Behavior Management - Contemporary Dental Care for Children
Behavior Management - Appendix A: Clinical Issues
Techniques
   Communicative Techniques
   Non-Communicative Techniques
      Immobilization
      Analgesia
      Sedation
      General Anesthesia
References

Behavior Management - Contemporary Dental Care for Children

It has been estimated that 85 percent of children are generally cooperative in dental treatment settings, while the remaining 15 percent require more advanced behavior management approaches in order to provide dental care. Behavior management has been defined as the purposeful application of accepted techniques - both pharmacological and non-pharmacological - to reduce fear and anxiety, enhance cooperation, and effect treatment. Descriptions of common behavior management techniques used in pediatric dentistry can be found [below] in Appendix A: Clinical Issues. A more complete description of techniques, rationale and indications for various approaches can be found in the current Reference Manual of the American Academy of Pediatric Dentistry, available on the Internet at www.aapd.org.

Behavioral management of anxious children, who are unable to readily accept even routine dental treatment, often require additional time on the part of practitioners and support personnel to provide dental procedures. Dentists may be reluctant to treat very young children and those with disabling conditions. This can contribute to limited access to care for both groups of children. Therefore, it is important that dentists receive adequate training in behavior management to be able to provide care for Medicaid children.

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It has been estimated that 85 percent of children can cooperate for dental treatment, while the remaining 15 percent will require behavior management of some type in order to effect dental treatment. While definitions may vary, behavior management can be defined as purposeful application of accepted techniques, both pharmacologic and non-pharmacologic, to reduce fear and anxiety, enhance cooperation and effect treatment. Behavior management is a skill acquired by a provider through training and enhanced with experience. Behavioral management of anxious and children who are unable to cooperate easily in the traditional dental office may require additional time on the part of the provider for a dental procedure that would otherwise be provided in less time.

Techniques

Communicative (non-aversive) techniques are considered inherent in care of children. These include tell-show-do, voice control, positive reinforcement and distraction. These techniques are used routinely to effect treatment in the pediatric population and are indicated when a child shows mild anxiety, failure to attend, or mild disruptive behavior. It is assumed that a general consent for dental care encompasses the dentist's use of these techniques. The cost of these services is usually assumed within the fee for the service. On occasion, a clearly necessary dental service may be made substantially more difficult because of inability of the patient to easily cooperate in receiving the service as a result of anxiety, inappropriate behaviors, or mental or other disability. Such situations may require the dentist to devote substantially more time than normal to communicative behavioral techniques in an effort to provide the service while avoiding the need for additional, more invasive behavioral management techniques. Since the additional time spent when such situations arise substantially increases the cost of providing the service, state Medicaid programs may wish to consider separate reimbursement for extensive use of communicative behavior management techniques. A separate procedure code ("behavioral management, by report") is available for such use in the American Dental Association's code of dental procedures and nomenclature, Current Dental Terminology (CDT-3).

Non-communicative techniques include immobilization, analgesia (nitrous oxide), sedation and general anesthesia. These techniques are considered supplemental to routine care and as such require additional consent. These techniques are covered and reported using separate procedure codes in the American Dental Association's code of dental procedures and nomenclature, Current Dental Terminology (CDT-3). These procedures also are detailed in the Guidelines for Behavior Management of the American Academy of Pediatric Dentistry in the AAPD Reference Manual.

Immobilization is used to prevent injury to patient and providers. Immobilization can require additional staff, caretakers and/or devices to safely constrain movement that might be dangerous to patient or staff or affect quality of care.

Indications: Patient is unwilling or unable to control movements and presents a danger to staff or self during treatment procedures deemed necessary.

Contraindications: Immobilization cannot be used as punishment or when it presents risk of injury to the patient.

Analgesia (Nitrous Oxide-Oxygen Analgesia) is an inhalation technique using a combination of nitrous oxide and oxygen in concentrations that relax, but do not render a patient unconscious.

Indications: Analgesia can be used for the anxious or obstreperous child, certain CSHN, patients with hyperreflexia of the gag reflex, and for those with inadequate response to local anesthetic.

Contraindications: Certain pulmonary conditions, emotional illnesses, drug dependencies, pregnancy may be contraindications to analgesia.

Sedation is administration of a centrally acting pharmacologic agent orally, intravenously, rectally, intranasally, or submucosally to induce a level of consciousness that will permit safe and effective dental care. A complete perspective of the use of sedation in children can be found in guidelines for use of conscious sedation from the American Academy of Pediatric Dentistry.

Indications: Children who are anxious or uncooperative for dental care, whose health status permits use of sedative agents, and who, in the judgment of the dentist or from previous ineffective care under other behavioral techniques, are best treated with this technique.

Contraindications: Children whose health status precludes use of sedative agents or whose dental disease status requires or permits utilization of alternative methods.

General Anesthesia is a technique in which a child is rendered unconscious with a single or combination of pharmacologic agents. General anesthesia is most appropriately administered in an approved facility by a trained provider. A complete description of general anesthesia and indications for its use can be found in the Guidelines for Behavioral Management of the American Academy of Pediatric Dentistry.

Indications: Children whose physical, mental, or medical condition precludes other behavior management choices, who are precooperative, and whose dental needs merit treatment best performed under general anesthesia.

Contraindications: Children whose dental needs are minor and those children whose medical status precludes use of general anesthesia.

References:

1. American Academy of Pediatric Dentistry Reference Manual, Chicago, IL: American Academy of Pediatric Dentistry. 2000.
2. U.S. Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General. Rockville, MD: U. S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health, 2000.

See also:
     Guide to Children's Dental Care in Medicaid