineffective for children with severe hearing impairments and may need to be adapted for non-English-speaking families whose language uses voice modulation and sounds differently. Voice control can be considered an aversive technique because some people may view it as punishing the child by “yelling at them.” This is not an accurate reflection of the intent of voice control. It is human nature to value the approval of others, and a negative tone signals disapproval. Therefore the benefit of voice control may be the withdrawal of positive reinforcement as much as the introduction of an aversive technique.4 Involving parents in communication is crucial when voice control is used.


  1. Gain the child’s attention and achieve compliance
  2. Avert negative or avoidance behaviors
  3. Establish appropriate adult-child roles

Communication and Communicative Guidance—Nonverbal Communication

Nonverbal communication is the reinforcement and guidance of behavior through appropriate contact, posture, and facial expression. This technique is critical for children with hearing impairments. Contact to calm the child is important; however, some children have tactile defensiveness or exaggerated startle reflexes. Use of face masks can impair this type of communication, so initial communication without the face mask before initiating dental procedures is necessary. Use of hand signals by the provider and the child can help communicate directions and give the child some degree of control.


  1. Enhance the effectiveness of other communicative guidance techniques
  2. Gain or maintain the child’s attention and achieve compliance
  3. Give the child a way to communicate and a degree of control
  4. Provide reassurance

Communication and Communicative Guidance—Positive Reinforcement and Descriptive Praise

Positive reinforcement is an effective technique to reward desired behaviors and thus increase the likelihood that those behaviors will recur. Social reinforcers include positive voice modulation, pleasant facial expression, verbal praise, and appropriate physical demonstrations of approval. Some other reinforcers include stickers, tokens, and toys. It is important to make sure that the child actually perceives the nonsocial reinforcers as meaningful and reinforcing. Descriptive praise emphasizes specific cooperative behaviors (e.g., “thank you for sitting still,” “you’re doing a great job keeping your hands in your lap”) rather than generalized praise (e.g., “good job”).


  1. Reinforce desired behavior so that it recurs

Communication and Communicative Guidance—Distraction

Distraction is the technique of diverting the child’s attention from what may be perceived as an unpleasant procedure. This can be done through talking, asking parents to play with the child, using headphones to play music, or allowing the child to watch a movie or show or play a game on an electronic device.


  1. Decrease the perception of unpleasantness by focusing on pleasant stimuli
  2. Avert negative or avoidance behavior

Communication and Communicative Guidance—Memory Restructuring

Memory restructuring is a behavioral approach where negative memories associated with a difficult event (e.g., first dental visit, local anesthesia, restorative procedure, extraction) are restructured into positive memories using information introduced after the event has taken place. Restructuring involves four components: (1) visual reminders, (2) positive reinforcement through verbalization, (3) concrete examples to encode sensory details, and (4) a sense of accomplishment. A visual reminder could be a photograph of the child smiling at the initial visit (before the difficult experience). Positive reinforcement through verbalization could be asking if the child told her parents what a good job she did at the last appointment. Concrete examples to encode sensory details could include praising the child for specific positive behavior such as keeping her hands on her lap or opening her mouth wide when asked to do so. The child then is asked to demonstrate these behaviors, which leads to a sense of accomplishment.


  1. Restructure memories of difficult experiences into positive memories
  2. Improve child’s behavior at subsequent visits

Communication and Communicative Guidance—Parent Presence or Absence

This technique involves using the presence or absence of parents during oral health procedures to gain the child’s cooperation and also to help parents understand the level of cooperation needed for various procedures. Health professionals’ philosophies and parents’ attitudes about this issue vary widely. Children’s responses to their parents’ presence or absence vary as well. Each oral health professional must be aware of his own skills, the abilities of the particular child, and the desires and skills of parents in evaluating the usefulness of this technique.

Parents can be a valuable resource in the operatory. Parameters of their involvement should be discussed ahead of time. It is important that one person serves as primary communicator with the child; otherwise mixed messages may be transmitted, and the child may become confused. Particularly for children with communication disorders, parents may be the most effective communicators.


  1. Gain the child’s attention and achieve compliance
  2. Enhance effective communication among the dentist, child, and parents
  3. Avert negative or avoidance behaviors
  4. Establish appropriate adult-child roles
  5. Enhance the communication environment


Should parents participate in children’s dental visits? What is their role?
Larry Salzmann, D.D.S. responds.

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Please note: Since this audio was recorded, The American Academy of Pediatric Dentistry has changed the wording in its guideline from "behavior management" to "behavior guidance."

Nitrous Oxide/Oxygen-Inhalation Sedation

Nitrous oxide/oxygen-inhalation sedation is a safe and effective technique in most cases to reduce anxiety and enhance effective communication. Its onset of action is rapid, the depth of sedation is easily titrated and reversible, and recovery is rapid and complete. Additionally, nitrous oxide mediates a variable degree of analgesia, amnesia, and gag reflex reduction.

The decision to use nitrous oxide must take the following factors into consideration: (1) alternative behavior guidance modalities, (2) the child’s oral health needs, (3) the effect on the quality of care, (4) the child’s emotional development, and (5) the child’s physical condition.

Indications for nitrous oxide/oxygen-inhalation sedation include (1) a fearful, anxious, or obstreperous child; (2) a cognitively, physically, or medically compromised child; (3) a child whose gag reflex interferes with oral health care; or (4) a child for whom profound local anesthesia cannot be obtained.

Contraindication to the use of nitrous oxide/oxygen-inhalation sedation include (1) a child with chronic obstructive pulmonary diseases, (2) a child with severe emotional disturbances or drug-related dependencies, (3) a child with methylenetetrahydrofolate reductase deficiency, or (4) a child with recent illnesses (e.g., cold or congestion) that may compromise the airway.


  1. Reduce or eliminate anxiety
  2. Reduce untoward movement and reaction to oral health procedures
  3. Enhance communication and the child’s cooperation
  4. Raise the pain reaction threshold
  5. Increase tolerance of long appointments
  6. Reduce gagging