Nonpharmacological Behavior Guidance for the Pediatric Dental Patient

Board takeaway

Select behavior guidance with the child and family according to the procedure, developmental abilities, health, prior experiences, and preferences.

• Build trust and adapt the technique to the observed response.
• Every recommendation in this guideline is conditional and most evidence has very low certainty; a large estimated benefit does not prove reliable superiority.
• Obtain informed consent for techniques beyond communicative management as required by applicable law.

Scope and evidence

• Preventive visits: examination, prophylaxis, radiographs, fluoride. Treatment visits include sealants, local anesthesia, restorations, pulp therapy, simple extractions.
• Separate recommendations address special health care needs (SHCN). Parental anxiety/behavior management is outside scope.
• Eight systematic reviews informed GRADE decisions. Bias, imprecision, inconsistency, indirectness, and population differences limit confidence.
• No recommendation means insufficient evidence, not a contraindication.
• Moderate-certainty exceptions: positive reinforcement for preventive visits and VR glasses for restorative treatment; both remain conditional.

Before and after the visit

• Home preparation: preventive videos/imagery offer small fear and trivial anxiety/cooperation benefits.
  • Treatment videos may reduce anxiety; illustrations/storytelling may modestly improve behavior.
  • SHCN stepwise visual preparation offers trivial cooperation benefit.
• Waiting spaces: ensure accessibility and inclusion; no recommendation establishes games, media, or music efficacy.
• Positive dental imagery: trivial preventive anxiety benefit; treatment effects range from trivial to large, with small cooperation benefit. No SHCN recommendation.
• In-office modeling: preventive cooperation benefit ranges from trivial to large, anxiety benefit trivial to small; treatment benefits range from trivial to large. SHCN effects are trivial.
• Suggestion and preparatory information: local-anesthesia pain benefit is trivial and informed by medical needle-procedure evidence. No recommendation for preventive care or SHCN.
• Posttreatment modeling: trivial subsequent-visit anxiety benefit; no SHCN recommendation or specified follow-up interval.

Communication and familiar techniques

• Communication: foundational despite sparse trials; adapt to age, cognition, health, and culture. Preventive nonverbal guidance may slightly improve fear-related behavior.
• Tell-show-do (TSD), tell-play-do: age-appropriate explanations; variable anxiety benefit, trivial treatment pain/cooperation effects. No SHCN recommendation; often the trial comparator.
• Ask-tell-ask; enhancing control: no eligible evidence supports a formal recommendation; select according to individual factors and preferences.
• Voice control: increased volume has trivial benefit; lower-volume modification is also described. Parental acceptance varies—discuss before use.
• Positive reinforcement: small preventive anxiety benefit; variable treatment fear benefit, trivial anxiety/cooperation effects. SHCN evidence is indirect; specific descriptive praise was unstudied.
• Memory restructuring: trivial treatment fear/pain benefit; no preventive or SHCN recommendation. Consider training and family acceptance.
• Desensitization: may slightly improve cooperation across groups; preventive and SHCN guidance draws on indirect treatment evidence.

Relaxation, combinations, and animals

• Biofeedback: physiological feedback teaches voluntary regulation; variable treatment anxiety benefit. Requires resources; no preventive or SHCN recommendation.
• Diaphragmatic breathing: variable anxiety reduction, trivial fear/pain effects; preventive guidance is indirect. No SHCN recommendation. Happiness findings conflict within the source and should not be promised.
• Combined techniques: TSD plus audiovisual distraction (AVD) has variable anxiety benefit. TSD plus active parental presence may slightly improve anxiety/cooperation. No SHCN combination recommendation.
• Animal-assisted therapy: variable anxiety/small cooperation benefit; pooled anxiety results were trivial. Consider regulations, resources, acceptance. No SHCN recommendation.

Distraction and procedure-specific decisions

• Magic tricks: may improve readiness to sit/accept care; anxiety/cooperation effects are trivial for preventive care. Treatment readiness guidance is indirect; no SHCN recommendation.
• Toys, stories, mirror/conversation: insufficient evidence for an anxiety/cooperation recommendation.
• During local anesthesia: counter-stimulation or motor/breathing distraction may substantially reduce anxiety/pain; cooperation benefit is unproven.
  • Syringe camouflage may reduce pain-related behavior/anxiety and improve cooperation.
  • Certainty is very low.
• Digital injection technology: evidence suggests small anxiety reduction, trivial-to-small pain reduction, and trivial cooperation effects—not established broad superiority.
• Preventive mobile dental apps: anxiety benefit ranges from trivial to large; readiness benefit is small.
• Restorative music: small anxiety benefit; cooperation benefit unproven. AVD/3D glasses generally yield trivial-to-small anxiety/cooperation benefits.
• Restorative VR: largely trivial caries-removal/rubber-dam effects; potentially large restorative pain benefit. Habituation may contribute.
• Injection distraction: music/3D AVD benefits are supported principally in children with positive baseline behavior; applicability to negative baseline behavior is uncertain.
  • Tablets have trivial/no pain-experience benefit and small pain-behavior benefit.
  • In children younger than 12, VR during local anesthesia offers trivial/no anxiety or pain benefit.
• Safety: video/VR glasses must meet dental eye-protection standards. Periodically assess eyes/coping and possible health concerns; preserve full visibility of surroundings for children with hearing impairment.

Compare the evidence by procedure

Effects on pain experience, pain behavior, anxiety, and cooperation are distinct. All recommendations remain conditional. Match the technique to procedure, developmental/sensory needs, preferences, and response; absence of a recommendation does not establish ineffectiveness or an indication for restraint.

Parents and special health care needs

• Parental presence: trivial/no benefit; decide collaboratively using child/procedure factors. Absence often meets resistance. No SHCN recommendation.
• SHCN AVD: Appendix 1 reports trivial anxiety/cooperation effects and variable pain benefit. This is more cautious than the abstract's large-anxiety-benefit statement.
• Sensory-adapted environment: SHCN anxiety/cooperation effects range from trivial to large; much evidence concerns prophylaxis. Consider sensory sensitivities and resources. No healthy-child recommendation.
• Picture exchange communication system (PECS): limited SHCN evidence, especially autism; mobile apps may perform better on some outcomes.
  • No healthy-child recommendation.
  • Individualize visual schedules/social stories rather than assume a universal response.

Advanced techniques

• CBT: consider for anxiety, especially older children with dental/injection fear; potentially large phobia benefit.
  • Preschool results vary; sequential visits may help.
  • Collaborate with behavioral health professionals; consider training/time.
  • No SHCN recommendation.
• Hypnosis: during local anesthesia, anxiety/pain effects range from trivial to large, partly using indirect medical evidence.
  • Cooperation/behavioral-pain benefit is unproven.
  • Requires expertise, resources, and parental shared decisions.
  • No preventive or SHCN recommendation.
• Protective stabilization: no eligible evidence supported a recommendation in any group.
  • Consider medical history, individual factors, and preferences; parental acceptance is inconsistent.
  • This guideline supplies no detailed indication/contraindication or monitoring protocol.

Documentation, implementation, and research

• Record individualized techniques to help reproduce successful future visits. Effective guidance may reduce sedation/general-anesthesia needs, but resource costs vary.
• The source describes D9920 for especially difficult/uncooperative patients or SHCN requiring additional staff time/skill—not simply extra appointment time.
• Document medical necessity, technique, and duration; verify current local coverage rules.
• It advises against Medicaid billing for basic reinforcement or parental presence/absence.
• Common techniques remain understudied; research popularity does not establish suitability.
• AAPD planned updates five years after the last systematic search, or sooner if new evidence warrants; this is not a patient recall schedule.

Common board traps

Answer aloud

An anxious child needs local anesthesia. How should behavior guidance be chosen?

Build rapport, assess development and baseline behavior, and choose an acceptable technique with the child/family.

• Adapt communication, tell-show-do, and distraction to the observed response.
• Music/3D audiovisual injection benefits mainly involve positive baseline behavior; evidence for negative baseline behavior is uncertain.
• Counter-stimulation and motor/breathing distraction may reduce anxiety/pain, but cooperation benefit is unproven.
• Explain uncertainty rather than promise success.

Do restorative VR results justify promising painless injections?

No. Effects differ by procedure and population.

• Glasses must meet eye-protection standards; assess coping/eyes and preserve surrounding visibility for hearing impairment.

How do you prepare a child with autism for dental treatment?

Individualize communication and sensory supports using caregiver input and ongoing tolerance assessment.

• Ask about triggers, routines, and successful strategies; consider visual supports/PECS, desensitization, AVD, or sensory adaptation.
• Sensory-adapted evidence often concerns prophylaxis; do not assume equivalent treatment effects.
• Appendix 1 gives SHCN AVD trivial anxiety/cooperation effects with variable pain benefit, more cautiously than the abstract.
• Document what works; autism alone does not select one technique.

Does very low certainty rule out a technique, or no recommendation endorse restraint?

Neither. Low certainty limits confidence, and absent evidence is not a clinical indication or contraindication.

• All recommendations here are conditional; most are very low certainty.
• Preventive positive reinforcement and restorative VR have moderate certainty but remain conditional.
• No eligible stabilization evidence supported a recommendation; use separate indication, consent, and monitoring guidance.
• Use judgment, preferences, resources, and response without claiming established superiority.