• American Academy of Pediatric Dentistry Clinical Affairs Committee-Behavior, American Academy of Pediatric Dentistry Council on Clinical Affairs. Guideline on behavior guidance for the pediatric dental patient. Pediatr Dent 2008-2009;30(7 Suppl):125-33. [63 references] PubMed

• Description: Nitrous oxide/oxygen inhalation is a safe and effective technique to reduce anxiety and enhance effective communication. Its onset of action is rapid, the effects easily are titrated and reversible, and recovery is rapid and complete. Additionally, nitrous oxide/oxygen inhalation mediates a variable degree of analgesia, amnesia, and gag reflex reduction.

  The need to diagnose and treat, as well as the safety of the patient and practitioner, should be considered before the use of nitrous oxide/oxygen analgesia/anxiolysis. Detailed information concerning the indications, contraindications, and additional clinical considerations may be found in the National Guideline Clearinghouse (NGC) summary of the American Academy of Pediatric Dentistry's (AAPD) Clinical Guideline on Appropriate Use of Nitrous Oxide for Pediatric Dental Patients.

Advanced Behavior Guidance

Most children can be managed effectively using the techniques outlined in basic behavior guidance. These basic behavior guidance techniques should form the foundation for all of the management activities provided by the dentist. Children, however, occasionally present with behavioral considerations that require more advanced techniques. The advanced behavior guidance techniques commonly used and taught in advanced pediatric dental training programs include protective stabilization, sedation, and general anesthesia. They are extensions of the overall behavior guidance continuum with the intent to facilitate the goals of communication, cooperation, and delivery of quality oral health care in the difficult patient. Appropriate diagnosis of behavior and safe and effective implementation of these techniques necessitate knowledge and experience that are generally beyond the core knowledge students receive during predoctoral dental education. While most predoctoral programs provide didactic exposure to treatment of very young children (i.e., aged birth – 2 years), patients with special health care needs, and advanced behavior guidance techniques, hands-on experience is lacking. A minority of programs provides educational experiences with these patient populations, while few provide hands-on exposure to advanced behavior guidance techniques. Dentists considering the use of these advanced behavior guidance techniques should seek additional training through a residency program, a graduate program, and/or an extensive continuing education course that involves both didactic and experiential mentored training.

Protective Stabilization

• Description: The use of any type of protective stabilization in the treatment of infants, children, adolescents, or persons with special health care needs is a topic that concerns healthcare providers, care givers, and the public. The broad definition of protective stabilization is the restriction of patient's freedom of movement, with or without the patient's permission, to decrease risk of injury while allowing safe completion of treatment. The restriction may involve another human(s), a patient stabilization device, or a combination thereof. The use of protective stabilization has the potential to produce serious consequences, such as physical or psychological harm, loss of dignity, and violation of a patient's rights. Stabilization devices placed around the chest may restrict respirations; they must be used with caution, especially for patients with respiratory compromise (e.g., asthma) and/or who will receive medications (i.e., local anesthetics, sedatives) that can depress respirations. Because of the associated risks and possible consequences of use, the dentist is encouraged to evaluate thoroughly its use on each patient and possible alternatives. Careful, continuous monitoring of the patient is mandatory during protective stabilization.

  Partial or complete stabilization of the patient sometimes is necessary to protect the patient, practitioner, staff, or the parent from injury while providing dental care. Protective stabilization can be performed by the dentist, staff, or parent with or without the aid of a restrictive device. The dentist always should use the least restrictive, but safe and effective, protective stabilization. The use of a mouth prop in a compliant child is not considered protective stabilization.

  The need to diagnose, treat, and protect the safety of the patient, practitioner, staff, and parent should be considered for the use of protective stabilization. The decision to use patient stabilization should take into consideration:

  1. Alternate behavior guidance modalities
  2. Dental needs of the patient
  3. The effect on the quality of dental care
  4. The patient's emotional development
  5. The patient's emotional and physical considerations

  Protective stabilization, with or without a restrictive device, performed by the dental team requires informed consent from a parent. Informed consent must be obtained and documented in the patient's record prior to use of protective stabilization. Due to the possible aversive nature of the technique, informed consent also should be obtained prior to a parent's performing protective stabilization during dental procedures. Furthermore, when appropriate, an explanation to the patient regarding the need for restraint, with an opportunity for the patient to respond, should occur.

  In the event of an unanticipated reaction to dental treatment, it is incumbent upon the practitioner to protect the patient and staff from harm. Following immediate intervention to assure safety, if techniques must be altered to continue delivery of care, the dentist must have informed consent for the alternative methods.

  The patient's record must include:

  1. Informed consent for stabilization
  2. Indication for stabilization
  3. Type of stabilization
  4. The duration of application of stabilization
  5. Behavior evaluation/rating during stabilization

• Objectives: The objectives of patient stabilization are to:
  1. Reduce or eliminate untoward movement
  2. Protect patient, staff, dentist, or parent from injury
  3. Facilitate delivery of quality dental treatment
• Indications: Patient stabilization is indicated when:
  1. Patients require immediate diagnosis and/or limited treatment and cannot cooperate due to lack of maturity or mental or physical disability
  2. The safety of the patient, staff, dentist, or parent would be at risk without the use of protective stabilization
  3. Sedated patients require limited stabilization to help reduce untoward movement
• Contraindications: Patient stabilization is contraindicated for:
  1. Cooperative non-sedated patients
  2. Patients who cannot be immobilized safely due to associated medical or physical conditions
  3. Patients who have experienced previous physical or psychological trauma from protective stabilization (unless no other alternatives are available)
  4. Nonsedated patients with nonemergent treatment requiring lengthy appointments
• Precautions: The following precautions should be taken prior to patient stabilization:
  1. Careful review of the patient's medical history to ascertain if there are any medical conditions e.g., asthma) which may compromise respiratory function
  2. Tightness and duration of the stabilization must be monitored and reassessed at regular intervals
  3. Stabilization around extremities or the chest must not actively restrict circulation or respiration
  4. Stabilization should be terminated as soon as possible in a patient who is experiencing severe stress or hysterics to prevent possible physical or psychological trauma

Sedation

• Description: Sedation can be used safely and effectively with patients unable to receive dental care for reasons of age or mental, physical, or medical condition. Background information and documentation for the use of sedation is detailed in the NGC summary of the AAPD's Guidelines for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures.

  The need to diagnose and treat, as well as the safety of the patient, practitioner, and staff, should be considered for the use of sedation. The decision to use sedation must take into consideration:

  1. Alternative behavioral guidance modalities
  2. Dental needs of the patient
  3. The effect on the quality of dental care
  4. The patient's emotional development
  5. The patient's physical considerations

  Documentation shall include: (See the NGC summary of the AAPD's Guidelines for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures).

  1. Informed consent. Informed consent must be obtained from the parent and documented prior to the use of sedation
  2. Instructions and information provided to the parent
  3. Health evaluation
  4. A time-based record that includes the name, route, site, time, dosage, and patient effect of administered drugs
  5. The patient'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
  7. Time and condition of the patient at discharge

• Objectives: The goals of sedation are to:
  1. Guard the patient's safety and welfare
  2. Minimize physical discomfort and pain
  3. Control anxiety, minimize psychological trauma, and maximize the potential for amnesia
  4. Control behavior and/or movement so as to allow the safe completion of the procedure
  5. Return the patient to a state in which safe discharge from medical supervision, as determined by recognized criteria, is possible
• Indications: Sedation is indicated for:
  1. Fearful, anxious patients for whom basic behavior guidance techniques have not been successful
  2. Patients who cannot cooperate due to a lack of psychological or emotional maturity and/or mental, physical, or medical disability
  3. Patients for whom the use of sedation may protect the developing psyche and/or reduce medical risk
• Contraindications: The use of sedation is contraindicated for:
  1. The cooperative patient with minimal dental needs
  2. Predisposing medical conditions which would make sedation inadvisable

General Anesthesia

• Description: 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 sometimes is necessary to provide quality dental care for the child. Depending on the patient, this can be done in a hospital or an ambulatory setting, including the dental office. Additional background information may be found in the American Academy of Pediatric Dentistry's Clinical Guideline on Use of Anesthesia Care Providers in the Administration of In-office Deep Sedation/General Anesthesia to the Pediatric Dental Patient.

  The need to diagnose and treat, as well as the safety of the patient, practitioner, and staff, should be considered for the use of general anesthesia. The decision to use general anesthesia must take into consideration:

  1. Alternative behavioral guidance modalities
  2. Dental needs of the patient
  3. The effect on the quality of dental care
  4. The patient's emotional development
  5. The patient's medical status

  Prior to the delivery of general anesthesia, appropriate documentation shall address the rationale for use of general anesthesia, informed consent, instructions provided to the parent, dietary precautions, and preoperative health evaluation. Because laws and codes vary from state to state, minimal requirements for a time-based anesthesia record should include:

  1. The patient's heart rate, blood pressure, respiratory rate, and oxygen saturation at specific intervals throughout the procedure and until predetermined discharge criteria have been attained
  2. The name, route, site, time, dosage, and patient effect of administered drugs, including local anesthesia
  3. Adverse events (if any) and their treatment
  4. That discharge criteria have been met, the time and condition of the patient at discharge, and into whose care the discharge occurred

• Objectives: The goals of general anesthesia are to:
  1. Provide safe, efficient, and effective dental care
  2. Eliminate anxiety
  3. Reduce untoward movement and reaction to dental treatment
  4. Aid in treatment of the mentally, physically, or medically compromised patient
  5. Eliminate the patient's pain response
• Indications: General anesthesia is indicated for:
  1. Patients who cannot cooperate due to a lack of psychological or emotional maturity and/or mental, physical, or medical disability
  2. Patients for whom local anesthesia is ineffective because of acute infection, anatomic variations, or allergy
  3. The extremely uncooperative, fearful, anxious, or uncommunicative child or adolescent
  4. Patients requiring significant surgical procedures
  5. Patients for whom the use of general anesthesia may protect the developing psyche and/or reduce medical risk
  6. Patients requiring immediate, comprehensive oral/dental care
• Contraindications: The use of general anesthesia is contraindicated for:
  1. A healthy, cooperative patient with minimal dental needs
  2. Predisposing medical conditions which would make general anesthesia inadvisable

• American Academy of Pediatric Dentistry Clinical Affairs Committee-Behavior, American Academy of Pediatric Dentistry Council on Clinical Affairs. Guideline on behavior guidance for the pediatric dental patient. Pediatr Dent 2008-2009;30(7 Suppl):125-33. [63 references] PubMed

Electronic copies: Available from the American Academy of Pediatric Dentistry Web site.

Print copies: Available from the American Academy of Pediatric Dentistry, 211 East Chicago Avenue, Suite 700, Chicago, Illinois 60611.

• Overview. American Academy of Pediatric Dentistry 2007-08 definitions, oral health policies, and clinical guidelines. Available from the American Academy of Pediatric Dentistry Web site.
• Sedation record. Available in Portable Document Format (PDF) from the American Academy of Pediatric Dentistry Web site.

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