Behavior Guidance

Parents want the best for their children, whether their children are at school, camp or the dental office. Two important steps will get your child the best dental care.
First, choose the right dental professional for a particular child. Second, be an active partner in the child’s dental health decisions.
Parents have two important rights in the dental treatment of their children. The first is a right to information. As a parent, you should know exactly what treatment your child will receive – and why. The second is a right of choice. Parents can support or deny any treatment approach suggested for their child. This is called informed consent.
Each child responds in her own way to a dental visit. Pediatric dentists stand ready with a variety of methods to help an individual child feel comfortable with dental treatment. You can and should be a partner in selecting which technique will work best for your child.
Why would a dentist use behavior guidance with a child? The main goals of behavior guidance are:
1. Establish communication.
2. Alleviate fear and anxiety
3. Deliver quality dental care
4. Build a trusting relationship between dentist and child
5. Promote the child’s positive attitude toward oral/dental health and oral health care
Since every child is different, pediatric dentists have a wide range of approaches to help a child complete needed dental treatment. A pediatric dentist makes a recommendation of behavior guidance methods for the child based upon her health history, special health care needs, dental needs, type of treatment required, the consequences of no treatment, her emotional and intellectual development and parental preferences.
There are two main reasons why a pediatric dentist may recommend behavior guidance for the child. The first reason is anxiety. Children typically respond to an unfamiliar dental office in the same way they respond to a new pediatrician, new childcare provider, or first visit to someone’s home. Some are totally comfortable; others are fearful in the new or unfamiliar situation. The second reason is pain. If a child’s first visit to a dentist is an emergency situation, perhaps because of a toothache or mouth injury, she is far more likely to be unhappy during the visit. This is why the most important behavior guidance technique is early and regular dental visits. If a child visits a dentist when her mouth is comfortable, she is much more likely to find the visit pleasant and fun.
Parents play an important role in their child’s safety during dental treatment. In particular, stay up-to-date on the child’s health status. Be certain to inform the pediatric dentist about changes in the child’s medical history, including any illnesses and any medications, both prescription and over-the-counter.
A well-informed parent should know the choices available to relieve the anxiety or discomfort of the child during dental treatment. Working together, a parent and the pediatric dentist can select the best treatment methods to make the child’s visit as safe and comfortable as possible.

The pediatric dentist explains the treatment in words just right for the child’s age and level of understanding, shows the child the treatment in a simplified manner, then performs the treatment without deviating from the explanation.
The pediatric dentist praises and rewards the child for any behavior that helps with treatment. (In pediatric dental offices, every child does something right during a dental visit.)
In this technique, the child’s attention is diverted away from what might be perceived as unpleasant. The pediatric dental team chooses treatment words carefully, passes instruments out of the child’s sight and occasionally distracts the child’s attention away from the treatment with conversation, music, movies or even video games.
The pediatric dentist changes voice tone or volume to calm a child or get a child’s attention. Typically, the pediatric dentist speaks in a soft, controlled tone and repeats messages as necessary. Some dentists advocate use of a loud tone occasionally to discourage disruptive behavior or movements, such as reaching for a sharp instrument that can pose a risk to the child. If parents are not comfortable with the use of voice control with their child, then they should certainly speak to the pediatric dentist about the issue.
This technique encourages a child to replicate the behavior of another patient undergoing a positive dental visit. Prior to her own appointment, she would observe a cooperative “model” patient receiving dental treatment. When children can see and hear others experiencing dental care in a positive fashion, they may be more relaxed and more inclined to cooperate for their own treatment. Modeling can be accomplished by watching an audiovisual video or by observing a live patient model such as a sibling, other children or even parents.
Modeling also can occur on a recurring basis within an open clinic setting. Some pediatric dentists design patient treatment areas without walls or partitions between patient chairs. The ability to observe other children’s positive responses to treatment at every appointment can help promote a positive attitude and build a trusting relationship between the child and the dentist.
A topical anesthetic can be applied with a cotton swab to numb the surface of the cheek or gums. (It is similar to the gel you rub on a child’s gums when they are teething.) A local anesthetic, such as lidocaine or articaine (similar to Novocaine), may be injected in a specific area of a child’s mouth to prevent discomfort during treatment. These local anesthetics cause temporary numbness that may last longer than the appointment. Parents must be careful about giving children hot food or liquids, and watch that their children do not bite their lips or cheeks before the numbness wears off.
If a child is worried by the sights, sounds or sensations of dental treatment, she may respond more positively with the use of nitrous oxide/oxygen. Nitrous oxide/oxygen, which you might know better as laughing gas, can reduce anxiety and gagging in children and make long appointments easier. The child breathes the gas through a mask placed on her nose and remains fully conscious during treatment. Recovery after treatment is rapid and complete.

Protective stabilization is an approach that limits a patient’s movement during treatment in order to decrease risk of injury and allow treatment to be completed safely. Possibilities in this category include asking the parent to hold the child on her lap with her arms hugging the child. Another approach is the use of a body “blanket” that holds the child’s arms and legs still and away from the mouth. Stabilization may be recommended for children who are very young or have difficulty remembering the importance of keeping their hands away from dental instruments. Used only after other behavior guidance techniques have been considered, this approach is sometimes necessary to protect a child from the sharp, fast moving instruments required in dental treatment. It also can be used in conjunction with other techniques such as sedation.
This technique uses medications for your child’s safety and comfort during dental treatment. Sedation can help increase cooperation and reduce anxiety and/or discomfort associated with dental procedures. In particular, it can prevent injury by helping a child stay still around the sharp or fast-moving instruments needed for treatment.
For this technique, the pediatric dentist selects a medication and dose based upon your child’s overall health, level of anxiety and dental treatment recommendations. It is not intended to cause a loss of consciousness. (In other words, the child is relaxed but not asleep. She is able to respond to touch or voices.)
This approach may be recommended for apprehensive children, very young children and children with special health care needs who would not be able to receive necessary dental care in a safe and comfortable manner without it.
Sedation is safe for children when it is administered by a pediatric dentist who follows the sedation guidelines of the American Academy of Pediatric Dentistry. Parents should feel free to discuss with their pediatric dentist the different medications and sedation options, as well as the special monitoring equipment used for patient protection.
Medically speaking, general anesthesia is an induced state of unconsciousness. In practical terms, the patient is asleep and unable to respond to touch or voices. It is most often recommended for children with extensive dental needs who cannot tolerate the treatment required to restore their oral health. For example, if a toddler was suffering from severe early childhood caries and required multiple root canals and crowns, the parents might agree that general anesthesia was the most comfortable and safest way to complete treatment. Or, it may be the treatment of choice for a child with a mental or physical disability for whom a hospital setting provides the safest and best approach to care.
All parents should know that children face the same risk under general anesthesia for dental treatment as for any other surgical procedure. The treatment should be provided only by highly qualified health professionals, including pediatric dentists with advanced education in anesthesiology, dental or medical anesthesiologists, oral surgeons, and certified registered nurse anesthetists. Whether the treatment is provided in a pediatric dental office or a hospital, it should feature special monitoring and emergency equipment and trained support personnel. Parents should talk openly with their pediatric dentist about the benefits and risks of this treatment.
Should you go back to treatment with your little Sarah or should you stay in the reception area and relax with a magazine? Pediatric dentists differ on whether parents should accompany their children during treatment. In some offices, parents are required to accompany their children as a way to ensure parent education about good oral health. In other offices, children are encouraged to go back for treatment on their own. That way, the pediatric dentist and team can focus on the child, work directly with the child and build a positive relationship with the child right away. In still other offices, parents make the decision. They are welcome to relax in the reception area or join their child during treatment. Bottom line: You can find a pediatric dentist whose approach matches your preferences.

If you do go in with your child:

Stand or sit in a location where your child knows you are nearby but can not see your face. (Even a very young child is totally tuned in to your facial cues. It only takes one worried look to inadvertently upset your child.)

Be a silent observer. Let the pediatric dentist build rapport and provide positive coaching for your child.

If your child needs physical reassurance, you might consider holding your child’s hand or having your toddler sit on your lap.
If you do not go in with your child:

Be assured that the pediatric dentist or a member of the team will keep you carefully informed about your child’s dental health and development. Typically, this takes place in a one-on-one conversation right after the treatment is completed.

Stay at the dental office during the appointment. Although some parents are tempted to drop their children off and run errands, knowing that you are nearby can be reassuring to your child.
                                                                                             Dr. Daniel Ravel, DDS
                                                                                                  Pediatric Dentist
                                                                               1031 Weiss Ave, Fayetteville, NC 28305 
                                                                                                    (910) 486-4180