Teaching Behavior Management of Pediatric Dental Patients
Are we off track?
Constance M. Killian, DMD | Ari Kupietzky, DMD, MSc | Theodore P. Croll, DDS
There is a trend in pediatric dentistry that has spawned a variety of techniques to manage dental caries infections in pediatric patients. Methods such as interim therapeutic restoration (ITR), which is sometimes referred to as the atraumatic restorative technique; the use of silver diammine fluoride (SDF); and the Hall technique have all been proposed as means to treat carious primary teeth with a minimal need for behavior guidance. Although many practitioners hail these techniques as solutions to the problem of dental caries in pediatric patients, we propose that the proliferation of these limited methods is a symptom of a larger and more concerning phenomenon: the increasing number of dentists who do not have the education or skills needed to guide the behavior of our youngest patients in a positive way. Only in the absence of expertise in managing the behavior of children could a dentist consider such techniques as long-term "solutions."
When managing the behavior of a pediatric patient, there is a need for knowledge, understanding, trust, and expertise. Experience serves to improve all of these attributes. The pediatric dentist, or any dentist who treats children, must have expertise in managing pediatric patients as well as in discussing with parents the need for any recommended treatment and the behavioral techniques that will be used to provide the treatment. Parents also need to be educated about the causes of dental caries and other oral disease states as well as the methods of prevention. This education of parents and caregivers is critical for the young patient in that it helps to build the relationship with the dentist. The resulting dentist-family partnership helps to establish a "dental home" for the child. Ultimately, parents must trust that the dentist will use his or her acquired skills and knowledge, which are based on science, to provide optimal care for their child. Parental trust of a dentist is predictably transferred to the child and that, in turn, enhances the child's ability to cooperate with the dentist and his or her staff. Historically, this has been the experience of many thousands of pediatric and general dentists.
Pediatric dentistry is a unique specialty in our profession because it is age- and patient-defined, not procedure-defined as with the other specialties. Pediatric dental patients range from pre-cooperative infants to toddlers, children, and even teens and may include individuals with intellectual or physical special healthcare needs. In all of these age groups, there are those who are fearful, anxious, or angry and therefore difficult to manage. Changing parenting styles, dysfunctional family conditions, and societal expectations all contribute to the challenges faced by dentists who treat pediatric patients. The ability to guide the behavior of young patients has been the hallmark of pediatric dentistry, and acquiring the skills to do so begins during our specialty training. Traditionally, we have been taught to manage the behavior of our patients using basic behavior guidance techniques (eg, tell-show-do, distraction, voice control, parental presence/absence, nitrous oxide/oxygen inhalation) and advanced behavior management techniques (eg, protective stabilization, sedation, general anesthesia) as adjuncts to providing dental care. This training was always what set pediatric dentists apart, giving them the expertise to manage a child's behavior to facilitate ideal preventive, restorative, and oral surgical care in caring, safe, and comfortable ways. We were taught to choose the forms of behavior management that were best suited to the condition of the individual patient, taking into consideration his or her age, medical history, overall behavior, temperament, and the extent of the treatment required. Even the selection of the most suitable time of day for an appointment for a child is a routine consideration. Pediatric dentists and their teams who have practiced compassionately and humanely in this manner develop long-term relationships with patients and their families. These relationships can become so strong that many former patients will return to their original pediatric dentist when their own children are ready for dental care.
The Shift Toward Pharmacologic Management
Of course, there are indications for dental treatment using sedation or general anesthesia, but the decision about which form of behavior management to use must be made based on each individual patient's needs. Currently, it seems that the decision to use advanced behavior management techniques is often made, even if only subconsciously, because the pediatric dentist is lacking in the necessary skills to provide optimal treatment without the use of sedation or general anesthesia. One is reminded of the law of the instrument: "If the only tool you have is a hammer, everything looks like a nail," which illustrates cognitive bias involving overreliance on a familiar tool. Dentists with limited skills in behavior guidance techniques may rationalize that in making the decision to recommend advanced (ie, pharmacological) behavior management techniques, they are doing so in order to protect the child's developing psyche. More recently, pediatric dentistry residents are learning less about basic behavior guidance techniques and, instead, are being trained to provide extensive restorative treatment with their patients under sedation or general anesthesia. This may occur for a variety of reasons, including:
• a greater incidence of difficult cases in hospital/teaching environments, so residents receive more experience and become proficient in dentistry for sedated or completely anesthetized patients;
• the desire and need to learn complex procedures at the expense of learning techniques that are perceived as less important;
• time constraints, which limit the opportunities to teach basic behavior management techniques in an educational setting;
• a lack of faculty with sufficient knowledge, expertise, and experience in basic behavior management;
• scheduling practices that limit opportunities to develop a relationship with the patient and parents throughout the course of repeated visits;
• financial implications; and
• the belief that it is impossible to provide restorative dental treatment for a child in a comfortable and humane fashion without the use of pharmacologic agents.
Regardless of the reasons, pediatric dentistry residents are increasingly being trained to treat patients under sedation or general anesthesia. Beyond the obvious risks associated with sedation and general anesthesia, it should be noted that some pediatric patients treated in this manner receive more extensive restorative treatment than they would have if basic behavior guidance had been used. In addition, when sedation or general anesthesia is used as a form of behavior management, some clinicians place full coronal restorations to treat teeth with only minor caries lesions or decalcification without cavitation. A common justification for this approach is that children who "require" sedation or general anesthesia for treatment are at high risk for future caries and are therefore indicated for more extensive (and more costly) treatment to obviate future needs. A good example of this is when a stainless steel crown restoration is used for a primary molar with only a minimal two-surface caries lesion as opposed to placing a direct restoration using a resin-modified glass ionomer or resin-based composite.
It is our contention that the failure to teach students and residents how to properly manage the behavior of children using basic behavior guidance techniques and not providing them with experience in doing so has contributed to an increased use of sedation and general anesthesia in pediatric dentistry. Research into the effects of general anesthesia on the developing brain indicates that there may be some concern regarding repeated exposure of the developing cerebral tissue to general anesthetic agents.1 The sedation of young children has also become a subject of scrutiny due to concerns regarding the safety of young patients who are sedated while having dental treatment.In the absence of proper behavior guidance skills and in light of the concerns of some parents and researchers about the overuse of pharmacologic agents to facilitate dental treatment, some practitioners have been motivated to employ "simple" dental procedures (eg, ITR, SDF, Hall Technique) to manage dental caries. These procedures can be performed without the use of general anesthesia or sedation and do not require the practitioner to have expertise in basic behavior guidance. The flaw in this approach is that some of these methods are, at best, interim in nature, and parents may not be aware that continued and periodic professional supervision is indicated when they are used. Furthermore, without the use of basic behavior guidance techniques, even these "simple" procedures are unlikely to be successful long-term.
Expertise in basic behavior guidance techniques is critical to the continuing success of our specialty and, more importantly, the overall oral health of young patients. Pediatric dentists must continue to master the ability to manage the behavior of young and difficult children in order to be best prepared to provide therapies that are grounded in science and provide long-term solutions. Educators must make renewed efforts to teach basic behavior management and emphasize the critical role that it has in providing effective pediatric dental care. We recognize the place and importance of advanced pharmacological behavior management in our specialty, and we are grateful for those options when they are truly needed. However, we are concerned that the pendulum has swung too far and that children who can safely and comfortably be guided with basic behavior management techniques to accept routine chairside dental care and become excellent dental patients throughout childhood and beyond are not given that opportunity. Pediatric dentistry specialists and other dentists who treat children must not dilute or abandon the unique techniques that have been the basis for successful clinical care for generations of children. Our patients and their parents are trusting us to meet this challenge.
About the Authors
Constance M. Killian, DMD
Adjunct Associate Professor
University of Pennsylvania
School of Dental Medicine
Ari Kupietzky, DMD, MSc
Department of Pediatric Dentistry
Rutgers School of Dental Medicine
Newark, New Jersey
Department of Pediatric Dentistry
The Hebrew University-Hadassah School of Dental Medicine
Theodore P. Croll, DDS
Case Western Reserve University
School of Dental Medicine
1. Loepke AW, Soriano SG. An assessment of the effects of general anesthetics on developing brain structure and neurocognitive function. Anesth Analg. 2008;106(6):1681-1707.