Chapter 4: Pediatric Dentistry Introduction

Section B: Behavior Management Introduction

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Section B: Behavior Management


Behavior management techniques are a continuum of care directed toward communication and education of the pediatric dental patient. The goals of these techniques are to:

  • maintain communication

  • reduce fear and anxiety

  • extinguish inappropriate behavior

  • elicit behavior consistent with the need for successful completion of dental treatment

Behavior Management Techniques

Behavior management techniques include the following examples:

  • communicative management

  • nitrous oxide—oxygen inhalation sedation

  • physical restraint

  • hand-over-mouth

  • conscious sedation

  • general anesthesia

Decision Making

The choice of behavior management techniques must be based on an evaluation that weighs risks versus benefits to the child. The following considerations enter into the decision making:

  • urgency of care

  • need for cooperation

  • skill of the practitioner

  • options available at each clinic

  • parental considerations

Decision Making Factors

Prior to choosing a technique you should consider the following factors:

  • alternative methods, including referral

  • dental needs

  • expectations of the parents or caregiver

  • emotional development of the child

  • past medical history

  • ability of caregiver or person accompanying child to give consent


Decisions involving behavior management techniques must involve the parents and, if appropriate, the assent of the patient. Successful completion of dental services must be viewed as a partnership of dentist, parent, and child. When consent is required for any technique it must be informed consent prior to treatment. Documentation of consent may be by the use of specific forms or progress note entries.

Parental Presence

  • The presence of parents in the dental operatory during treatment has been a concern historically. There may be limitations based on infection control, patient flow, or confidentiality. Some studies have shown children less than three years of age respond better if their parents are present. At a minimum, parents should be encouraged to participate in examination appointments if possible.

  • Parental presence should be addressed in the clinic policy and procedure manual, and possibly in the infection control manual.

  • Parental presence is inappropriate for conscious sedation and general anesthesia.


The IHS Technical Quality Assurance document calls for documen­tation in the patient record for children less than 6 years of age on:

Documentation of Behavior

The Frankl Scale is recommended as a way to meet this criterion without having to make extensive notes in the chart.

A system of pluses and minus can be used to approximate the Frankl Scale.

Frankl Scale


Category #1: (- -)

Definitely negative. Child refuses treatment, cries forcefully, fearfully, or displays any agitated, overt evidence of extreme negativism.

Combative, thrashing, verbal, unable to be restrained, need to terminate procedure.

Category #2: (-)

Negative. Reluctant to accept treatment and some evidence of negative attitude (not pronounced).

Slightly combative, verbal, slightly agitated, able to be restrained and procedure safely completed

Category #3: (+)

Positive. The child accepts treatment but may be cautious. The child is willing to comply with the dentist, but may have some reservations.

Quiet, not combative, cooperative, nonverbal.

Category #4: (+ +)

Definitely positive. This child has a good rapport with the dentist and is interested in the dental procedures.

Happy, helpful


Documentation in the clinical progress notes provides the practitioner with a record of success or failure with behavior management techniques. An entry such as "2 --> 3; VC,TSD" indicates that the patient went from a Frankl category 2 to a Frankl category 3 with voice control and tell-show-do techniques. This notation will facilitate treatment in successive appointments, and is important in multi-practitioner facilities.

Facility Guidelines

Facility policy and procedure guidelines may restrict behavior management options. It is the responsibility of the dental practitioner to participate in the development of local policy, and to be aware of their content. Specific privileging for some procedures (e.g., nitrous oxide-oxygen sedation, conscious sedation, or general anesthesia) may be required.

Communicative Management


Communicative management is an ongoing process used to:

  • gain attention and compliance

  • avert negative behavior


The following are specific communicative management techniques:

  • voice control

  • tell-show-do

  • positive reinforcement

  • distraction

  • nonverbal communication


Communicative management is indicated for any child with minimal management demands.


Communicative management may be contraindicated in children non-communicative due to:

  • age

  • disability

  • immaturity

  • medication


No specific consent is required.

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