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 Patient. 3
Most children’s behavior can be effectively managed using basic behavior guidance techniques. These techniques should form the foundation for all oral health professionals’ behavior guidance strategies. However, managing some children’s behavior requires more advanced techniques. Advanced behavior guidance techniques include protective stabilization, deep sedation, and general anesthesia.
An appropriate diagnosis of potential behavioral issues, and safe and effective implementation of behavior techniques, requires knowledge, skill, and experience generally beyond that gained during predoctoral dental education. Oral health professionals considering using these advanced techniques should seek additional training through a residency program, a graduate program, and/or extensive continuing education courses that involve both didactic and experiential mentored training. Some techniques require special certification, which may vary by state.
When considering the use of these advanced techniques, oral health professionals should consult with the child’s physician(s) about the appropriateness of the selected techniques and any adaptations needed or contraindications. Sending the physician a report of oral health care provided will help ensure that oral health care is referenced in the child’s health record as an integral aspect of overall health care and will alert the physician that the child has a dental home.
Most important, these techniques require clear and frequent communication with parents before, during, and after the procedures. Debriefing after the procedures will help parents understand their role in preventing, recognizing, and addressing adverse side effects or reactions at home. The dental office should call parents to check on how the child is doing.
Protective stabilization should be used only when absolutely necessary to protect the child and oral health staff during oral health procedures. There are no universal guidelines for this technique that apply to all settings. Before employing any kind of protective stabilization, consult available guidelines on federally funded care, the state’s department of mental health, the state’s dental practice act, and AAPD’s Guideline on Behavior Guidance for the Pediatric Patient. The least restrictive protective stabilization technique that enables the oral health staff to provide care safely should be chosen. Protective stabilization should be used only when less-restrictive interventions are not effective. It should not be used as a means of discipline, convenience, or retaliation. 5
Protective stabilization should not cause physical injury, pain, undue discomfort, or emotional distress. Some children actually feel more secure if supportive techniques are used to stabilize them in the dental chair, especially if the chair is too large for them or if uncontrolled movements, such as those that may occur in children with cerebral palsy, make them feel unstable.
Partial or complete immobilization of the child is sometimes necessary to protect the child and the oral health staff from injury while providing care. Protective stabilization can be performed by an oral health professional (e.g., dentist, dental therapist, dental hygienist), staff, or parents with or without the aid of a stabilization device.
There are a variety of forms and levels of protective stabilization. For instance, if active immobilization is used, parents may be asked to hold the child in their lap and use their arms to hug and stabilize the child. If passive stabilization is used, the oral health professional might use a “wrap” or “blanket” to stabilize the child’s arms and legs, similar to the way a car seat stabilizes a child in a moving vehicle. 6
Common examples of protective stabilization devices include PediWraps®, Papoose Boards®, and supportive seat belts. Some new types of suction incorporate a plastic mouth prop. The use of a mouth prop in a compliant child is not considered protective stabilization. An oral health professional, staff, or parents can also gently hold the child’s hands, arms, or legs.
Protective stabilization is indicated when (1) a child needing an immediate diagnosis or limited oral health care cannot cooperate and (2) the physical safety of the child and/or oral health staff would be at risk without the use of protective stabilization. It should not be used if the child (1) is cooperative, (2) has a physical or medical condition that prevents safe stabilization, (3) has a history of physical or psychological trauma due to immobilization (unless no other alternatives are available), and (4) requires non-emergent full-mouth or multiple quadrant care. In addition, oral health professionals should never use protective stabilization for their own convenience.
The decision to use protective stabilization should also take into consideration the following: (1) alternative behavior guidance techniques that could be used instead, (2) the child’s oral health needs, (3) the length and invasiveness of the procedure, (4) the effect of this technique on the quality of oral health care, (5) the child’s emotional and cognitive developmental levels, (6) the child’s medical and physical condition, (7) the oral health professional’s comfort with, and skill in, using these techniques, and (8) parents’ understanding and acceptance of their use.
An oral health professional performing protective stabilization with or without a stabilization device must obtain and document in the child’s record written informed consent from parents. Protective stabilization performed by parents does not require written informed consent before the procedures are used. The child’s record should include (1) informed consent, (2) type of stabilization used, (3) indication for stabilization, (4) duration of stabilization (5) reason for parent exclusion during stabilization (if applicable), (6) behavior evaluation/rating during stabilization, and (6) any untoward outcome, such as skin markings, and management implications for future appointments.
Sedation can be used safely and effectively with children who are unable to cooperate with oral health care owing to lack of psychological or emotional maturity and/or mental, physical, or medical disability. For more information about the use of sedation in children, see Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures: Update 2016. 7
The need to diagnose and treat, as well as the safety of the child, practitioner, and staff, should be considered for the use of sedation. The decision to use sedation must take into consideration alternative behavioral guidance modalities, the child’s oral health needs, the effect on the quality of oral health care provided, the child’s emotional development, and the child’s medical and physical considerations.
1. Minimize physical discomfort and pain
2. Control anxiety, minimize psychological trauma, and maximize potential for amnesia
3. Control behavior and/or movement so as to allow the safe completion of the procedure
4. Return the child to a state in which safe discharge from medical supervision, as determined by recognized criteria, is possible
Sedation can be considered for (1) a fearful, anxious child for whom basic behavior guidance techniques have not been successful; (2) a child who cannot cooperate owing to a lack of psychological or emotional maturity and/or mental, physical, or medical disability; and (3) a child for whom the use of sedation may protect the developing psyche and/or reduce medical risk.
Sedation is not indicated for (1) a cooperative child with minimal oral health needs and (2) predisposing medical and/or physical conditions that would make sedation inadvisable.
The child’s record should include (1) informed consent, which must be obtained from parents and documented before the use of sedation; (2) instructions and information provided to parents; (3) a health evaluation; (4) a time-based record that includes the name, route, site, time, dosage, and effect on the child of administered drugs; (5) the child’s level of consciousness, responsiveness, heart rate, blood pressure, respiratory rate, and oxygen saturation at the time of treatment and until predetermined discharge criteria have been attained; (6) adverse events (if any) and their treatment; and (7) time and condition of the child at discharge.
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 is sometimes necessary to provide quality oral health care for children.
Anesthesia can be administered in a hospital or in an ambulatory setting. (Read more about preparing CSHCN for the hospital experience. The need to treat the child, as well as the safety of the child, dentist, and staff, and the understanding and acceptance of parents should be considered when deciding whether to use 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 that the benefits of these agents should be considered in the context of their potential to cause harm.
The decision to use general anesthesia should take into consideration (1) alternative techniques that could be used instead, (2) the child’s oral health needs, (3) the effect of general anesthesia on the quality of oral health care, (4) the child’s emotional and cognitive developmental levels, and (5) the child’s medical status.
General anesthesia can be considered for (1) a child who is unable to cooperate owing to a lack of psychological or emotional maturity and/or cognitive, physical, or medical disability; (2) a child for whom local anesthesia is ineffective because of acute infection, anatomic variations, or allergy; (3) an extremely uncooperative, fearful, anxious, or uncommunicative child; (4) a child requiring significant surgical procedures; (5) a child for whom the use of general anesthesia may protect the developing psyche and/or reduce medical risks; or (6) a child requiring immediate, comprehensive oral health care.
General anesthesia is not indicated for (1) a healthy, cooperative child with minimal oral health needs, (2) a young child with minimal oral health needs that can be addressed with therapeutic interventions (e.g., interim therapeutic restorations), fluoride varnish) and/or treatment deferral, (3) child/practitioner convenience, and (4) a child with a predisposing medical condition that would make general anesthesia inadvisable.
Written informed consent from parents must be obtained and documented in the child’s record before general anesthesia is used. The child’s record should include (1) informed consent and (2) indication for the use of general anesthesia.
For more information about managing sedation-induced life-threatening events in children, see Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures: Update 2016. 7