QUALITY ASSURANCE CRITERIA FOR PEDIATRIC DENTISTRY

BEHAVIOR MANAGEMENT

INTRODUCTION
Behavior management methods in pediatric dentistry are directed toward the goals of communication and education. The relationship between the dentist and child is built through a dynamic process of dialogue, facial expression, and voice tone; all methods of delivering a message. Some of the specific methods in this document are intended to maintain the communication process while others are intended to extinguish inappropriate behavior. Behavior management methods cannot be evaluated on an individual basis as to validity, but must be evaluated within the context of the child's total dental experience. Behavior management for the pediatric patient is as much an art form as it is a science. It is not an application of individual techniques created to "deal" with children, but rather a comprehensive methodology meant to build a relationship between patient and doctor which ultimately builds trust and allays a child's fears and anxieties. Since children exhibit a wide range of development and a diversity of attitudes toward dental treatment, it is imperative that dentists have at their disposal a wide range of behavior management methods and communication techniques to meet the needs of the individual child.

The need to diagnose and treat as well as the safety of the patient and the practitioner must justify the use of any of the behavior management methods in these guidelines. The decision to use any of these methods must also take into consideration:

a) Other alternate behavioral modalities
b) Dental needs of the patient
c) Quality of dental care to be provided
d) Patient's emotional development
e) Patient's physical status

The child who presents with significant pathology and non-compliance test the skills of every practitioner. A dentist treating children should have a variety of behavior management approaches and should, under most situations, be able to accurately diagnose the child's developmental level, dental attitudes, and predict the child's reactions to the necessary treatment. However, by virtue of each practitioner's differences in training, experience, and personality, methods utilized by each individual practitioner, all management decisions must be based upon objective evaluation, weighing benefit versus risk to the child. Considerations regarding the patient's need of treatment and it's urgency, sequelae of deferred treatment, and potential physical/emotional trauma must enter into the decision making equation.

Decisions regarding treatment and methods for children must not be made unilaterally by the dentist. Decisions must involve parents and, if appropriate, the child. The dentist serves as the expert regarding dental pathology, the need for treatment and the method by which treatment can be provided. The parent, however, maintains responsibility over the management and treatment of the child and must be consulted regarding treatment options and potential risks. Therefore, the successful completion of diagnostic and therapeutic services must be viewed as a partnership between the dentist, parent, and child.

INFORMED CONSENT
Although the behavior management methods included in this document are frequently used by a significant number of dentists, parents may not be entirely familiar with some of them. Therefore, it is important that the dentist inform the parent (or legal guardian) and answer any questions about the use of unfamiliar methods, their indications, contraindications, significant risks, and alternate treatment methods before the method is used. In an emergent situation which necessitates the use of a technique to avoid immediate injury to the patient, doctor, and/or staff prior to obtaining consent, consent may be implied.

All behavior management methods utilized for controlling undesirable behavior, and their effectiveness, shall be documented in the patient's record according to Section II of this document.

OUTCOMES
Two primary objectives of all behavior management methods are to effectively and efficiently perform necessary dental treatment of the child and to instil in the child a positive dental attitude. These objectives must be the emphasis of any practitioner who treats children. Achievement of these objectives relies on communication and education. Behavior management is a continuum of interaction with the child directed toward communication and education in an endeavor to allay anxiety and fear and promote an understanding of the need for good dental health and the process by which it is achieved.

Unfortunately, many barriers hinder the achievement of these ambitious objectives. The causes of inappropriate behavior of a child in the dental office are varied. Developmental delay, mental retardation and acute or chronic disease are all obvious reasons for potential noncompliance. Reasons for non-compliance in the communicative child is often more subtle and difficult to diagnose. Major contributing factors, however, can often be identified. Fears transmitted from parents; a child's prior experience with a dentist not adept at relating to children; or an inappropriately prepared child's first encounter in the dental situation can lead to a child's uncooperative behavior. To address these factors, the dentist becomes a teacher. Within this role, the dentist must have a methodology for good communication, including analysis of the patient's developmental level and comprehension skills, a message directed to that level, and a patient who is attentive to the message being delivered. In order to achieve quality dental care and an educated patient, it is mandatory that the "teacher-student" roles and relationship be established and maintained.

It must be understood that none of the behavior management techniques in this document are expected to be successful in all instances where they are used. Because pediatric dental patient management is a continuum, in the event that the desired behavior change is not achieved with one technique, it must be understood that appropriate transition to alternative techniques, along with their documentation , shall be considered an integral part of any behavior management outcome.

A. COMMUNICATIVE MANAGEMENT
Communicative management is universally used in pediatric dentistry with both the cooperative and uncooperative child. It comprises the most fundamental form of behavior management in that it is the basis for establishing a relationship with the child which can allow the successful completion of dental procedures and, at the same time, can help the child develop a positive attitude toward dental care. Communicative management is an ongoing, subjective process and an extension of the personality and skills of the dentist rather than a well described technique. Associated with this process are the specific techniques of voice control, distraction, reinforcement, tell-show-do, and nonverbal communication. Since these comprise basic elements of communication and since they are widely used and widely accepted, they are appropriate for all communicative patients. In addition, no specific consent is necessary prior to their use, and no specific documentation is generally required.

However, such documentation may be of value to the practitioner for subsequent visits.

(1) Voice Control: Voice control is a controlled alteration of voice volume, tone, or pace to influence and direct the patient's behavior.

Indications: Voice control is indicated for the uncooperative or inattentive, communicative child to gain the patient's attention and compliance, avert negative or avoidance behavior, and establish authority. It should not be used with children who, due to age, disability, medication, or emotional immaturity are unable to understand and communicate.

(2) Tell-Show-Do: Tell-show-do is a method of behavior shaping used by many professionals who work with children. The three components of this method involve Tell: verbal explanations of procedures in phrases appropriate to the developmental level of the patient; Show: demonstrations for the patient of the visual, auditory, olfactory, and tactile aspects of the procedure in a carefully defined, non-threatening setting: Do: without deviating from the explanation and demonstration, completion of the procedure.

Indications: Tell-show-do is indicated for all patients who can communicate, regardless of the level or the method of communication, to teach the patient important aspects of the dental visit and shape the patient's response to procedures through desensitization and well-described expectations.

(3) Positive Reinforcement: In the process of establishing desirable patient behavior, it is essential to give appropriate feedback. Reinforcement is an effective method to strengthen the occurrence of desired behaviors. Social reinforcers include verbal praise, voice modulation, facial expression and appropriate physical demonstrations of affection by all members of the dental team. Nonsocial reinforcers include tokens and toys.

Indications: Reinforcement may be useful for any dental patient to reinforce desired behavior and increase the likelihood of its recurrence.

(4) Distraction: Distraction is the technique of diverting the patient's attention from what may be perceived as an unpleasant procedure.

Indications: Distractions may be used with any child to decrease the perception of unpleasantness.

(5) Nonverbal Communication: Nonverbal communications is conveying reinforcement and guiding behavior through contact, posture, and facial expression.

Outcome Indicators

Expected/Desirable:

· Patient's behavior assessed at initial patient contact and throughout treatment sequence.

· Patient's behavior appropriate and enabled planned treatment to be accomplished in a quality manner or clinician appropriately modified patient's behavior.

· Child who initially exhibited unacceptable behavior developed acceptable coping behavior appropriate for developmental level and comprehension skills during the treatment process.

B. ADAPTIVE SUPPORT (PHYSICAL RESTRAINT)
Partial or complete immobilization of the patient is sometimes necessary to protect the patient an/or the dental staff from injury while providing dental care. Restraint can be performed by the dentist, staff, or parent, with or without the aid of a restraining device. In addition to informed consent, documentation shall include the indication(s) for use, the type of restraint used, and the time used.

Indications: Physical restraint is indicated for use in a patient who requires diagnosis and/or treatment and cannot cooperate due to lack of maturity or mental or physical handicap; does not cooperate after other behavior management techniques have failed and/or when the safety
of the patient, practitioner, and/or staff would be at risk without the protective use of restraint. It should be used to reduce or eliminate untoward movement, protect patient and dental staff from injury, and facilitate delivery of quality dental treatment. Restraint should be used only when absolutely necessary, when deemed necessary, the least restrictive alternative should be chosen. Physical restraint should not be utilized for a cooperative patient or patient who cannot be safely restrained due to underlying medical systemic conditions. Restraint shall not be used as punishment and shall not be used solely for the convenience of staff.

Outcome Indicators

Expected/Desirable

· Patient's behavior assessed at initial patient contact and throughout treatment sequence.

· Patient's behavior appropriate and enabled planned treatment to be accomplished in a quality manner or clinician appropriately modified patient's behavior.

· Child who initially exhibited unacceptable behavior developed acceptable coping behavior appropriate for developmental level and comprehension skills during the treatment process.

· Restrain modified patient's behavior appropriately.

· Restraint appropriately documented along with parental consent.

C. CONSCIOUS SEDATION
Conscious sedation is a minimally depressed level of consciousness that retains the patient's ability to maintain a patent airway independently and continuously, and respond appropriately to physical stimulation and/or verbal command, e.g., "Open your eyes". For the very young or handicapped individual, incapable of the usually expected verbal responses, a minimally depressed level of consciousness for that individual should be maintained. The caveat that loss of consciousness should be unlikely is a particularly important part of the definition of conscious sedation, and the drugs and techniques used should carry a margin of safety wide enough to render unintended loss of consciousness unlikely.

Appropriate documentation for the use of conscious sedation is detailed in the AAPD/AAP "Guidelines for the elective use of conscious sedation, deep sedations, and general anesthesia in pediatric dentistry;" Pediatric Dentistry 7:334-337, 1985.

It may be utilized to reduce or eliminate anxiety in dental patients so that safe, comfortable, quality dental treatment can be provided; reduce untoward movement and reaction to dental treatment; enhance communication and patient cooperation; increase tolerance for longer appointments; and/or aid in treatment of the mentally, physically, or medically compromised patient. Conscious sedation should not be used in the cooperative patient with minimal dental needs or when there are medical contraindications to sedative drugs.

Indications: Conscious sedations can be used safely and effectively with patients unable to receive dental care for reasons of age, or mental, physical or medical condition. Conscious sedation may be utilized in patients who are ASA Class I or II who have any of the following characteristics:

(1) Require dental care but cannot cooperate due to a lack of psychological or emotional maturity;
(2) Cannot cooperate due to mental, physical, or medical disability;
(3) May benefit from the use of sedation may protect the developing psyche.

Patients who are ASA Class III or IV require special consideration and should be dealt with on an individual basis, probably in a hospital setting.

Outcome Indicators

Expected/Desirable:

· Patient's behavior assessed at initial patient contact and throughout treatment sequence.

· Patient's behavior appropriate and enabled planned treatment to be accomplished in a quality manner or clinician appropriately modified patient's behavior.

· Child who initially exhibited unacceptable behavior developed acceptable coping behavior appropriate for developmental level and comprehension skills during the treatment process.

· Conscious sedation appropriately documented along with parental consent.

· Sedative and/or general anesthetic drugs or agents utilized appropriately documented along with parental consent.

· No untoward reactions to sedative or anesthetic drugs or agents.

· Recovery following uneventful treatment.

D. NITROUS OXIDE AND OXYGEN INHALATION SEDATION
Nitrous oxide and oxygen inhalation sedation is a conscious sedation technique which is a safe and effective behavior management adjunct to the treatment of selected dental patients. Its onset of action is fast, its depth of sedations is easily titrated and recovery is rapid and complete. Additionally, the technique provides a variable degree of analgesia for some patients.

Indications: Nitrous oxide and oxygen inhalation sedations is indicated for fearful or anxious parents; certain mentally, physically, or medically compromised patients; patients whose gag reflex interferes with dental care; and patients for whom profound local anesthesia cannot be obtained.

Nitrous oxide and oxygen inhalation sedation may be used to:
(1) Reduce or eliminate anxiety in dental patients so safe, comfortable, quality dental treatment can be rendered;
(2) Reduce untoward movement and reaction to dental treatment;
(3) Enhance communication and patient cooperation;
(4) Raise the pain reaction threshold;
(5) Increase tolerance for longer appointments;
(6) Aid in treatment of the mentally, physically, or medically compromised patient;
(7) Reduce gagging

It should not be used in patients unwilling or unable to breathe nasally. It may be contraindicated in some chronic obstructive pulmonary diseases, in certain patients with severe emotional disturbances or drug related dependencies, in patients with drug or disease induced pulmonary fibrosis, and in patients in the first trimester of pregnancy.

In addition to consent, the indication(s) for use, the present nitrous oxide and oxygen and the flow rate, as well as duration of administration must be documented.

Outcome Indicators

Expected/Desirable:
· Patient's behavior assessed at initial patient contact and throughout treatment sequence.

· Patient's behavior appropriate and enabled planned treatment to be accomplished in a quality manner or clinician appropriately modified patient's behavior.

· Child who initially exhibited unacceptable behavior developed acceptable coping behavior appropriate for developmental level and comprehension skills during the treatment process.
· Nitrous oxide and oxygen sedation modified patient's behavior appropriately.

· Sedative and/or general anesthetic drugs or agents utilized appropriately documented along with parental consent.

· No untoward reactions to sedative or anesthetic drugs or agents.

· Recovery following uneventful treatment.

E. GENERAL ANESTHESIA
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.

Documentation for the use of general anesthesia to provide dental care for children is detailed in the AAPD/AAP "Guidelines for the elective use of conscious sedation, deep sedations, and general anesthesia in pediatric dentistry;" Pediatric Dentistry 7:334-337, 1985.

Indications: The use of general anesthesia is indicated to facilitate the provision of safe, efficient and effective quality dental care for the following:

(1) Patients with certain physical, mental, or medically compromising conditions;
(2) Patients with dental needs for whom local anesthesia is ineffective because of acute infection, anatomic variations, or allergy;
(3) The extremely uncooperative, fearful, anxious, or noncommunicative child or adolescent with dental needs;
(4) Patients who have sustained extensive orofacial and/or dental trauma;
(5) Patients with dental needs who otherwise would not obtain the necessary dental care;
(6) For protection of the developing psyche of fearful children.

General anesthesia should not be utilized for a healthy, cooperative patient with minimal dental needs or when there are medical contraindications to general anesthesia.

Outcome Indicators

Expected/Desirable:

· Patient's behavior assessed at initial patient contact and throughout treatment sequence.

· Patient's behavior appropriate and enabled planned treatment to be accomplished in a quality manner or clinician appropriately modified patient's behavior.

· Child who initially exhibited unacceptable behavior developed acceptable coping behavior appropriate for developmental level and comprehension skills during the treatment process.

· General anesthesia utilized appropriately documented along with parental consent.

· Sedative and/or general anesthetic drugs or agents utilized appropriately documented along with parental consent.

· No untoward reactions to sedative or anesthetic drugs or agents.

· Recovery following uneventful treatment.