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Pediatric Behavior Management
PEDIATRIC BEHAVIOR MANAGEMENT:
A Little Art, A Little Science, & A Little Medicine
John Portwood, DDS, MS, MAGD
Robert L. Delarosa, DDS
AAPD/AGD Webinar
April 24, 2015
Webinar Objectives
Become familiar with the various behavior
management techniques and when to utilize them.
Understand the challenges of today’s parenting
philosophies and behavior management.
Understand how case selection affects
outcome/parental expectations.
Become aware of future trends and options for
patient management.
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April 24, 2015
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Pediatric Behavior Management
Do you allow parents in the treatment
area?
• Poll question
A. Yes, always
B. Yes, patient specific
C. No
Behavioral Management
Generalist Perspective
Why do we treat children?
• Pediatric specialists can’t
see them all!
• They are fun to treat!
• Great practice builders
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Pediatric Behavior Management
Behavioral Management
Generalist Perspective
When do we treat
children?
• Age
• Demeanor
• Health Issues
Special needs
Health risk
Behavioral Management
Generalist Perspective
How do we treat children?
• Phone call or office visit
Remember that parents have anxieties too!
Refer parents to website.
• Décor of the office
• Office team
• Treatment philosophies
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Pediatric Behavior Management
The Good, the Bad, and the Ugly Terrified
Ideal Behavior vs. Non-ideal Behavior and when is
it time to refer
The Good
Ideal behavior
• Communication
Child
Parent
• Team Interaction
• Basic Behavior
Guidance
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Pediatric Behavior Management
Basic Behavior Guidance
Basic behavior guidance recommendations from the
American Academy of Pediatric Dentistry (AAPD) include:
• Communication & communicative guidance
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•
•
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Tell-show-do
Voice Control
Nonverbal communication
Positive Reinforcement
Distraction
Nitrous oxide/oxygen inhalation
Parental presence/absence
Basic Behavior Guidance
Parental presence/absence
Parental Objectives:
Participate in infant
examinations and/or
treatment (if asked)
Offer very young children
physical and psychological
support
Observe the reality of their
child’s treatment
Survey says
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April 24, 2015
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Pediatric Behavior Management
Basic Behavior Guidance
Parental presence/absence
Practitioner Objectives:
Gain the patient’s attention and
improve compliance
Avert negative or avoidance
behaviors
Establish appropriate dentist-child
roles
Enhance effective communication
among the dentist, child, and parent
Minimize anxiety and achieve a
positive dental experience
Facilitate rapid informed consent for
changes in treatment or behavior
guidance.
The Bad
Ideal behavior
Non-ideal behavior
• Distraction
• Voice Control
Gains patient’s attention
Establishes authority role
Correct behavior
problem
Let parent know first
• Nitrous Oxide
• Sedation
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Pediatric Behavior Management
The Ugly Terrified
Ideal behavior
Non-ideal behavior
Time to refer
• Keep child a potentially
good patient
• Child’s best interest
• Dentist’s best interest
Time to Refer
• Communication with parent
Explain the reason.
Why this particular specialist?
• Communication with specialist
Why is the patient being referred?
Written instructions and directions to the office.
• Seamless transition
Call the specialist while the patient is in the office.
Both offices must work to make it simple and easy.
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Pediatric Behavior Management
What is your protocol for referring a
patient?
• Poll Question
A. Explain the need for a specialist and allow the
patient/parent to choose. (No communication
between referring doctor and specialist)
B. Write down the name and phone number of the
specialist you recommend and let the patient call.
C. Send the patient with a written referral to a specified
specialist.
D. Send the patient with a written referral to a specified
specialist and call the specialist to discuss patient’s
condition prior to appointment.
Advanced Behavior Guidance
Advanced behavior guidance recommendations from the
American Academy of Pediatric Dentistry (AAPD) include:
• Protective stabilization
• Sedation
• General anesthesia
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Pediatric Behavior Management
Advanced Behavior Guidance
Protective Stabilization
Considerations to take into account when choosing
protective stabilization:
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Alternative behavior guidance modalities
Dental needs of the patient
The effect on the quality of dental care
The patient’s emotional development
The patient’s medical and physical considerations
Advanced Behavior Guidance
Protective Stabilization
Objectives:
Reduce or eliminate untoward movement
Protect patient, staff, dentist, or parent from injury
Facilitate delivery of quality dental treatment
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April 24, 2015
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Pediatric Behavior Management
Advanced Behavior Guidance
Protective Stabilization Risks
“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.”
Dr. Steve Perlman (past president of AADMD) has organized a morning conference to all
represented organizations to participate in a "moderated" open discussion on Protective
stabilization/Restraint/Medical Immobilization.
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April 24, 2015
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Pediatric Behavior Management
Advanced Behavior Guidance
Sedation
Objectives:
Guard the patient’s safety and
welfare
Minimize physical discomfort and
pain
Control anxiety, minimize
psychological trauma, and
maximize the potential for amnesia
Control behavior and/or movement
so as to allow the safe completion
of the procedure
Return the patient in a state in
which safe discharge from medical
supervision, as determined by
recognized criteria, is possible
Advanced Behavior Guidance
Sedation
Indications:
Fearful, anxious patients for whom basic behavior
guidance techniques have not been successful
Patients who cannot cooperate due to lack of
psychological or emotional maturity and/or mental,
physical, or medical disability
Patients for whom the use of sedation may protect
the developing psyche and/or reduce medical risk.
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Pediatric Behavior Management
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Pediatric Behavior Management
Sedation Protocol
Demerol 50mg/5cc
Hydroxyzine 25mg/5cc
Valium 5mg/5cc
Dosages
• Demerol .5-1.0 mg/lb ( 1-2 mg/kg )
• Hydroxyzine .3-.4 mg/lb ( .6 mg/kg )
• Valium .1-.2 mg/lb (.2-.3 mg/kg )
• Dr. Steve Brandt UTHSCSA
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Pediatric Behavior Management
Dosage Calculations
Demerol: 0.5-1.0 mg/lb
32 lbs x 0.5 = 16.0 mg
32 lbs x 1 = 32 mg
25 mg/2.5 cc
Hydroxyzine: 0.3-0.4 mg/lb
32 lbs x 0.3 = 9.6 mg
32 lbs x 0.4 = 12.8 mg
10 mg/5 cc
Valium: 0.1-0.2 mg/lb
32 lbs x 0.1 = 3.2 mg
32 lbs x 0.2 = 6.4 mg
2 mg/2 cc
Reversal Agents
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Pediatric Behavior Management
Naloxone Dosage
Dosage I.M., I.V. (preferred), intratracheal, SubQ:
Postanesthesia narcotic reversal: Infants and Children: 0.01 mg/kg; may
repeat every 2-3 minutes, as needed based on response
Opiate intoxications:
Children:
Birth (including premature infants) to 5 years or <20kg: 0.1 mg/kg; repeat every
2-3 minutes if needed; may need to repeat doses every 20-60 minutes
>5 years or ≥20 kg: 2 mg/dose; if no response, repeat every 2-3 minutes; may
need to repeat doses every 20-60 minutes.
Children and Adults: Continuous infusion: I.V.: If continuous infusion is required,
calculate dosage/hour based on effective intermittent dose used and duration of
adequate response seen, titrate does 0.04-0.16 mg/kg/hour for 2-5 days in
children, adult dose typically 0.25-6.25 mg/hour (short-term infusions as high as
2.4 mg/kg/hour have been tolerated in adults during treatment for septic
shock); alternatively, continuous infusion utilized 2/3 of the initial naloxone bolus
on an hourly basis; add 10 times this dose to each liter of D5W and infuse at a
rate of 100 mL/hour; ½ of the initial bolus does should be readministered 15
minutes after initiation of the continuous infusion to prevent a drop in naloxone
levels; increase infusion rate as needed to assure adequate ventilation.
Flumazenil Dosage
Pediatric Dosage (further studies needed)
Pediatric Dosage for reversal of conscious sedation
and general anesthesia:
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April 24, 2015
Initial dose
0.01 mg/kg over 15 seconds (maximum: 0.2 mg)
Repeat doses (maximum: 4 doses)
0.005-0.01 mg/kg (maximum: 0.2 mg) repeated at
1-minute intervals
Maximum total cumulative dose
1 mg or 0.05 mg/kg (whichever is lower)
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Pediatric Behavior Management
Advanced Behavior Guidance
General Anesthesia and IV Sedation
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April 24, 2015
Objectives:
Indications:
Provide safe, efficient, and effective dental
care
Eliminate anxiety
Reduce untoward movement and reaction
to dental treatment
Aid in treatment of the mentally,
physically, or medically compromised
patient
Eliminate the patient’s pain response
Patients who cannot cooperate due to lack
of psychological or emotional maturity
and/or mental, physical, or medical
disability
Patients for whom local anesthesia is
ineffective because of acute infection,
anatomical variations, or allergy
The extremely uncooperative, fearful,
anxious, or uncommunicative child or
adolescent
Patients requiring significant surgical
procedures
Patients for whom the use of general
anesthesia may protect the developing
psyche and/or reduce medical risk
Patients requiring immediate,
comprehensive oral/dental care.
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Pediatric Behavior Management
Advanced Behavior Guidance
General Anesthesia and IV Sedation
Pain Management
“Pain management during dental procedure is crucial for
successful behavior guidance. Prevention of pain can
nurture the relationship between the dentist and the
patient, build trust, allay fear and anxiety, and enhance
positive dental attitudes for future visits.”
Faces Pain Scale- Revised (FPS-R)
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Pediatric Behavior Management
Local Anesthesia Dosages
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Pediatric Behavior Management
References
American Academy of Pediatric Dentistry. Guideline on
behavior guidance for the pediatric dental patient.
Pediatr Dent 2014;36(special issue):179-91.
Malamed, Stanley F. Sedation: A Guide to Patient
Management. St. Louis. The C.V. Mosby Company
1985. Print.
Wynn, Richard L., et al. Drug Information Handbook for
Dentistry: Including Oral Medicine for Medically
Compromised Patients & Specific Oral Conditions. 12th
ed. Hudson: Lexi-Comp, 2006. Print.
Links
• 2014-2015 AAPD Pediatric Dentistry Reference Manual
• http://www.aapd.org/policies/
• 2015 AADMD Conference Meeting: Global Summit on Innovations in
Health and IDD
• http://www.aadmd.org/conference
• AAPD’s Guideline on Behavior Guidance for the Pediatric Dental
Patient
• http://www.aapd.org/media/Policies_Guidelines/G_BehavGuid.pdf
• AAPD’s Guideline on Protective Stabilization for the Pediatric Dental
Patient
• http://www.aapd.org/media/Policies_Guidelines/G_Protective.pdf
• AAPD’s Guideline on Use of Nitrous Oxide for Pediatric dental
Patients
• http://www.aapd.org/media/Policies_Guidelines/G_Nitrous.pdf
• Parental attitudes about observing in the operatory
• http://www.ada.org/epubs/highroad/jadaPediatric/150330.html#one
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