G Behaviorguidance

PEDIATRIC DENTISTRY V 45 / NO 5 SEP / OCT 23
RECOMMENDATIONS: CLINICAL PRACTICE GUIDELINE O
Nonpharmacological Behavior Guidance for the Pediatric Dental Patient

Vineet Dhar, BDS, MDS, PhD1 • Elizabeth Gosnell, DMD, MS2 • Jayakumar Jayaraman, BDS, MDS, MS, PhD3 • Clarice Law, DMD, MS4 •
Martina Majstorović, DDS, PhD5 • Abdullah A. Marghalani, BDS, MSD, DrPH6 • Cameron L. Randall, PhD7 • Janice Townsend, DDS, MS8 • Martha Wells, DMD, MS9 •
Chia-Yu Chen, DDS10 • Rachel Wedeward, MLIS, AHIP11
Abstract: Purpose: To present evidence-based recommendations on nonpharmacological behavior guidance for the pediatric dental patient. Methods:
The work group assessed eight systematic reviews for effectiveness of nonpharmacological behavior guidance techniques in children undergoing
preventive care or a dental treatment visit. The key outcomes assessed included cooperative behavior, anxiety, and procedural pain. To formulate
the recommendations, the work group used the GRADE framework to obtain consensus on domains such as priority of the problem, certainty of the
evidence, balance between desirable and undesirable consequences, patients’ values and preferences, acceptability, and feasibility. Results: Overall,
the use of basic nonpharmacological behavior guidance techniques resulted in trivial-to-small effect on improvement in behavior or reduction in
anxiety. However, for children and adolescents undergoing preventive care, mobile applications and modeling showed large effects in reduction of
anxiety. For those undergoing dental treatment, strategies such as modeling, positive reinforcement, biofeedback relaxation, breathing relaxation,
animal-assisted therapy, combined tell-show-do, audiovisual distraction, and cognitive behavior therapy showed large reduction in anxiety. For
children and adolescents with special health care needs, audiovisual distraction and sensory-adapted dental environment showed large reduction of
anxiety. Conclusions: All the formulated recommendations were conditional and were mostly based on very low certainty of evidence. Conditional
recommendations imply that different choices or combinations of behavior guidance techniques may be most appropriate for different patients.
Clinicians should use techniques consistent with the parent/patient values and preferences. These recommendations are based on the best avail-
able evidence to-date and are intended to aid clinical decision making. (Pediatr Dent 2023;45(5):385-410) Received April 7, 2023 | Last Revision
August 7, 2023 | Accepted August 8, 2023
KEYWORDS: CLINICAL PRACTICE GUIDELINE, NONPHARMACOLOGICAL BEHAVIOR GUIDANCE, PEDIATRIC DENTAL PATIENT, CHILDREN, ADOLESCENT
Plain language summary basic and advanced nonpharmacological behavior guidance

Purpose. The purpose of this first clinical practice guideline techniques for children and adolescents undergoing dental
on nonpharmacological behavior guidance published by the treatment.
American Academy of Pediatric Dentistry (AAPD) was to for- Background. Children and adolescents undergo periodic
mulate evidence-based recommendations on use of previsit and preventive dental care visits and dental treatment visits as
in-office (pretreatment, during treatment, and posttreatment) needed. Dental anxiety and existing and anticipated pain are
among factors likely to influence the experience of the child at
the dental office. In this clinical practice guideline document,
1 Dr. Dhar is a clinical professor and chair, and 5Dr. Majstorović is a clinical associate the term 'office' implies the dental environment and/or dental
professor, both in the Department of Orthodontics and Pediatric Dentistry, University of operatory and encompasses those environments in private prac-
Maryland School of Dentistry, Baltimore, Md; 7Dr. Randall is an assistant professor, tice, hospital settings, community clinics, academic settings, etc.
Department of Oral Health Sciences, University of Washington School of Dentistry, Seattle,
Wash; 3Dr. Jayaraman is an associate professor, Department of Pediatric Dentistry, VCU
While dental visits can be stressful, most of the care in dental
School of Dentistry, Richmond, Va; 10Dr. Chen is a pediatric dentist in private practice, offices can be provided using nonpharmacological behavior
Kent, Wash; 9Dr. Wells is chief of dentistry, St. Jude Children’s Research Hospital, and guidance techniques. Children with special health care needs
4
Dr. Law is an associate professor and chair, Department of Pediatric Dentistry and may need additional consideration and utilization of specific
Community Oral Health, The University of Tennessee Health Science Center, both in behavior guidance techniques tailored to their individual needs.
Memphis, Tenn; 2Dr. Gosnell is an associate professor, Department of Pediatrics, Univer- Study characteristics. The guideline is based on systematic
sity of Cincinnati College of Medicine, and Division of Pediatric Dentistry, Cincinnati
reviews of evidence on basic and advanced nonpharmacologi-
Children’s Hospital Medical Center, Cincinnati, and 8Dr. Townsend is a professor and
chief, Pediatric Dentistry, Nationwide Children’s Hospital, and chair, Division of Pediatric
cal behavior guidance interventions used during preventive
Dentistry, The Ohio State University College of Dentistry, both in Columbus, Ohio; and dental visits (i.e., examination, cleaning, fluoride application,
11Ms.Wedeward is a research project manager, Pediatric Oral Health Research and Policy x-rays) and treatment visits (i.e., sealants, dental local anesthesia,
Center, American Academy of Pediatric Dentistry, Chicago, Ill, all in the United States. fillings [restorations], nerve treatment [pulp treatment], simple
6Dr. Marghalani is an assistant professor, Department of Preventative Dentistry, Umm
extractions). The work group included five1-5 existing moderate-
Al-Qura University, Makkah, Saudi Arabia. to high-quality systematic reviews published in the last five
Correspond with Dr. Dhar at VDhar@umaryland.edu
years on basic nonpharmacological behavior guidance tech-
niques such as parental presence/absence, preparation, traditional
HOW TO CITE: distraction techniques (i.e., counter-stimulation, camouflaging
Dhar V, Gosnell E, Jayaraman J, et al. Nonpharmacological behavior guid- of syringe, positive suggestion, mirror and conversation, toys,
ance for the pediatric dental patient. Pediatr Dent 2023;45(5):385-410. books/children stories), and technology-based distraction
techniques (audio distraction, audiovisual distraction, virtual
Copyright © 2023 American Academy of Pediatric Dentistry. All rights reserved. reality glasses, and smart phones/tablets) and an advanced
NONPHARMACOLOGICAL BEHAVIOR GUIDANCE 385

techniques), the use of animal assisted therapy, and combined

ABBREVIATIONS therapy of TSD with audiovisual distraction (AVD) may help
AAPD: American Academy of Pediatric Dentistry. during the dental visit. When used appropriately, advanced non-
AAT: Animal-assisted therapy. pharmacological behavior guidance techniques such as cognitive
AGREE: Appraisal of Guidelines Research and Evaluation. behavior therapy and hypnosis may help patients with severe
AMSTAR: A MeaSurement Tool to Assess systematic Reviews. anxiety undergoing a dental treatment visit. AVD, sensory-adapted
app: Application.
dental environment, and picture exchange communication
ASD: Autism spectrum disorder.
system (PECS) or other visual schedules and social stories could
ATA: Ask-tell-ask.
AVD: Audiovisual distraction.
help alleviate anxiety for children with special health care needs.
BPRS: Behavior Profile Rating Scale. Conclusion. Evidence-based recommendations have been
CBC: Chotta Bheem-Chutki. formulated considering the best available evidence in context
CBT: Cognitive behavior therapy. of clinical expertise and patient values and preferences. This
CFSS: Children's Fear Survey Scale. guideline is intended to assist clinicians in decision making and
CFSS-DS: Children’s Fear Survey Scale Dental Subscale. does not replace clinical judgment.
FBRS: Frankl’s Behavior Rating Scale.
FIS: Facial Image Scale. Scope and specific objectives
GRADE: Grading of Recommendations Assessment, Development and The AAPD intends for this guideline to help clinicians in
Evaluation. choosing from the evidence-based nonpharmacological behavior
HR: Heart rate. guidance techniques to optimize patient care during dental
PDAS-CH: Picture Dental Anxiety Scale-Child.
treatment. The work group (WG) defined the Population,
PECS: Picture exchange communication system.
Interventions, Comparisons, and Outcomes (PICO) to be
PICO: Population Intervention Control Outcome.
RCT: Randomized clinical trial.
assessed and formulated a comprehensive list of relevant clinical
SADE: Sensory-adapted dental environments. questions6, which were reviewed and approved by the stake-
SHCN: Special health care needs. holders including the AAPD’s Council on Clinical Affairs,
SMD: Standardized mean difference. Council on Scientific Affairs, and Evidence-Based Dentistry
3D: Three-dimensional. Committee. The AAPD has previously published a Best Practices
TPD: Tell-play-do. document on Behavior Guidance for the Pediatric Dental Patient 7.
TSD: Tell-show-do. To develop clinical practice guidelines, the WG met be-
UK: United Kingdom. tween June 2021 and December 2022 to systematically search,
U.S.: United States. select, synthesize, appraise, and contextualize the best avail-
VAS: Visual analogue scale. able evidence to create evidence-based recommendations. The
VR: Virtual reality. WG formulated evidence-based recommendations on basic and
VPT: Venham Picture Test. advanced nonpharmacological behavior guidance techniques
WG: Work group.
for children undergoing preventive dental visits (examination,
prophylaxis, radiographs, fluoride application), for children
undergoing dental treatment visits (sealants, local anesthe-
nonpharmacological behavior guidance techniques (hypnosis) sia, restorative care, pulp therapy, simple extractions), and for
for healthy children and adolescents undergoing preventive and children with special health care needs (SHCN) undergoing
treatment visits. In addition, the work group conducted three preventive or treatment visits.
new systematic reviews 6,8,9 based on 65 studies from various Clinical questions:
countries that met the inclusion criteria. The new systematic 1. In children and adolescents, does the use of previsit
reviews evaluated basic nonpharmacological behavior guidance and in-office pre-/posttreatment preparation as basic
techniques such as communication (verbal/nonverbal), positive behavior guidance strategies influence cooperative
imagery, direct observation/modeling, desensitization, various behavior, dental anxiety, procedural pain, and treat-
distraction techniques, tell-show-do (TSD), tell-play-do ([TPD], ment completion during the dental visit?
a modification of TSD), ask-tell-ask, voice control, positive re- 2. In children and adolescents, does the use of basic
inforcement, memory restructuring, biofeedback relaxation, behavior guidance techniques influence cooperative
breathing relaxation, animal assisted therapy, sensory-adapted behavior, dental anxiety, procedural pain, and treat-
dental environment, combination of basic behavior guidance ment completion during the dental visit?
therapies, picture exchange communication system, as well as 3. In children and adolescents, does the use of advanced
advanced nonpharmacological behavior guidance techniques nonpharmacological behavior guidance techniques
such as cognitive behavior therapies and protective stabilization, influence cooperative behavior, dental anxiety, pro-
when used individually or in combination. cedural pain, and treatment completion during the
Key results. The evidence from all the eight systematic dental visit?
reviews was generally of very low quality, leading to conditional Guidance on parental anxiety and behavior is beyond the
recommendations for the studied basic and advanced nonphar- scope of this document.
macological behavior guidance techniques. Although the evi- Search strategy and evidence inclusion criteria. The WG
dence is uncertain, it supports the use of basic behavior guidance identified eight moderate-to-high-quality systematic reviews1-6,
techniques to reduce anxiety and improve cooperative behavior 8,9
to inform these guidelines. Of the eight included systematic
during dental visits. Also, the use of technology (mobile applica- reviews, five1-5 were previously published and three6,8,9 were
tions) as distraction may reduce anxiety in patients undergo- conducted de novo by the WG to address clinical questions that
ing preventive care. For anxious patients, in addition to basic lacked existing moderate-to-high-quality systematic reviews
behavior guidance (modeling, positive reinforcement, relaxation (Figure).
386 NONPHARMACOLOGICAL BEHAVIOR GUIDANCE

phobia), and procedural pain as

measured by specific rating scales. 6
The WG categorized the variety
of self-reported (child or parent),
physician-rated (dentist or other
providers), and physiologic tools
used for ranking these outcomes
and developed a criterion to guide
the decision making.6 Considering
the variation in units of measure of
outcomes across the eight included
systematic reviews, where possible
the authors reanalyzed data and
calculated the standardized mean
difference (SMD) to measure the
effect in a standardized manner. To
calculate SMDs, the corresponding
author of included systematic re-
views was contacted for additional
information/data as needed. To
communicate the findings of the
systematic reviews using clinically
Figure. Clinical pratice guideline (CPG) plan. AMSTAR=A MeaSurement Tool to Assess systematic informative statements, the size of
Reviews; AAT=Animal-assisted therapy; AVD=Audiovisual distraction; SR=Systematic review; PECS=Picture estimate interpreted from SMD’s
exchange communication system; SADE=Sensory-adapted dental environments; VR=Virtual reality. was categorized as large effect,
moderate effect, small important
effect (interpreted as statistically
The three systematic reviews published by the WG focused significant), or trivial effect (interpreted as small unimportant
on nonpharmacological behavior guidance strategies for: (1) a or statistically nonsignificant or no effect).20
child undergoing a preventive visit,6 (2) a child undergoing a The certainty of the evidence was assessed using the
treatment visit,8 and (3) a child with special health care needs GRADE approach, which recognizes the certainty of evidence
undergoing preventive or treatment dental visit.9 as high, moderate, low, and very low based on serious or very
To identify the previously published systematic reviews that serious issues, including the risk of bias, imprecision, incon-
were relevant to the clinical questions, the WG utilized a search sistency, indirectness of evidence, and publication bias.21 The
strategy developed specific to the identified PICO questions WG evaluated and obtained consensus on the certainty of
with Filters / Limits: Language – English Language; and Age evidence for each studied outcome.
Groups – Children & Adolescents. There was no restriction to Values and preferences. The WG utilized a recent article
study design. The search strategy has been described in detail that surveyed the AAPD membership to identify the non-
elsewhere.6 For purposes of guideline development, the WG pharmacological behavior techniques routinely used in dental
agreed a priori to consider only moderate-to high-quality sys- offices in the United States (U.S.) and Canada.22 That survey
tematic reviews that included Grading of Recommendations, also sought information regarding clinicians’ perception of
Assessment, Development, and Evaluations ([GRADE] assess- parent/caregiver acceptance of various contemporary behavior
ment). From the search process, the WG identified 24 system- guidance techniques used in their practices. Of the 518 active
atic reviews which were reviewed by three WG members (VD, AAPD members who responded (response rate 7.45 percent), a
JJ, and AM). Fourteen systematic reviews/meta-analyses were majority (79.5 percent) of the participants were in private
found to be relevant to the clinical questions and were short- practice (solo or group), 5.8 percent worked at dental service
listed1-5,10-18 for quality assessment using A MeaSurement Tool organizations, 7.7 percent at community clinics, 12.9 percent at
to Assess systematic Reviews ([AMSTAR] 2 tool).19 Two WG academic institutions, and 11 percent in hospital settings.
members (AM and JJ) evaluated the reviews and met to reach Pediatric dentists certified by the American Board of Pediatric
consensus on the quality assessment of the selected reviews. Dentistry constituted 79 percent of the participants. In terms
Five moderate-to-high-quality systematic reviews1-5 that were of practice district and demographic characteristics, the survey
published within the past five years and included the GRADE respondents were comparable to large samples from previous
level of certainty assessment were selected to formulate the research and generally reflective of the profession in the U.S.
evidence-based recommendations (Table 1). The WG also used and Canada and the AAPD membership overall. The results
the publications shortlisted for data extraction to update the suggest that the responding pediatric dentists routinely use
selected systematic reviews where necessary. basic behavior guidance techniques recommended by AAPD.
Therefore, the WG analyzed data from a total of eight More resource-intensive (time, costs, or training-related)
systematic reviews and utilized the GRADE Evidence-to- techniques, such as memory restructuring and technology-based
Decision Framework to develop clinical practice guidelines. distraction, and advanced nonpharmacological behavior
Assessment of evidence. The variety of studied outcomes guidance techniques, such as cognitive behavior therapy, were
and their assessment methods were reviewed by the WG and used less frequently. Respondents reported that techniques such
ranked a priori by the WG as critical; important, but not cri- as voice control, parental absence, and protective stabilization
tical; and of limited importance. Three key outcomes were encountered higher parent/caregiver hesitancy and refusal.
included: cooperative behavior, anxiety (including fear and

Formulation of recommendations. The clinical question(s) ([AGREE] II) tool. 23 The recommendations were developed
informed by the included systematic reviews were subject to by the GRADE Evidence-to-Decision (EtD) process and are
the clinical practice guideline development process follow- referred to in the current document as “Evidence-based Rec-
ing the Appraisal of Guidelines for Research and Evaluation ommendations.” As a part of the process, the WG obtained
Table 1. AMSTAR 2.0 ASSESSMENT OF SELECTED SYSTEMATIC REVIEWS*

Author names (first three names, et al) and year
Birnie KA, Noel Prado I, Custódio N, Costa De Luca M, Monteiro J,
M, Chambers Carcavalli L, F, Cademartori Massignan C, Tanday A,
CT et al., Abreu L, et al., M et al., Bolan M, et al., Ashley PF,
20181 20182 20203 20204 et al., 20205
1. Did the research questions and inclusion criteria for the Yes Yes Yes Yes Yes
review include the components of PICO?
2. Did the report of the review contain an explicit statement Yes Yes Yes Yes Partially yes
that the review methods were established prior to the
conduct of the review and did the report justify any signi-
ficant deviations from the protocol?
3. Did the review authors explain their selection of the study Yes Yes Yes Yes Yes
designs for inclusion in the review?
4. Did the review authors use a comprehensive literature search Yes Yes Yes Yes Yes
strategy?
5. Did the review authors perform study selection in duplicate? Yes Yes No Yes Yes
6. Did the review authors perform data extraction in duplicate? Yes Yes Yes Yes Yes
7. Did the review authors provide a list of excluded studies Yes Yes Yes Yes Yes
and justify the exclusions?
8. Did the review authors describe the included studies in Yes Partially yes Partially yes Yes Yes
adequate detail?
9a. For RCT’s, did the review authors use a satisfactory tech- Yes Yes Yes Yes Yes
nique for assessing the RoB in individual studies that were
included in the review?
9b. For NRSI’s, did the review authors use a satisfactory Includes only Includes only Includes only Yes Includes only
technique for assessing the RoB in individual studies that RCTs RCTs RCTs RCTs
were included in the review?
10. Did the review authors report on the sources of funding Yes No No No Yes
for the studies included in the review?
11. If meta-analysis was performed did the review authors use Yes NA Yes Yes NA
appropriate methods for statistical combination of results?
12. If meta-analysis was performed, did the review authors Yes NA Yes Yes NA
assess the potential impact of RoB in individual studies on
the results of the meta-analysis or other evidence synthesis?
13. Did the review authors account for RoB in individual Yes Yes Yes Yes Yes
studies when interpreting/ discussing the results of the review?
14. Did the review authors provide a satisfactory explanation Yes Yes Yes Yes Yes
for, and discussion of, any heterogeneity observed in the
results of the review?
15. If they performed quantitative synthesis did the review Yes No Yes No Yes
authors carry out an adequate investigation of publication
bias (small study bias) and discuss its likely impact on the
results of the review?
16. Did the review authors report any potential sources of Yes Yes Yes Yes Yes
conflict of interest, including any funding they received
for conducting the review?
Your score on overall confidence in the results of the review High High Moderate Moderate High
(zero or one (zero or one (more than one (more than (zero or one
noncritical noncritical noncritical one noncritical noncritical
weakness) weakness) weakness; weakness; no weakness)
no critical flaw) critical flaw)
* Abbrevations used in this table: AMSTAR=A MeaSurement Tool to Assess systematic Reviews: The systematic reviews relevant to clinical questions that include
GRADE Certainty assessment were selected for evaluation using AMSTAR Tool; NA=Not applicable; NRSI=Nonrandomized studies of interventions; PICO=
Population, Interventions, Comparisons, and Outcomes; RCTs=Randomized clinical trials; RoB=Risk of bias.
Copyright © 2017, BMJ Publishing Group Ltd. BMJ 2027;358:j4008. Available at: "https://www.bmj.com/content/bmj/358/bmj.j4008.full.pdf".
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License: "https://creativecommons.org/licenses/by-nc/4.0/?ref=chooser-v1".

consensus on domains such as priority of the problem, certainty Table 3, the recommendations on basic behavior guidance
of the evidence, balance between desirable and undesirable con- techniques during treatment in Appendix 1, and the recom-
sequences, patients’ values and preferences, acceptability, and mendations on advanced nonpharmacological behavior guid-
feasibility.24 ance techniques are presented in Appendix 2. A decision tree
The presented recommendations are primarily based on has been presented to summarize available evidence and aid
the direct evidence from the relevant systematic reviews and, clinicians in decision making (Appendix 3).
where appropriate, on the indirect evidence from other included A recommendation statement with 'must' or 'shall' indicates
systematic reviews applicable to the clinical question. an imperative need and/or duty, is an essential or indispensable
No recommendation was made for interventions that item/mandatory; a recommendation with 'should' indicates
lacked supporting evidence or if the available evidence had very the recommended need and/or duty is highly desirable; and a
serious indirectness and/or uncertain applicability. A summary recommendation with 'may' or 'could' indicates freedom or
of the available evidence was provided when possible. liberty to follow a suggested alternative.25
The supporting evidence informing the evidence-based Clinicians must utilize the presented evidence-based
recommendations has been described in the summary of find- recommendations in an empathetic manner to facilitate treat-
ing sections. ment completion, optimize dental experience, and instill a
Understanding and interpreting the recommendations. positive dental attitude in a child. Decisions regarding the use
The formulated evidence-based recommendations aim to help of behavior guidance techniques, other than communicative
clinicians, clinician educators, parents (as defined by the AAPD25) management, should be made in collaboration with the parent
/patients and policy makers make decisions on usage of various and, if appropriate, the child; and an informed consent should
behavior guidance techniques7 in a dental office. The recommen- be obtained consistent with the applicable state laws.7
dations are intended to aid clinical judgement and not replace it.
The strength of an evidence-based recommendation was Recommendations
assessed to be either strong or conditional, which presents dif- 1. In children and adolescents, does the use of previsit and
ferent implications for patients, clinicians, and policy makers in-office pre-/posttreatment preparation as basic behav-
(Table 2).21 A strong recommendation in favor of the interven- ior guidance strategies influence cooperative behavior,
tion implies the WG is confident that the desired benefits of dental anxiety, procedural pain, and treatment comple-
the intervention outweigh any undesirable effects and that, in tion during the dental visit?
most situations, clinicians should follow the suggested interven- The recommendations formulated by the WG to address
tion. A conditional recommendation in favor indicates that, this question are presented in Table 3.
while there is appreciable uncertainty, the desired effects may
outweigh the undesired effects of the intervention and that the 1.1. Effect of previsit techniques implemented at home or in
clinician may want to follow the suggested course of action a nonclinical setting
while being cognizant of the various other treatment choices Summary of findings: For children and adolescents under-
and individual patient’s circumstances, preferences, and values. going preventive visits, the systematic review6 conducted
The recommendations for children and adolescents on previsit by the WG found two randomized clinical trials (RCTs)26,27
and in-office pre-/posttreatment strategies are presented in conducted in Australia and the U.S. that tested the effect
Table 2. GRADE INTERPRETATION OF STRENGTH OF RECOMMENDATIONS 21 *
Implications Strong recommendations Conditional recommendations

For patients Most individuals in this situation would want the recommended The majority of individuals in this situation would want the suggested course
course of action and only a small proportion would not. of action, but many would not.
For clinicians Most individuals should receive the recommended course of Recognize that different choices will be appropriate for different patients, and
action. Adherence to this recommendation according to the that you must help each patient arrive at a management decision consistent
guideline could be used as a quality criterion or performance with her or his values and preferences. Decision aids may well be useful help-
indicator. Formal decision aids are not likely to be needed to ing individuals making decisions consistent with their values and preferences.
help individuals make decisions consistent with their values Clinicians should expect to spend more time with patients when working
and preferences. towards a decision.
For policy The recommendation can be adapted as policy in most situations Policymaking will require substantial debates and involvement of many stake-
makers including for the use as performance indicators. holders. Policies are also more likely to vary between regions. Performance
indicators would have to focus on the fact that adequate deliberation about
the management options has taken place.
GRADE Certainty in the Evidence
High We are very confident that the true effect lies close to that of the estimate of the effect.
Moderate We are moderately confident in the effect estimate. The true effect is likely to be close to the estimate of the effect.
Low Our confidence in the effect estimate is limited.
Very low We have very little confidence in the effect estimate.
* Abbrevation used in this table: GRADE=Grading of Recommendations, Assessment, Development, and Evaluations.
Reprinted with permission. GRADE Handbook: Handbook for grading the quality of evidence and the strength of recommendations using the GRADE approach. Update October 2013.
The GRADE Working Group. Available at: “https://gdt.gradepro.org/app/handbook/handbook.html#h.9rdbelsnu4iy”.

Table 3. RECOMMENDATIONS ON USE OF PREVISIT AND IN-OFFICE PRE-/POSTTREATMENT NONPHARMACOLOGICAL BEHAVIOR GUIDANCE
Clinical question 1 In children and adolescents, does the use of previsit and in-office pre-/posttreatment preparation as basic behavior guidance
strategies influence cooperative behavior, dental anxiety, procedural pain, and treatment completion during the dental visit?
Statement* Strength Certainty
Previsit nonpharmacological behavior guidance strategies
Children undergoing** For children and adolescents needing a preventive care visit, the use of previsit video (filmed) Conditional Very Low
preventive visits modeling techniques or imagery may have a small effect on reduction in fear, a trivial effect on
reduction in anxiety, and a trivial effect on improvement in cooperative behavior compared to no
intervention. Clinicians may choose to implement previsit strategies considering costs and resources
involved and parent/patient values and preferences.
Children undergoing† For children and adolescents needing dental treatment visits, the use of previsit video (filmed) Conditional Very Low
dental treatment visits modeling techniques may result in a variable (small to large effect) reduction in anxiety. Use of illus-
trations (computer or paper) and storytelling at home may lead to small improvement in behavior
at the treatment visit. Clinicians may choose to implement previsit strategies considering costs and
resources involved and parent/patient values and preferences.
Children with SHCN‡ For children and adolescents with SHCN needing preventive or dental treatment visits, the use of Conditional Very Low
undergoing preventive previsit strategies such as visual pedagogy (positive imagery) illustrating the dental visit step-by-
or dental treatment step may have a trivial effect on improvement in cooperative behavior. Given lack of evidence on
visits other strategies, clinicians should make the decision based on their expertise, individual patient
factors, and parent/patient values and preferences.
In-office pretreatment nonpharmacological behavior guidance strategies
Waiting spaces
Children undergoing** The Workgroup recognizes the importance of creating a welcoming and inclusive environment
preventive visits in the dental office; however, given the lack of evidence, the Workgroup was unable to formulate
a recommendation. The decision on incorporating distraction strategies in office design such as
Children undergoing†
dental treatment visits games, music, and media in the waiting spaces should be made based on clinician’s expertise, costs
and resources needed, necessary accessibility features, and parent/patient values and preferences.
Children with SHCN‡
undergoing preventive or
dental treatment visits
Positive imagery in dental office
Children undergoing** For children and adolescents needing preventive care visits, the use of positive imagery may have Conditional Very Low
preventive visits a trivial effect on reduction in anxiety. Clinicians may choose to implement positive imagery
considering costs and resources involved and parent/patient values and preferences.
Children undergoing† For children and adolescents needing dental treatment visits, the use of positive imagery technique Conditional Very Low
dental treatment visits may result in a variable (trivial to large effect) reduction in anxiety and have a small effect on im-
provement in cooperative behavior. Clinicians may choose to use positive imagery during treatment
visits considering costs and resources involved and parent/patient values and preferences.
Children with SHCN‡ For children and adolescents with SHCN needing preventive or dental treatment visits, given the
undergoing preventive or lack of evidence, the Workgroup was unable to formulate a recommendation. The decision on use of
dental treatment visits positive imagery should be made based on clinical expertise, individual patient factors, and parent/
patient values and preferences.
Direct observation/ modeling in dental office
Children undergoing** For children and adolescents needing preventive care visits, the use of modeling techniques (direct Conditional Very Low
preventive visits observation, video modeling, video modeling with stress coping skills) may result in a variable
(trivial to large) improvement in cooperative behavior and a variable (trivial to small) reduction in
anxiety as compared to no intervention. Clinicians may choose to implement modeling strategies
considering costs and resources involved and parent/patient values and preferences.
Children undergoing† For children and adolescents needing dental treatment visits, the use of modeling techniques (direct Conditional Very Low
dental treatment visits observation, video modeling, video modeling with stress coping skills) may result in a variable (trivial
to large) improvement in cooperative behavior and variable (trivial to large) reduction in anxiety
compared to no intervention. Clinicians may choose to implement modeling strategies considering
costs and resources involved and parent/patient values and preferences.
Children with SHCN‡ For children and adolescents with SHCN needing preventive or dental treatment visits, the use of Conditional Very Low
undergoing preventive or video modeling techniques may have a trivial effect on improvement in cooperative behavior and a
dental treatment visits trivial reduction in anxiety compared to no intervention. Clinicians may choose to implement model-
ing strategies considering costs and resources involved and parent/patient values and preferences.
* orAssessment of effect=large effect, moderate effect, small important (statistically significant) effect, or trivial (small unimportant or statistically nonsignificant
no effect).
** Preventive visits=included procedures such as examination, prophylaxis, fluoride, radiographs.
† Dental treatment visits=included procedures such as sealants, restorative care, use of local anesthesia, pulp therapies, and simple extractions.
‡ SHCN=Special health care needs.

Table 3. CONTINUED
In-office pretreatment nonpharmacological behavior guidance strategies
Suggestion
Children undergoing** For children and adolescents needing preventive care visits, given the lack of evidence, the Work-
preventive visits group was unable to formulate a recommendation. The decision on use of suggestion strategies
should be made based on clinical expertise and parent/patient values and preferences.
Children undergoing† For children and adolescents undergoing local anesthesia, suggestion may lead to a trivial effect on Conditional Very Low
dental treatment visits reduction in self-reported pain. Clinicians may choose to use positive suggestions to reassure patients
(dental local anesthesia) considering their expertise and parent/patient values and preferences.
undergoing preventive or lack of evidence, the Workgroup was unable to formulate a recommendation. The decision on
dental treatment visits use of suggestion strategies should be made based on clinical expertise, individual patient factors,
and parent/patient values and preferences.
Preparation and information
Children undergoing** For children and adolescents needing preventive care visits, given the lack of evidence, the Work-
preventive visits group was unable to formulate a recommendation. The decision on use of preparation and informa-
tion strategies should be made based on clinical expertise and parent/patient values and preferences.
Children undergoing† For children and adolescents undergoing local anesthesia, preparation strategies may have a trivial Conditional Very Low
dental treatment visits effect on reduction in self- or observer-reported pain. Clinicians may choose to provide preparatory
information considering their expertise and parent/patient values and preferences.
undergoing preventive or lack of evidence, the Workgroup was unable to formulate a recommendation. The decision on use
dental treatment visits of preparation and information strategies should be made based on clinical expertise, individual
patient factors, and parent/patient values and preferences.
In-office posttreatment nonpharmacological behavior guidance strategies
Children undergoing** For children and adolescents needing preventive or dental treatment visits, the use of posttreatment Conditional Very Low
preventive visits live modeling may have trivial effect on reduction in anxiety. Clinicians may use posttreatment
strategies based on their clinical expertise and parent/patient values and preferences.
undergoing preventive or lack of evidence, the Workgroup was unable to formulate a recommendation. The decision on use
dental treatment visits of posttreatment strategies should be made based on clinical expertise, individual patient factors,
and parent/patient values and preferences.
* orAssessment of effect=large effect, moderate effect, small important (statistically significant) effect, or trivial (small unimportant or statistically nonsignificant
no effect).
of a filmed model demonstrating coping techniques and illustration improved coping behavior in children prior to
the guided rehearsal of these techniques. Weinstein et al.27 general anesthesia induction. Another study31 used previsit
reported a small reduction in dental fear measured by the conditioning by the mother telling stories related to the
visual analogue scale (VAS). Another study 26 reported a dental procedure, with results indicating that conditioning
trivial effect on reduction in anxiety as measured by Picture by mothers can improve patients’ behavior.
Dental Anxiety Scale (PDAS) and heart rate (HR) and a For children and adolescents with SHCN undergoing
trivial effect on reduction in behavioral disturbance as preventive or treatment visits, the systematic review 9
measured by Dimensions of Anxiety Index (DAI). conducted by the WG found no studies on the effect of
For children and adolescents undergoing dental treat- previsit techniques conducted prior to dental visit that
ment visits, the systematic review8 conducted by the WG met the inclusion criteria.
found four RCTs28-31 conducted in the UK and Iran that Remarks: The WG noted lack of high-quality research
evaluated the effectiveness of previsit preparatory tech- needed to establish association of pre-/postvisit preparation
niques. Two studies evaluated modeling, 28,29 one study with improvement in cooperative behavior and reduction
evaluated computer illustration, 30 and one study used in anxiety and pain. Therefore, the recommendation is
storytelling. 31 The children who received the modeling based on very low certainty evidence. There were no unde-
intervention exhibited significantly less anxiety through- sirable effects reported on use of pre-/postvisit techniques
out the dental procedure, as reported by the self-reported to manage patient’s experience during the dental visit. It
Abeer Children Dental Anxiety Scale (ACDAS) and VAS. was judged that there is no important uncertainty or vari-
Campbell et al. 30 concluded that interactive computer ability about how the parents/patients would value these

techniques. A recent AAPD member survey revealed that a pretreatment strategy. The recommendations were based
62.5 percent of the responding pediatric dentists use pre- on very low certainty evidence. It was judged that there is
visit preparation to provide information to patient and/or no important uncertainty or variability about how the
the parent, and most providers reported never or rarely en- parents/patients would value these techniques. Given no
countering any hesitancy, reluctance, or refusal by parents/ undesirable effects, the techniques were considered accept-
caregivers when attempting to provide previsit informa- able to providers and parents/patients and feasible to
tion 22. The pre-/postvisit techniques were considered implement with low resource utilization.
acceptable to providers and parents/caregivers and feasible 1.2.3 Direct observation/modeling
to implement with low resource utilization. Summary of findings: For children and adolescents under-
going preventive visits, the systematic review1 conducted
1.2 Pretreatment techniques implemented in a dental office. by the WG found six RCTs35-40 representing five different
1.2.1 Waiting spaces countries (Canada, India, Lebanon, Spain, and two from
Summary of findings: A systematic review13 evaluated inter- the U.S.) that explored the effects of direct observation/
ventions aimed at reducing anxiety in pediatric health modeling during a preventive clinical visit including
care waiting spaces and found eight studies investigating various combinations of examination, radiographs, oral
play opportunities, media distractions, combined play prophylaxis, and/or fluoride application. Hine et al.39 re-
opportunities and media distractions, and music. The ported a large improvement in cooperative behavior from
studies used various assessment tools in children such as video modeling compared to control which was watching
HR, behavior mapping, VAS, Venham Picture Test (VPT), children’s cartoons. A trivial effect on reduction in anxiety
and Modified Yale Preoperative Anxiety Scale (mYPAS). In was reported by three studies using physiologic measures
pediatrics, play opportunities, including provision of small (HR)37,38,40 and by one study using the self-reported Facial
toys, access to a playroom, and distribution of coloring Image Scale (FIS).40
books were most studied and facilitated statistically signi- For children and adolescents undergoing dental treat-
ficant preprocedural anxiety reduction. Overall, there was ment visits, the systematic review8 conducted by the WG
insufficient evidence to corroborate effectiveness of play found ten RCTs41-50 conducted in the U.S., Australia, Saudi
opportunities, media distractions, and music for mitigating Arabia, and South Korea that evaluated the use of direct
anxiety in pediatric waiting areas. The WG decided not observation/modeling. Six studies found significantly less
to formulate recommendations because the quality of the negative behavior in children exposed to video modeling,
systematic review was judged to be critically low using the as rated by the dentist utilizing Frankl’s Behavior Rating
AMSTAR 2 tool. Scale (FBRS) 41,43 , the Behavior Profile Rating Scale
Remarks: The AAPD member survey 22 revealed that (BPRS) 42,44,45 , and the modified Houpt scale. 47 Nine
about one-half of the members who responded used dis- studies found a reduction in dental anxiety in children
traction by office design. There is need for high-quality receiving dental treatment, based on assessment results
research studying the effect of interventions used in dental obtained using the self-reported Children’s Fear Survey
office waiting spaces on reduction in anxiety and improve- Scale (CFSS) 42,44, Picture Dental Anxiety Scale-Child
ment in cooperation. (PDAS-CH)46, State-Trait Anxiety Inventory (STAI)47, and
1.2.2 Positive imagery physiologic assessment using the Palmer Sweat Index
Summary of findings: For children and adolescents under- test42,45, HR47,49, respiration44, and skin conductance tests.
going preventive visits, the systematic review1 conducted For children and adolescents with SHCN undergoing
by the WG found one RCT32 conducted in Brazil that preventive or treatment visits, the systematic review9 con-
tested the effect of positive previsit imagery (i.e., photos ducted by the WG found one clinical trial51 conducted in
of positive dental situations such as a child smiling in the U.S. that reported trivial effect on reduction in anxiety
the dental chair) and reported a trivial effect on reduction and improvement in cooperative behavior in the group
in dental anxiety during dental examination as measured that was exposed to video modeling, with a slideshow of
by VPT. images with voiceover depicting a preventive visit shown
For children and adolescents undergoing dental treat- immediately prior to a preventive visit (examination, oral
ment visits, the systematic review8 conducted by the WG prophylaxis, and fluoride application).
found two RCTs33,34 conducted in the United Kingdom Remarks: The AAPD member survey22 revealed that 80
(UK) and Egypt that evaluated the effectiveness of positive percent of the responding pediatric dentists used direct
dental images as a pretreatment preparation strategy. observation/modeling and reported rarely encountering
Results showed a wide range of effect (trivial to large) on any hesitancy, reluctance, or refusal by parents/caregivers
reduction in anxiety33,34 and a small improvement in co- for its use. The recommendations were based on very low
operative behavior.34 certainty of evidence. It was judged that there is no impor-
For children and adolescents with SHCN undergoing tant uncertainty or variability about how the parents/
preventive or treatment visits, the systematic review 9 patients would value these techniques. Given no undesirable
conducted by the WG found no studies on the effect of effects, the techniques were considered acceptable to pro-
positive imagery conducted prior to dental visit that met viders and parents/patients and feasible to implement with
the inclusion criteria. low resource utilization.
Remarks: The AAPD member survey22 revealed that only 1.2.4 Suggestion
one-third of the responding pediatric dentists used positive Summary of findings: One systematic review1 studied the
imagery and reported rarely encountering any hesitancy, effect of positive suggestion before needle-related proce-
reluctance, or refusal by parents/caregivers for its use as dures in a medical setting, that is, reassuring the patient

that adequate steps have been taken to make treatment 2. In children and adolescents, does the use of basic be-
easier or less painful, and reported a trivial effect on reduc- havior guidance techniques influence cooperative
tion in self-reported pain. The WG found no publications behavior, dental anxiety, procedural pain, and treatment
that studied the effect of suggestion in a dental setting for a completion during the dental visit?
preventive visit, for a treatment visit, or for children with The recommendations formulated by the WG to address
SHCN undergoing a preventive or treatment visit. this question are presented in Appendix 1.
Remarks: There is need for high quality research study-
ing the effect of suggestion on reduction in anxiety and 2.1 Communication and communicative guidance
improvement in cooperation. 2.1.1 Communication (verbal)
1.2.5 Preparation and information Summary of findings: The WG found no studies on the
Summary of findings: One systematic review1 studied the effect of communicative guidance conducted in the dental
effect of preparatory information provided to children office that met the inclusion criteria for children under-
through pictures/photo storybooks before needle-related going preventive visit, for children undergoing dental
procedures in a medical setting and reported a trivial effect treatment visit, or for children with SHCN undergoing
on reduction in self-/observer-reported pain. The WG preventive or treatment visit.
found no publications that studied the effect of prepara- 2.1.2 Communication (nonverbal)
tion in a dental setting for preventive visit, for treatment Summary of findings: For children and adolescents under-
visit, or for children with SHCN undergoing preventive going preventive visits, the systematic review6 conducted
or treatment visit. by the WG found one RCT53 conducted in the U.S. that
Remarks: The AAPD member survey 22 revealed that studied the effect of nonverbal communication (e.g., reas-
62.5 percent of the responding pediatric dentists use suring pat on the arm) and reported trivial effect on reduc-
preparation and information in their practice and never or tion in dental fear-related-emotion and a small reduction
rarely encountered any hesitancy, reluctance, or refusal by in fidgeting behavior in children older than seven compared
parents/caregivers. There is need for high quality research to children younger than seven as measured by BPRS.
studying the effect of preparation and information on re- For children and adolescents undergoing dental treat-
duction in anxiety and improvement in cooperation. ment visits and for the children with SHCN undergoing
either preventive or treatment visits, the systematic re-
1.3 Posttreatment techniques in dental office views 8,9 conducted by the WG found no studies on the
Summary of findings: For children and adolescents under- effect of nonverbal communication conducted in the dental
going preventive visits, the systematic review6 conducted office that met the inclusion criteria.
by the WG found no studies on the effect of posttreatment Remarks: Communication was considered universally
interventions conducted in the dental office that met the applied and integral to the success of accompanying be-
inclusion criteria. However, the indirect evidence from the havior guidance techniques. The AAPD member survey22
systematic review on children undergoing dental treatment revealed that 97.3 percent of the responding pediatric den-
visits5 was deemed acceptable and subjected to GRADE tists use verbal communication and counseling skills to
process to inform the recommendations for children under- build rapport and trust and 72.1 percent report using non-
going preventive visits. verbal communication as a behavior guidance technique.
For children and adolescents undergoing dental treat- Respondents never or rarely encountered any hesitancy,
ment visits, the systematic review8 conducted by the WG reluctance, or refusal by parents/caregivers when using
found one RCT52 conducted in the UK that tested the the communication techniques. The recommendation for
effectiveness of a posttreatment modeling intervention nonverbal communication was based on very low certainty
(passivity to activity through live symbolic modeling) after evidence. It was judged that there is no important uncer-
dental restorative visits. The study reported trivial effect tainty or variability about how the parents/patients would
on reduction in anxiety in the subsequent treatment visit value these techniques. Given no undesirable effects,
using Modified Child Dental Anxiety Scale (MCDAS). communicative techniques were considered acceptable to
For children and adolescents with SHCN undergoing providers and parents/patients and feasible to implement
preventive or treatment visits, the systematic review9 con- with low resource utilization.
ducted by the WG found no studies on the effect of post-
treatment interventions conducted in the dental office that 2.2 Tell-show-do and its modifications
met the inclusion criteria. Summary of findings: For children and adolescents under-
Remarks: The AAPD member survey 22 revealed that going preventive visits, the systematic review6 conducted
only 33.9 percent of the responding pediatric dentists by the WG found three RCTs 40,54,55 conducted in India
use postvisit debrief/preparation as a behavior guidance and Pakistan that tested the effectiveness of TSD or its
technique and reported never or rarely encountering any modification TPD compared to other behavior guidance
hesitancy, reluctance, or refusal by parents/caregivers in techniques (modeling and mobile dental application).
relation to its implementation. The recommendations were Vishwakarma et al. 54 compared TPD to live modeling
based on very low certainty evidence. It was judged that and reported a small reduction in dental anxiety in the
there is no important uncertainty or variability about how TPD group measured by HR, FIS, and VPT as deter-
the parents/patients would value these techniques. Given mined by SMD. Karekar’s study40 compared TSD to both
no undesirable effects, the techniques were considered filmed and live modeling and reported large reduction in
acceptable to providers and parents/patients and feasible anxiety measured by HR favoring both modeling tech-
to implement with low resource utilization. niques compared to TSD, as well as a trivial effect on

reduction in anxiety measured by FIS favoring TSD. Abbasi by the WG found no studies on the effect of voice control
et al.55 compared TSD to no behavior guidance techniques conducted in the dental office that met the inclusion cri-
and reported a trivial effect on reduction in dental anxiety teria. However, the indirect evidence from the systematic
between two groups measured by HR and FIS. review on children undergoing dental treatment visits8
For children and adolescents undergoing dental treat- was deemed acceptable and subjected to GRADE process
ment visits, the systematic review8 conducted by the WG to inform the recommendation for children undergoing
found eight randomized clinical trials54,56-62 conducted in preventive visits.
India, China, Israel, and Brazil that studied the effect of For children and adolescents undergoing dental treat-
TSD and TPD, TPD/audio and AVD, and virtual reality ment visits, the systematic review8 conducted by the WG
(VR) glasses in different population samples of healthy found one RCT63 conducted in the U.S. that tested the
children. Only one study compared TSD with a control effectiveness of voice control (contingent, loud, and firm
group (no specific behavior guidance technique) 58 and voice command) during dental restorative visits and re-
found trivial to small effect on reduction in anxiety ported trivial effect on reduction in fear and a trivial effect
measured by VPT and physiologic methods. Compared to on improvement in cooperative behavior when voice
TSD, distraction interventions had a large reduction in control was used compared to normal voice.
anxiety measured by physiologic methods (HR and blood For children and adolescents with SHCN undergoing
pressure, rated as critical outcomes).56,61 Another study com- preventive or treatment visits, the systematic review 9
pared TSD with hiding/camouflaging the dental needle conducted by the WG found no studies on voice control
technique and found trivial effect on reduction in anxiety conducted in the dental office that met the inclusion
(assessed by FIS and HR), reduction in pain (assessed by criteria.
the Wong-Baker FACES Pain Rating Scale), and improve- Remarks: The AAPD member survey 22 revealed that
ment in cooperative behavior (assessed by the FBRS).62 59.2 percent of the responding pediatric dentists use voice
For children and adolescents with SHCN undergoing control in their practice. The practitioners frequently en-
either preventive or treatment visits, the systematic review9 countered hesitancy, reluctance, or refusal by parents/
conducted by the WG found no studies on the effect of caregivers on the use of loud voices. Though traditional
TSD and its modifications conducted in the dental office voice control involves use of loud voice, its modification
that met the inclusion criteria. (i.e., the practice of lowering the voice) may also be utilized.
Remarks: TSD and its modifications are among the Given the lack of high-quality research, the recommen-
most used and universally applied basic behavior guidance dation for use of voice control was based on very low
techniques. The AAPD member survey22 revealed that 98.3 certainty evidence. While voice control was considered
percent of the responding pediatric dentists use TSD in feasible to implement with low resource utilization, it is
their practice and never or rarely encountered any hesi- likely to have inconsistent acceptance by providers and
tancy, reluctance, or refusal by parents/caregivers. Given the parents/patients thus necessitating engaging parents in
lack of high-quality research, the recommendation for use shared decision making before implementing the technique.
of TSD was based on very low certainty evidence. Many
studies used TSD as a control group comparing it to an 2.5 Positive reinforcement and descriptive praise
active technology-based distraction technique. It was judged Summary of findings: For children and adolescents under-
that there is no important uncertainty or variability about going preventive visits, the systematic review6 conducted
how parents/patients would value these techniques. Given by the WG found one RCT64 conducted in Brazil that
no undesirable effects, TSD and its modifications were studied children receiving a positive reinforcement reward
considered acceptable to providers and parents/patients and after dental care. The reward after dental care led to a small
feasible to implement with low resource utilization. reduction in anxiety among preschool children at the sec-
ond visit assessed in the reception room before any dental
2.3 Ask-tell-ask (ATA) treatment.
Summary of findings: The WG found no studies on the For children and adolescents undergoing dental treat-
effect of ATA conducted in the dental office that met ment visits, the systematic review8 conducted by the WG
the inclusion criteria for children undergoing preventive found two randomized clinical trials65,66 conducted in the
visits, for children undergoing dental treatment visits, U.S. and China studying the effectiveness of positive
and for children with SHCN undergoing preventive or reinforcement (small prize such as a sticker or eraser66 or
treatment visits. contingent access to AVD65) for dental treatment. In the
Remarks: The AAPD member survey22 on AAPD mem- Xia et al.66 study, there was a large reduction in fear assessed
bers revealed that less than one-half of the members who by the Children’s Fear Survey Scale Dental Subscale
responded used ATA as a behavior guidance technique in (CFSS-DS) Chinese version. Ingersoll et al.65 reported that
their practices. Those who used this technique never or in the contingent reinforcement group there was a signi-
rarely encountered any hesitancy, reluctance, or refusal by ficant reduction in disruptive behavior measured by the
parents/caregivers. There is need for high quality research Allard Stokes Scale for disruptive behavior (critical out-
studying the effect of interventions used in a dental envi- come), and an insignificant tendency toward reduction in
ronment on reduction in anxiety and improvement in self-reported fear and anxiety measured by CFSS-DS and
cooperation. VPT.
For children and adolescents with SHCN undergoing
2.4 Voice control and its modifications preventive or treatment visits, the systematic review 9
Summary of findings: For children and adolescents under- conducted by the WG found no studies on the effect of
going preventive visits, the systematic review6 conducted positive reinforcement conducted in the dental office that

met the inclusion criteria. However, the indirect evidence techniques those allowing patients an opportunity to receive
from the systematic review on children undergoing dental feedback on their physiological responses using electro-
treatment visits 8 was deemed acceptable and subjected mechanical devices and voluntarily learning to control some
to GRADE process to inform the recommendations for facets of their response resulted in a large reduction in
children with SHCN undergoing preventive or treatment anxiety measured by HR but a trivial effect on reduction in
visits. anxiety measured by the Chotta Bheem-Chutki (CBC)
Remarks: Positive reinforcement and descriptive praise Scale.68 In the other study, the SMD showed a large reduc-
are among the most used and universally applied basic tion in anxiety measured by HR as measured by VAS.69
behavior guidance techniques. The AAPD member survey22 For children and adolescents with SHCN undergoing
revealed that 95.1 percent of responding pediatric dentists preventive or treatment visits, the systematic review 9
use positive reinforcement in their practice and never or conducted by the WG found no studies on biofeedback
rarely encountered any hesitancy, reluctance, or refusal by relaxation conducted in the dental office that met the
parents/caregivers. However, no studies examined the effec- inclusion criteria.
tiveness of descriptive, specific praise on anxiety, fear, or Remarks: Given the lack of high-quality research, the
behavior. The recommendation on use of positive rein- recommendation for use of biofeedback relaxation was
forcement was based on moderate certainty evidence for based on very low certainty evidence. Given unknown
preventive visits and very low certainty evidence for dental undesirable effects, biofeedback relaxation may be accepted
treatment visits and for children with SHCN. It was judged as an intervention by providers and parents/patients, how-
that there is no important uncertainty or variability about ever, the feasibility is likely to vary based on the resources
how the parents/patients would value these techniques. needed to implement it.
Given no undesirable effects, positive reinforcement and
descriptive praise were considered acceptable to providers 2.8 Breathing relaxation
and parents/patients and feasible to implement with low Summary of findings: For children and adolescents under-
resource utilization. going preventive visits, the systematic review6 conducted by
the WG found no studies on the effect of breathing relax-
2.6 Memory restructuring ation conducted in the dental office that met the inclusion
Summary of findings: For children and adolescents under- criteria. However, the indirect evidence from the systematic
going preventive visits, the systematic review6 conducted review on children undergoing dental treatment visits8
by the WG found no studies on memory restructuring was deemed acceptable and subjected to GRADE process
conducted in the dental office that met the inclusion criteria. to inform the recommendations for children undergoing
For children and adolescents undergoing dental treat- preventive visits.
ment visits, the systematic review8 conducted by the WG For children and adolescents undergoing dental treat-
found one study conducted in the U.S. that examined ments, the systematic review8 conducted by the WG found
memory restructuring completed just prior to the second one study70, conducted in Italy, which examined the use
(restorative) treatment and reported a trivial effect on of diaphragmatic breathing (i.e., breathing relaxation)
reduction in fear and pain.67 and reported variable reduction in anxiety based on HR
For children and adolescents with SHCN undergoing data and large reduction based on respiratory rate (RR)
preventive or treatment visits, the systematic review 9 data. The effect on reduction in pain, fear, sadness, and
conducted by the WG found no studies on memory re- anger and the improvement in happiness were assessed to
structuring conducted in the dental office that met the be trivial.
inclusion criteria. For children and adolescents with SHCN undergoing
Remarks: The AAPD member survey 22 revealed that preventive or treatment visits, the systematic review9 con-
only 22.4 percent of the responding pediatric dentists use ducted by the WG found no studies on breathing relax-
memory restructuring in their practice and never or rarely ation conducted in the dental office that met the inclusion
encountered any hesitancy, reluctance, or refusal by parents/ criteria.
caregivers. Given the lack of high-quality research, the Remarks: The AAPD member survey 22 revealed that
recommendation for use of memory restructuring was two-thirds of the responding pediatric dentists use
based on very low certainty evidence. While memory re- breathing relaxation techniques in their practice and
structuring was considered feasible to implement with low never or rarely encountered any hesitancy, reluctance, or
resource utilization, it is likely to have varying acceptance refusal by parents/caregivers. It was judged that there is no
among providers and parents/patients thus necessitating important uncertainty or variability about how the parents/
parental engagement in shared decision making prior to caregivers would value these techniques. Given the very
implementing the technique. low likelihood of undesirable effects, breathing relaxation
techniques were considered acceptable to providers and
2.7 Biofeedback relaxation parents/patients and feasible to implement with low
Summary of findings: For children and adolescents under- resource utilization.
going preventive visits, the systematic review6 conducted
by the WG found no studies on biofeedback relaxation 2.9 Desensitization
conducted in the dental office that met the inclusion criteria. Summary of findings: For children and adolescents under-
For children and adolescents undergoing dental treat- going preventive visits, the systematic review6 conducted
ment visits, the systematic review8 conducted by the WG by the WG found no studies on the effect of desensitiza-
found two RCTs68,69 conducted in India that tested the effec- tion conducted in the dental office that met the inclusion
tiveness of biofeedback relaxation. Biofeedback relaxation criteria. However, the indirect evidence from the systematic

review on children undergoing dental treatment visits8 For children and adolescents undergoing dental treat-
was deemed acceptable and subjected to GRADE process ment visits, the systematic review8 conducted by the WG
to inform the recommendation for children undergoing found no studies on the effect of magic tricks conducted in
preventive visits. the dental office that met the inclusion criteria. However,
For children and adolescents undergoing dental treat- the indirect evidence from the systematic review on children
ment visits, the systematic review8 conducted by the WG undergoing preventive visit8 was deemed acceptable and
found one RCT41 conducted in the U.S. that tested the subjected to GRADE process to inform the recommenda-
effectiveness of desensitization and reported small improve- tion for children undergoing treatment visits.
ment in cooperative behavior when desensitization was For children and adolescents with SHCN undergoing
used compared to the control group. preventive or treatment visits, the systematic review9 con-
For children and adolescents with SHCN undergoing ducted by the WG found no studies on the effect of
preventive or treatment visits, the systematic review9 con- magic tricks conducted in the dental office that met the
ducted by the WG found no studies on the effect of inclusion criteria.
desensitization conducted in the dental office that met the Remarks: Given the lack of high-quality research, the
inclusion criteria. However, the indirect evidence from the recommendations for use of magic tricks as distraction
systematic review on children undergoing dental treatment techniques were based on very low certainty evidence.
visits8 was deemed acceptable and subjected to GRADE Given unknown undesirable effects, magic tricks are likely
process to inform the recommendation for children with to have inconsistent acceptance as an intervention among
SHCN. providers and parents/patients, however, it may be feasible
Remarks: The AAPD member survey 22 revealed that to implement after considering the needed resources and
three-fourths of the responding pediatric dentists use de- training.
sensitization in their practice and never or rarely encoun- 2.11.2 Traditional distraction techniques
tered any hesitancy, reluctance, or refusal by parents/ Summary of findings: For children and adolescents under-
caregivers. It was judged that there is no important going preventive and dental treatment visits, one systematic
uncertainty or variability about how the parents/patients review2 evaluated the effect of mirror and conversation,
would value these techniques. Given that the benefits of toys, and books and children’s stories and, based on one
desensitization outweigh any temporary undesirable effects, study64, found no difference in effect on dental anxiety
the technique is considered acceptable to providers and compared to control group. The systematic review6 found
parents/caregivers and is feasible to implement with low no additional studies on the effect of traditional distraction
resource utilization. techniques conducted in the dental office during a pre-
ventive visit that met the inclusion criteria. Due to limited
2.10 Enhancing control evidence, the WG was unable to formulate evidence-based
Summary of findings: The WG found no studies on the recommendations on its use.
effect of enhancing control techniques utilized in the For children and adolescents undergoing dental treat-
dental office that met the inclusion criteria for children ment visits (dental local anesthesia), two systematic reviews2,5
undergoing preventive visits, dental treatment visits, or evaluated the effect of traditional distraction techniques
for children with SCHN undergoing preventive or treat- (camouflaging of syringe, use of counterstimulation [shaking
ment visits. or pulling the mucosa with intraoral or extraoral finger]),
Remarks: The AAPD member survey22 revealed that two- and asking the patient to do breathing exercises or to draw
thirds of the responding pediatric dentists use enhancing letters in the air with their feet, cooperative behavior,
control in their practice and never or rarely encountered anxiety and pain during delivery of local anesthetic. Results
any hesitancy, reluctance, or refusal by parents/caregivers. of the meta-analysis were analyzed and converted into
Considering that the intervention is likely to be used by standardized terms using SMD to assist interpretation and
the majority of pediatric dentists, there is need for high deliberation among the WG members. Both systematic
quality research studying the effect of enhancing control reviews evaluated the effect of distraction techniques such
on reduction in anxiety and improvement in cooperation. as camouflaging the syringe on cooperative behavior dental
anxiety and pain perception triggered during dental treat-
2.11 Distraction ment. The results from Prado et al.2 suggested that camou-
2.11.1 Magic tricks flaging the syringe may result in a reduction in pain-related
Summary of findings: For children and adolescents under- behavior and improvement in overall cooperative behavior.
going preventive visits, the systematic review6 conducted Results from Monteiro et al. 5 suggested that the use of
by the WG found two RCTs71,72 conducted in Israel and counter stimulation and camouflaging the syringe showed
India that tested the effectiveness of distraction with a varying levels of reduction in anxiety and pain perception
'magic trick' on children’s dental anxiety72 and on children’s during administration of local anesthesia. In addition,
readiness to receive radiographs71 or a prophylaxis treat- camouflaging the syringe also resulted in improvement in
ment72 measured by the time it took to sit in the dental cooperative behavior. Based on very low certainty of evi-
chair71 or to enter the treatment area72. One study used an dence, one systematic review3 reported that local anesthetic
acrylic thumb light that could 'magically' appear and delivered using a digital injection technology (Wand)
reappear 72 and showed small effect on reduction in the compared to the traditional technique may result in small
anxiety when compared to baseline. Another study used reduction in anxiety, a variable effect (trivial to small) on
a ‘magic book’ in which pictures could be erased magic- reduction in pain perception, and a trivial effect on cooper-
ally and drawn again 71 and reported a trivial effect on ative behavior.
improvement in cooperative behavior.

For children and adolescents with SHCN undergoing Three studies on technology-based distractions were
preventive or treatment visits, the systematic review 9 identified and included in the review to update the most
conducted by the WG found no studies on the effect of recent systematic reviews published in 2020. One RCT73
traditional distraction techniques conducted in the dental conducted in Turkey tested robot distraction versus verbal
office that met the inclusion criteria. distraction on children needing restorative (with or without
Remarks: The AAPD member survey22 revealed that 82.4 local anesthesia) or pulpotomy treatment. They assessed
percent of responding pediatric dentists used distraction behavior using a physician-rated scale (FBRS) and anxiety
by imagination (e.g., stories) as a behavior guidance tech- using the self-reported FIS (by children), Corah’s Dental
nique and reported never or rarely encountering any Anxiety Scale ([DAS], answered by parents), and physio-
hesitancy, reluctance, or refusal by parents/caregivers. The logic measures (HR) and found that the robotic technol-
traditional distraction techniques are considered acceptable ogy can successfully help in coping with dental anxiety
to providers and parents/patients and feasible to imple- (small reduction) and stress and helps children cooperate
ment with low resource utilization. The recommendations (small effect) in the dental office. The second RCT, cross-
are based on very low certainty evidence. There is a need over design74 conducted in Spain, tested effectiveness of
for high-quality research to substantiate the effect of PlayStation™ video game (versus cartoon control group) for
traditional distraction techniques during dental treatment. restorative care. The outcomes studied were behavior,
2.11.3 Technology-based distraction techniques dental anxiety, and dental pain using child-rated (VPT,
Summary of findings: For children and adolescents under- Wong-Baker Faces Pain Rating Scale), physician-rated
going preventive visits, the systematic review6 conducted (FBRS), physiologic (HR), and parent-reported (Modified
by the WG found two RCTs55,72 conducted in India and Corah Dental Anxiety Scale [MDAS]) scales. The study
Pakistan that tested effectiveness of a mobile dental applica- showed no significant differences in self-reported anxiety
tion (app). One of the studies55 reported a small reduction (measured by VPT), no significant differences in self-
in anxiety measured by HR and a large reduction in anxiety reported pain (measured by Wong-Baker FACES Pain
as measured by FIS when a mobile app was used compared Rating Scale), and no significant differences in global
to no intervention control. The second study72 reported a behavior (measured by FBRS). The third RCT,75 conducted
trivial effect on reduction in anxiety compared to the TSD in Jordan, evaluated the use of immersive VR goggles during
group as measured by CBC Scale and found a small effect treatment completed without local anesthesia including
on reduction in time taken to accept dental treatment fissure sealant placement, space maintainer placement,
(readiness of the child) for the mobile app group compared fluoride application, impression, or scaling. The study
to the TSD group. measured dental pain, both self-rated (Wong-Baker FACES
For children and adolescents undergoing dental treat- Pain Rating Scale, VAS) and physician-rated (by a research
ment visits, three systematic reviews2,3,5 evaluated the effect assistant using the Face Legs Arms Crying Consolability
of technology-based distractions such as music distraction, scale). The use of VR was found to be an effective distraction
three-dimensional (3D) glasses, and AVD on cooperative tool to ease pain and anxiety in the tested dental procedures.
behavior, anxiety, and/or pain during restorative procedures. For children and adolescents with SHCN undergoing
Results of the meta-analysis were analyzed using SMD to preventive or treatment visits, the systematic review9 con-
assist interpretation and deliberation among the WG ducted by the WG found three RCTs76-78 conducted in the
members. Prado et al.2 evaluated the effect of distraction U.S. and Italy that evaluated the use of AVD techniques
techniques such as audio songs, 3D glasses, eyeglasses, and such as video goggles. One trial studied reported trivial
AVD on cooperative behavior, dental anxiety, and pain effect on improvement in cooperative behavior and reduc-
perception triggered during dental treatment. The results tion in anxiety in patients with autism spectrum disorder
suggested a small reduction in anxiety favoring audio songs, (ASD) during a preventive visit76. In the second study, the
and a variable (trivial to small) effect favoring use of AVD/ use of video glasses resulted in large reduction in pain
3D glasses/eyeglasses in reducing anxiety and improving during preventive care visit and in a trivial effect on
cooperative behavior. Custodio et al.3 reported trivial (small reduction in pain-related behavior during restorative visit,
unimportant) or no benefits for administering local anes- which was evident only in the second clinical session77. In
thesia, caries removal, and placement of rubber dam; the third study, when compared to protective eyeglasses,
however, that systematic review showed large reduction the use of video glasses resulted in a trivial effect on
in anxiety and pain perception during restorative treatment. reduction in pain during a preventive visit.78
The WG considered that part of this effect could be attrib- Remarks: The AAPD member survey22 revealed that the
uted to the natural reduction in anxiety (habituation) responding pediatric dentists commonly use technology-
experienced over the length of the procedure. Monteiro et based distraction techniques such as music/audio songs
al. 5 evaluated the effect of technology-based distraction (50.9 percent) and AVD (77 percent). The practitioners
techniques such as music, 3D glasses, video modelling, never or rarely encountered any hesitancy, reluctance, or
tablet, and VR box on cooperative behavior, dental anxiety, refusal by parents/caregivers. The technology-based dis-
and pain perception triggered during administration of local traction techniques are considered acceptable to providers
anesthesia. Use of technology-based distractions such as and parents/caregivers and have varying feasibility to its
VR-box and tablets showed trivial (small unimportant) or implementation depending on the costs and resources
no benefits; however, music distraction, 3D glasses, and needed for implementation. There is moderate certainty
video modeling showed varying levels of reduction in an- evidence to inform the recommendation for use of VR
xiety and pain perception and improvement in cooperative glasses during placement of a restoration; however, the
behavior during administration of local anesthesia. recommendations for other technology-based approaches
(such as audio songs and AVD/3D glasses/eyeglasses) are

based on very low certainty of evidence. Clinicians should and subjected to GRADE process to inform the recom-
ensure that any video or VR glasses used meet the standards mendations for children undergoing preventive visits.
required for eye protection during dental treatment. Also, For children and adolescents undergoing dental treat-
it may be prudent for clinicians to periodically monitor ment visits, the systematic review8 conducted by the WG
the eyes to see how the child is coping with the treatment found two RCTs58,80 conducted in India58 and Egypt80 that
and check for any early indicators of health-related issues. tested the effectiveness of combined therapies (TSD with
In addition, care should be taken so that children with AVD58 and parental active presence with TSD compared
hearing impairments have a full visibility of their surround- to parental passive presence with TSD80. The systematic
ings79. The AAPD member survey22 revealed that only 2.1 review reported variable reduction in anxiety for TSD with
percent of the respond-ing pediatric dentists use VR as a AVD, and small reduction in anxiety (assessed by FIS) and
behavior guidance technique in their practices, which high- small improvement in cooperative behavior (assessed by
lights a potential disparity in published research on tech- FBRS) for TSD with active parental presence.
niques that may be of research interest but have low For children and adolescents with SHCN undergoing
clinical application. It is important that practitioners use preventive or treatment visits, the systematic review 9
their clinical judgement based on their expertise, patient conducted by the WG found no studies on the effect of
preferences, costs, resources involved before implementing combining therapies that met the inclusion criteria.
new behavior guidance techniques in their offices. Remarks: Most practitioners use a combination of basic
and/or advanced nonpharmacological behavior guidance
2.12 Parental presence/absence techniques during the dental visit. Given the lack of data,
Summary of findings: For children and adolescents under- there is need for high quality research studying the effect
going preventive or dental treatment visits, one systematic of combined therapies on cooperative behavior, anxiety,
review6 evaluated whether parents’ presence in the operatory and procedural pain. The recommendations are based on
influenced children’s cooperative behavior, anxiety, and fear very low certainty evidence.
during dental treatment. The included studies used the
FBRS and VPT scales to assess behavior, VPT to assess 2.14 Sensory-adapted dental environments (SADE)
anxiety, CFSS–DS to assess fear, and Wong-Baker FACES Summary of findings: The WG found no studies that met
Pain Rating Scale to assess child’s perception of treatment/ the inclusion criteria on use of SADE in healthy children
pain. Results of the meta-analysis were analyzed and con- presenting for preventive or dental treatment visits.
verted into standardized terms using SMD to assist interpre- For children and adolescents with SHCN undergoing
tation and deliberation among the work group members. preventive or treatment visits, the systematic review9 con-
Parental presence showed trivial (small unimportant) ducted by the WG found four RCTs 81-84 conducted in
benefits for the studied outcomes. Israel81-83 and the U.S.84 that evaluated the effect of SADE
For children and adolescents with SHCN undergoing for dental prophylaxis. One study showed large improve-
preventive or treatment visits, the systematic review9 found ment in cooperative behavior as recorded by the hygienist
no studies on the effect of parental presence in the operatory using a Likert scale82, and another study showed a trivial
that met the inclusion criteria. effect on improvement in cooperative behavior using the
Remarks: The AAPD member survey 22 revealed that Children Dental Behavior Rating Scale.84 Another study83
86.7 percent of the responding pediatric dentists used showed moderate reduction in the duration (in minutes)
parental presence and 56.3 percent utilized parental of accumulative anxious behaviors using the Negative
absence as a behavior guidance technique. They reported Dental Behavior Checklist, favoring SADE. All four
encountering frequent hesitancy, reluctance, or refusal by studies 81-84 showed a variable (trivial to large) effect on
parents/caregivers when they were asked to leave the operatory reduction in anxiety for the SADE group.
(parental absence). The parental presence/absence tech- Remarks: The AAPD member survey22 revealed that 7.2
niques are considered acceptable to providers; however, percent of the responding pediatric dentists used SADE to
there is likely to be inconsistent acceptance to parental aid with behavior guidance and reported never or rarely en-
absence by the parents/patients. The techniques are feasible countering any hesitancy, reluctance, or refusal by parents/
to implement with low resource utilization. Considering caregivers. SADE is considered an acceptable technique by
that the recommendations are based on very-low certainty the providers and parents/patients to optimize dental visits
evidence, it is suggested that clinicians help parents of children with SHCN. The feasibility is likely to vary
understand the risks and benefits of their presence or depending on the cost and resources required for its imple-
absence in the operatory and make shared decisions best mentation. The recommendation is based on very-low
suited for the patient and the planned care. There is need certainty evidence. There is a need for high quality research
for high quality research to substantiate the effect of to substantiate the effect of SADE during dental treatment.
parental presence/absence on patient anxiety, procedural
pain, and cooperative behavior during dental treatment. 2.15 Animal-assisted therapy (AAT)
Summary of findings: For children and adolescents under-
2.13 Combined nonpharmacological behavior therapies going preventive visits, the systematic review6 conducted
Summary of findings: For children and adolescents under- by the WG found no studies on the effect of AAT that
going preventive visits, the systematic review6 conducted met the inclusion criteria. However, the indirect evidence
by the WG found no studies on the effect of combining from the systematic review on children undergoing dental
therapies that met the inclusion criteria. However, the treatment visits8 was deemed acceptable and subjected to
indirect evidence from the systematic review on children GRADE process to inform the recommendation for chil-
undergoing dental treatment visits8 was deemed acceptable dren undergoing preventive visits.

For children and adolescents undergoing dental treat- of evidence. There is a need for high quality research to
ment visits, the systematic review8 conducted by the WG substantiate the effect of PECS during dental treatment.
found two RCTs 85,86 conducted in the U.S. and one in
India 87 that evaluated effectiveness of AAT. The results 3. In children and adolescents, does the use of advanced
from one study showed no significant differences between nonpharmacological behavior guidance techniques in-
the groups for anxiety-related behavioral distress measured fluence cooperative behavior, dental anxiety, procedural
by the Observational Scale of Behavioral Distress and pain, and treatment completion during the dental visit?
physiologic arousal measured by peripheral skin temper- The WG’s literature search and systematic review work
ature. 85 The results from the Charowski et al. 86 study identified cognitive behavior therapy and hypnosis as
showed high level of satisfaction observed in children using relevant behavior guidance techniques. The WG con-
AAT; however, the behavioral outcomes, measured by the sidered these to be advanced nonpharmacological behavior
FBRS and Modified Houpt Scale (Movement, Crying, guidance techniques given their complexity (compared
Overall), and the physiologic outcomes (HR, pulse oxygen to basic techniques described above) and the training and
saturation) were similar to those who did not receive AAT. practice required to use them, which is comparable to the
The results from the other study showed AAT led to training and practice necessary to use other advanced
large reduction in anxiety measured by pulse rate and the behavior guidance techniques safely and effectively. The
revised modified faces version of the MCDAS. 87 The recommendations formulated by the WG to address this
pooled results from meta-analysis based on two studies question are presented in Appendix 2.
showed a trivial effect on reduction in anxiety (measured by
HR) during dental treatment following AAT when com- 3.1 Cognitive behavior therapy (CBT)
pared to the control group.86,87 Summary of findings: For children and adolescents under-
For children and adolescents with SHCN undergoing going preventive visits, the systematic review6 conducted
preventive or treatment visits, the systematic review 9 by the WG found no studies on the effect of CBT con-
conducted by the WG found no studies on the effect of ducted in the dental office that met the inclusion criteria.
AAT that met the inclusion criteria. However, the indirect evidence from the systematic review
Remarks: The AAPD member survey 22 revealed that on children undergoing dental treatment visits8 was deemed
only 7.7 percent of the responding pediatric dentists used acceptable and subjected to GRADE process to inform the
AAT to aid with behavior guidance and reported never or recommendation for children undergoing preventive visits.
rarely encountering any hesitancy, reluctance, or refusal For children and adolescents undergoing dental treat-
by parents/caregivers. The acceptability is likely to vary ment visits, the systematic review8 conducted by the WG
among the providers and parents/patients. The feasibility is found four RCTs 90-93 conducted in Sweden, the U.S.,
likely to vary depending on the local regulations, costs, and Norway, and Iran that tested the effectiveness of CBT
resources required for its implementation. The recom- sessions prior to dental treatment, involving different combi-
mendations are based on very low certainty evidence. There nations of two or more cognitive and behavioral strategies,
is need for high quality research to substantiate the effect including distraction, preparation/information, modeling
of AAT during dental treatment. and rehearsal, breathing, suggestion, relaxation, guided
imagery, positive coping statements, cognitive restructuring,
2.16 Picture exchange communication system (PECS) positioning, and parent coaching combined with sequential
Summary of findings: The WG found no studies that met visits for treating children.
the inclusion criteria on use of PECS in healthy children The effect on improvement in cooperative behavior
presenting for preventive or dental treatment visits. measured by HR was trivial in preschool children.91 The
For children and adolescents with SHCN undergoing difference in reduction of anxiety (assessed by VPT and
preventive or treatment visits, the systematic review9 con- HR) between the CBT intervention group and control
ducted by the WG found two randomized clinical trials88,89 group was also trivial in preschool children;91 however,
conducted in Canada and Brazil evaluating the use of PECS CBT combined with sequential visits in preschoolers with
for oral examination and prophylaxis with children with baseline anxiety showed a moderate reduction in anxiety
ASD. In one study, visual pedagogy using PECS showed (assessed by VPT) and a varied (small to large) improve-
a trivial effect on reduction in pain-related behavioral ment in cooperative behavior (assessed by Venham’s Clin-
distress and a trivial effect on improvement in cooperative ical Anxiety Scale and Venham’s Clinical Cooperation
behavior (assessed by the completion time). 88 Another Scale). 93 CBT showed a significant effect in reducing
study compared a mobile app and PECS using flash cards anxiety (measured by CFSS-DS) and phobia (assessed by
and found that the mobile app was more effective compared Self-Efficacy Questionnaire for Specific Phobias) during
to PECS in terms of improvement in patient communica- dental visit treatment in the seven- to 18-years-old chil-
tion and decreasing number of appointments for preventive dren with baseline dental anxiety and/or fear of injection.90
dental care and clinical examinations.89 The pooled data of two studies90,92 showed large improve-
Remarks: The AAPD member survey22 revealed that only ment in cooperative behavior and a large reduction in
5.2 percent of the responding pediatric dentists used PECS anxiety during dental treatment following CBT compared
to aid with behavior guidance and reported never or rarely to no intervention in older children with baseline dental
encountering any hesitancy, reluctance, or refusal by parents/ anxiety and/or fear of injection.
caregivers. For children with SHCN (especially ASD), For children and adolescents with SHCN undergoing
PECS is considered acceptable to providers and parents/ preventive or treatment visits, the systematic review9 con-
patients and feasible to implement with low resource utili- ducted by the WG found no studies on the effect of CBT
zation. The recommendation is based on very low certainty conducted in the dental office that met the inclusion
criteria.

Remarks: The AAPD member survey 22 revealed that Implications for practice
only 4.3 percent of the responding pediatric dentists used For delivery of evidence-based care at an interpersonal level,
CBT to aid with behavior guidance and reported never or it is important for clinicians to value and apply the behavioral
rarely encountering any hesitancy, reluctance, or refusal by sciences just as much as they value and apply the biological
parents/caregivers. For children with anxiety, CBT is likely sciences.94 Orodental disease as well as visits to a dental office
to have varying acceptance among providers and parents can be distressing, and the dental health care providers can
and inconsistent feasibility, especially considering the likely utilize various techniques, whether nonpharmacological or
need for collaboration with a behavioral health professional pharmacological for behavior guidance before, during, or after
and/or the training and resources (including time) needed the treatment to guide the dental experience.
to implement CBT in dental office. The recommendations “Behavior guidance is described as a continuum of inter-
are based on very low certainty evidence. There is a need actions involving the dentist, dental team, patient, and the
for high quality research to substantiate the effect of CBT parent, and is directed toward communication and education,
during dental treatment. while ensuring the safety of both oral health professionals and
the child, during the delivery of medically necessary care.”7
3.2 Hypnosis Correct and efficient use of appropriate nonpharmaco-
Summary of findings: For children and adolescents under- logical behavior guidance techniques should facilitate an
going preventive visits, the systematic review6 conducted optimal experience during the child’s dental visit. Thus, the
by the WG found no studies on the effect of hypnosis techniques used should be able to effectively alleviate dental
conducted in the dental office that met the inclusion anxiety, promote cooperative behavior, reduce procedural pain
criteria. Considering the lack of data and the limited or improve the ability to cope with it, facilitate treatment
applicability of hypnosis for preventive procedures, no completion, and instill a positive dental attitude. Though clearly
recommendations were formulated. important, there is limited evidence mostly of low to very low
For children and adolescents undergoing dental treat- certainty on the effectiveness of different nonpharmacologi-
ment visits, one systematic review 4 found trivial effect cal behavior guidance techniques on the outcomes. Moreover,
on reduction in anxiety from classic directive hypnosis (a the available evidence is complicated by the demographic and
form of audio distraction) during dental local anesthesia. cultural conditions of the varied study populations. Additional
Another systematic review1 conducted in a medical setting high-quality clinically oriented research and implementation
on children undergoing needle-related procedures, reported work is needed. It is also important to note that the application
that hypnosis led to a large reduction in self-reported pain, of behavior guidance techniques is largely influenced by the
self-reported distress, and behavioral distress and a trivial dentists’ training, preferences, and intrinsic personality traits
effect on behavioral pain. and continues to evolve due to societal changes and emerging
For children and adolescents with SHCN undergoing behavioral research.
preventive or treatment visits, the systematic review9 con- Recognizing the importance of behavior guidance, the
ducted by the WG found no studies on the effect of AAPD prioritized developing the current clinical practice
hypnosis conducted in the dental office that met the guidelines that are informed by systematic reviews constituting
inclusion criteria. Considering the lack of data and the the best available evidence. However, it is important to con-
limited applicability of hypnosis studies on healthy children sider the available research evidence in context, especially with
undergoing a dental treatment visit, no recommendations respect to provider experience specific to the patient popula-
were formulated. tion. That consideration entails recognizing the influences of
Remarks: Given the lack of high-quality research, the societal factors on patient values and preferences. A person-
recommendation for use of hypnosis was based on very centered approach requires a balance of the best available
low certainty evidence. Hypnosis is likely to have varying evidence with clinical expertise and patient values and pref-
acceptance as an intervention among providers and parents/ erences, with care delivered with compassion and patience to
patients; however, it may be feasible to implement based build trust and provide an optimal dental experience.
on the resources and training needed to implement it. It is This is the first comprehensive clinical practice guideline
necessary to engage parents in shared decision making on behavior guidance of a pediatric dental patient. Weaknesses
before implementing the technique. of this guideline are inherent to the limitations found in the
systematic reviews upon which this guideline is based.
3.3 Protective stabilization
Summary of findings: The WG found no studies that met Implications for research
the inclusion criteria on use of protective stabilization in The systematic review of literature revealed a significant gap
children presenting for preventive visits, dental treatment between the behavior guidance techniques routinely practiced
visits, or for children with SHCN undergoing preventive in dental offices and those that are of research interest and
or dental treatment procedures. have been published widely. For example, about 98 percent of
Remarks: The AAPD member survey22 revealed that 30.6 pediatric dentists use communication techniques, but there is
percent of the responding pediatric dentists used protective a dearth of research published to test the effectiveness of com-
stabilization in their practice; however, they frequently munication (and specific communication skills or techniques)
encountered hesitancy, reluctance, or refusal by parents/ as a behavior guidance tool in pediatric dentistry. Similarly,
caregivers when choosing to use physical restraints. While significant research and literature is dedicated to the use of VR
protective stabilization could be considered feasible to im- glasses while the national survey of AAPD-member dentists
plement with low resource utilization, it is necessary to reveals that only 2.1 percent use it in their offices. Therefore
engage parents in shared decision making prior to its usage the topic of research interests such as VR and hypnosis have
due to its inconsistent acceptability. more supporting data compared to routinely used behavior

guidance techniques. Reasons for high research interest in The AAPD supports Medicaid coverage for the appropriate
nontraditional approaches could be due to curiosity in new use of behavior guidance techniques to improve children’s dental
technology, increased likelihood of publication, and the care experiences and attitudes toward oral health, and to reduce
challenges related to methodology and tangible metrics while the need for dental rehabilitation through more invasive tech-
studying traditional approaches. The WG discussed lack of niques such as sedation and general anesthesia.96
high-quality data for the nonpharmacological behavior guid-
ance techniques used commonly in U.S. pediatric dental offices, Work group, stakeholders, review, and quality assurance
and efforts were made to factor indirect evidence while making In December 2018, the AAPD Board of Trustees approved a
the recommendations. Due to the very low certainty of available panel nominated by the Evidence-Based Dentistry Committee
evidence, it is suggested that more well-designed studies on to develop a new evidence-based clinical practice guideline on
nonpharmacological behavior guidance interventions used alone behavior guidance of pediatric patients in the dental office. The
or in various combinations should be conducted. WG consisted of pediatric dentists and a clinical health psycho-
logist who are involved in research, education, and clinical
Cost effectiveness practice across a variety of settings, including private practice.
Cost-effectiveness for therapies with proven health benefits The recommendations were circulated for feedback from
and minimal adverse effects is an important consideration for internal stakeholders including members of the AAPD Council
clinicians, patients, and third-party payors.95 Dental practitioners on Clinical Affairs, AAPD Council on Scientific Affairs, and
treating children incur initial and recurring costs associated the AAPD Evidence-Based Dentistry Committee, as well as the
with incorporating basic and advanced non-pharmacological external stakeholders, such as the American Dental Association,
behavior guidance techniques. The costs and resources needed the American Academy of Pediatrics, the American Dental
vary based on the nonpharmacological behavior guidance tech- Hygienists Association, and the International Association of
niques utilized by the dental practitioners. Paediatric Dentistry. Revisions were made by the WG based
An efficient use of nonpharmacological behavior guidance on the feedback received and the final version of the recommen-
techniques can alleviate anxiety and pain and improve patient dations was produced. This clinical practice guideline adhered
cooperation allowing for the completion of dental treatment. to the AGREE II23 instrument to ensure methodological quality
Such techniques can also reduce the need for sedation or gener- of the reported guideline.
al anesthesia. Taken together, nonpharmacological behavior Target population(s), end users, and settings: These
guidance can result in significant cost saving while facilitating guidelines are intended primarily for pediatric dentists. General
more positive dental experiences for children in a dental home dentists, other dental specialists, dental hygienists, policy
setting, which can have lifetime benefit. makers, and parents/caregivers may also benefit from this
About one-half of Medicaid state dental plans currently document.
cover the CDT code D9920 (Behavior Management, by
report).96 However, the code for behavior management is billed Guideline implementation
infrequently with a small percent of claims per population This clinical practice guideline the AAPD’s first evidence-
served submitted annually by general dentists and pediatric based guideline on behavior guidance of pediatric patients,
dentists.97 The coverage is important to allow the providers to is published in both the journal Pediatric Dentistry and The
take necessary time to carefully and sufficiently apply the be- Reference Manual of Pediatric Dentistry. Additionally, AAPD
havior guidance techniques. members will be notified of the new guidelines via social media,
The CDT code D9920 states this code is not for billing newsletters, and presentations. The guidelines are available as
services that merely take 'extra time' without additional re- an open-access publication on the AAPD’s website. Guidelines
porting. It is indicated for a patient with SHCN or a patient are used by insurers, patients, and health care practitioners to
that is especially uncooperative and difficult to manage result- determine the quality of care. Adherence to guideline recom-
ing in the dental staff providing additional time and skill to mendations and best practices is likely to reduce inappropriate
provide treatment. When billing this code, the patient record care and improve outcomes.
must include the reason (narrative of medical necessity), the
type of technique or therapies used, and the duration of the Guideline updating process
services provided. Documentation of the specific techniques The AAPD’s Evidence-Based Dentistry Committee will monitor
used according to individual patient’s needs may also aid in the research to identify new evidence that may impact the
reproducing positive dental experiences during future visits.96 current recommendations. These recommendations will be
Providers should check their local state regulations and cover- updated five years from the time of the last systematic search
age policies to guide the appropriate use of this code in their unless the Evidence-Based Dentistry Committee determines
practices. Rules around the coverage tend to be stringent to that an earlier revision or update is warranted.
safeguard against misuse, overreporting, fraud, and abuse.
Providers should not bill Medicaid for this code for basic
behavior guidance techniques such as positive reinforcement,
parental presence, or absence. References after Appendices.

Appendices
Appendix 1. RECOMMENDATIONS ON USE OF BASIC BEHAVIOR GUIDANCE TECHNIQUES

Clinical question 2 In children and adolescents, does the use of basic behavior guidance techniques influence cooperative behavior, dental anxiety, procedural
pain, and treatment completion during the dental visit?
Communication and communicative guidance
Communication (Verbal)
Children undergoing** For children and adolescents needing preventive or dental treatment visits, given the lack of evidence, the
preventive visits Workgroup was unable to formulate a recommendation. The Workgroup recognizes verbal communication
Children undergoing† is universally applied for all patients and integral for success of accompanying behavior guidance strategies.
dental treatment visits It is suggested that clinicians use a verbal communication strategy that is culturally sensitive and appropriate
for the patient’s age, cognitive development, and health condition to optimize the child’s behavior during
Children with SHCN‡ the dental visit.
Communication (Nonverbal)
Children undergoing** For children and adolescents needing preventive care visits, the use of nonverbal communication may have a Conditional Very Low
preventive visits trivial effect on reduction in fear and a small effect on improvement in behavior related to fear. The Workgroup
recognizes that nonverbal communication is universally applied for all patients and integral for the success of
accompanying behavior guidance strategies. The Workgroup suggests that clinicians use age-appropriate non-
verbal communication in a culturally sensitive manner to optimize the child’s behavior during the dental visit.
Children undergoing† For children and adolescents needing dental treatment visits, given the lack of evidence, the Workgroup was
dental treatment visits unable to formulate a recommendation. The Workgroup recognizes that nonverbal communication is
universally applied for all patients and integral for the success of accompanying behavior guidance strategies.
It is suggested that clinicians use nonverbal communication strategies that are appropriate given the patient’s
age, cognitive development, and health condition, and are culturally sensitive to optimize the child’s behavior
during the dental visit.
Children with SHCN‡ For children and adolescents with SHCN needing preventive or dental treatment visits, given the lack of
undergoing preventive evidence, the Workgroup was unable to formulate a recommendation. The Workgroup recognizes that non-
or dental treatment verbal communication is universally applied for all patients and integral for the success of accompanying
visits behavior guidance strategies. It is suggested that clinicians use nonverbal communication strategies that are
culturally sensitive and appropriate for the patient’s age, cognitive development, and health condition to
optimize the child’s behavior during the dental visit.
Tell-show-do (TSD) and its modifications
Children undergoing** For children and adolescents needing preventive care visits, the use of TSD and its modifications may result Conditional Very Low
preventive visits in a variable (trivial to large) effect on reduction in anxiety as compared to no intervention. The Workgroup
recognizes that TSD is among key basic behavior guidance techniques utilized and suggests that the clinicians
implement TSD strategies (using euphemistic/age-appropriate terms) considering their expertise and the parent/
Children undergoing† For children and adolescents needing dental treatment visits, the use of TSD and its modifications may Conditional Very Low
dental treatment visits have a trivial effect on improvement in cooperative behavior, trivial reduction in pain, and a variable (trivial
to large) effect on reduction in anxiety as compared to no intervention. Clinicians may choose to implement
TSD strategies (using euphemistic/age-appropriate terms) considering their expertise and the parent/patient
values and preferences.
undergoing preventive or evidence, the Workgroup was unable to formulate a recommendation. The decision on use of TSD (using
dental treatment visits euphemistic/age-appropriate terms) and its modifications should be made based on clinical expertise, individual
Ask-tell-ask
Children undergoing** Given the lack of evidence, the Workgroup was unable to formulate a recommendation. The decision on use
preventive visits of Ask-tell-ask should be made based on clinical expertise, individual patient factors, and parent/patient
Children undergoing† values and preferences.
Voice control and its modifications
Children undergoing** For children and adolescents needing preventive or dental treatment visits, the use of increased volume as a Conditional Very Low
preventive visits voice control technique may have a trivial effect on improvement in cooperative behavior and a trivial reduction
Children undergoing† in anxiety. Considering the lower parental acceptance, the Workgroup suggests use of voice control and its
dental treatment visits modifications only after engaging parents in shared decision making.
undergoing preventive or evidence, the Workgroup was unable to formulate a recommendation. The decision on use of voice control
dental treatment visits and its modifications should be made based on clinical expertise, individual patient factors, and shared decision
making based on parent/patient values and preferences.
Appendix 1. CONTINUED
Positive reinforcement and descriptive praise

Children undergoing** For children and adolescents needing preventive care visits, positive reinforcement strategies may have a small Conditional Moderate
preventive visits effect on reduction in anxiety compared to no intervention. The Workgroup recognizes that positive reinforce-
ment is among key basic behavior guidance techniques and suggests that the clinicians implement positive
reinforcement strategies considering their clinical expertise and parent/patient values and preferences.
Children undergoing† For children and adolescents needing dental treatment visits, positive reinforcement strategies may result in a Conditional Very Low
dental treatment visits variable (trivial to large) reduction in fear and have a trivial effect on reduction in anxiety and a trivial effect on
improvement in cooperative behavior compared to no intervention. The Workgroup recognizes that positive
reinforcement is among key basic behavior guidance techniques and suggests that clinicians implement positive
reinforcement strategies considering their clinical expertise and parent/patient values and preferences.
Children with SHCN‡ For children and adolescents with SHCN needing preventive or dental treatment visits, the use of positive Conditional Very Low
undergoing preventive or reinforcement strategies may result in variable reduction in anxiety or improvement in cooperative behavior;
dental treatment visits however, the decision should be made based on clinical expertise, individual patient factors, and parent/patient
Memory restructuring
Children undergoing** For children and adolescents needing preventive care visits, given the lack of evidence, the Workgroup was unable
preventive visits to formulate a recommendation. The decision on use of memory restructuring strategies if indicated should
be made based on clinical expertise, individual patient factors, and parent/patient values and preferences.
Children undergoing† For children and adolescents needing dental treatment visits, memory restructuring strategies may have a trivial Conditional Very Low
dental treatment visits effect on reduction in fear, and a trivial effect on reduction in pain compared to no intervention. Clinicians
may choose to implement these strategies considering their expertise, training, and parent/patient values and
preferences.
undergoing preventive or evidence, the Workgroup wasunable to formulate a recommendation. The decision on use of memory restruc-
dental treatment visits turing strategies if indicated should be made based on clinical expertise, individual patient factors, and parent/
Biofeedback relaxation
Children undergoing** For children and adolescents needing preventive care visits, given the lack of evidence, the Workgroup was
preventive visits unable to formulate a recommendation. The decision on use of biofeedback relaxation strategies should be
made based on clinical expertise, individual patient factors, and parent/patient values and preferences.
Children undergoing† For children and adolescents needing dental treatment visits, biofeedback relaxation strategies may result in a Conditional Very Low
dental treatment visits variable (trivial to large) reduction in anxiety compared to no intervention. Clinicians may choose to implement
biofeedback relaxation strategies considering costs and resources involved and parent/patient values and
preferences.
undergoing preventive or evidence, the Workgroup was unable to formulate a recommendation. The decision on use of biofeedback
dental treatment visits relaxation strategies should be made based on clinical expertise, individual patient factors, and parent/patient
Breathing relaxation
Children undergoing** For children and adolescents needing preventive or dental treatment visits, breathing relaxation strategies may Conditional Very Low
preventive visits have a variable (trivial to large) effect on reduction in anxiety, a trivial effect on reduction in fear and pain, and
Children undergoing† a large effect on improvement in happiness after treatment compared to no intervention. Clinicians may choose
dental treatment visits to implement breathing relaxation strategies considering their expertise and the parent/patient values and
preferences.
undergoing preventive or evidence, the Workgroup was unable to formulate a recommendation. The decision on use of breathing relax-
dental treatment visits ation strategies should be made based on clinical expertise, individual patient factors, and parent/patient values
and preferences.
Desensitization
Children undergoing** For all children and adolescents needing preventive or dental treatment visits, the use of desensitization tech- Conditional Very Low
preventive visits niques may have a small effect on improvement in cooperative behavior compared to no intervention. The
Children undergoing† Workgroup recognizes that desensitization is among key basic behavior guidance techniques utilized and sug-
dental treatment visits gests that the clinicians implement desensitization strategies considering their expertise and parent/patient
* Assessment of effect=large effect, moderate effect, small important (statistically significant) effect, or trivial (small unimportant
or statistically nonsignificant or no effect).
Table continued on the next page.

† Dental treatment visits=included procedures such as sealants, restorative care, use of local anesthesia, pulp therapies, and
simple extractions.

Enhancing control
preventive visits of enhancing control should be made based on clinical expertise, individual patient factors, and parent/patient
Children undergoing† values and preferences.
Distraction techniques
Magic tricks
Children undergoing** For children and adolescents needing preventive care visits, the use of magic tricks as a distraction tech- Conditional Very Low
preventive visits nique may have a trivial effect on improvement in cooperative behavior and a trivial effect on reduction in
anxiety; however, it may result in a variable (small to large) improvement in readiness to accept dental
treatment or sit on the dental chair compared to no intervention. Clinicians may choose to implement magic
tricks considering costs, training, and resources involved and parent/patient values and preferences.
Children undergoing† For children and adolescents needing dental treatment visits, there is lack of evidence on reduction in Conditional Very Low
dental treatment visits anxiety or improvement in cooperative behavior related to the use of magic tricks as a distraction tech-
nique; however, it may have a variable (small to large) effect on improvement in readiness to accept dental
treatment or sit on the dental chair compared to no intervention. Clinicians may choose to implement
magic tricks considering costs and resources involved and parent/patient values and preferences.
undergoing preventive or evidence, the Workgroup was unable to formulate a recommendation. The decision on use of magic tricks
dental treatment visits as a distraction technique should be made based on clinical expertise, individual patient factors, and parent/
Traditional distraction techniques
Children undergoing** For children and adolescents undergoing preventive or dental treatment visits, there is limited evidence to
preventive visits make a recommendation substantiating the effect of mirror and conversation, toys, and books/children’s
Children undergoing† story on reducing anxiety and improving cooperative behavior. The decision on use of these strategies should
dental treatment visits be made based on clinical expertise, individual patient factors, and parent/patient values and preferences.
Children undergoing† For children and adolescents undergoing dental local anesthesia, use of counter-stimulation or distraction Conditional Very Low
dental treatment visits techniques (pulling the mucosa, intraoral or extraoral finger vibration adjacent to the injection site during
(dental local anesthesia) delivery of local anesthetic, and distraction techniques by asking the patient to do breathing exercises or to
draw letters in the air with their feet) during delivery of local anesthetic may result in a large reduction in
pain and anxiety; however, there is no evidence of its effect on improving cooperative behavior. Clinicians
may choose to use traditional distraction strategies considering their expertise and parent/patient values and
preferences.
For children and adolescents undergoing dental local anesthesia, camouflaging of the syringe may result in Conditional Very Low
large reduction in pain-related behavior anxiety and improve overall cooperative behavior. It is suggested that
clinicians use their expertise to incorporate strategies to camouflage the syringe during the delivery of local
anesthesia.
undergoing preventive or evidence, the Workgroup was unable to formulate a recommendation. The decision on use of distraction
dental treatment visits strategies should be made based on clinical expertise, individual patient factors, and parent/patient values
and preferences.
Technology-based distractions
Children undergoing** For children and adolescents needing preventive care visits, use of mobile dental apps may have a variable Conditional Very Low
preventive visits (trivial to large) effect on reduction in anxiety, and a small effect on improvement in readiness to accept
treatment compared to no intervention. Clinicians may choose to implement mobile app-based strategies
considering their expertise, costs, resources, and parent/patient values and preferences.
Children undergoing† For children and adolescents needing dental treatment visits, use of audio songs (through computer screen) Conditional Very Low
dental treatment visits may have a small effect on reduction in anxiety; however, there is no evidence of effect in improving co-
(restorative) operative behavior. Clinicians may choose to implement music distraction considering their experience, child
sensitivities, resources, and parent/patient values and preferences.
* effect).
Assessment of effect=large effect, moderate effect, small important (statistically significant) effect, or trivial (small unimportant or statistically nonsignificant or no


Technology-based distractions (continued)
Children undergoing† In children and adolescents needing dental treatment visits, use of virtual reality (VR) glasses may cause Conditional Moderate
dental treatment visits a trivial effect on reduction in anxiety and small effect on improvement in cooperative behavior at the
(restorative) time of caries removal; a trivial effect on anxiety and cooperative behavior during the placement of rubber
dam; and a variable effect on reduction in anxiety and a large reduction in pain perception during restorative
procedures. Clinicians may choose to use VR glasses based on their expertise, available resources, and by
shared decision making with parents while considering individual circumstances pertaining to child’s
sensitivities, individual patient factors, and patient preferences.
For children and adolescents needing dental treatment visits, use of audiovisual distraction (AVD)/3D glasses/ Conditional Very Low
eyeglasses may produce a variable (trivial to small) effect in reducing anxiety and improving cooperative
behavior. Clinicians may choose to implement AVD, 3D glasses/eyeglasses considering their expertise, costs,
child sensitivities, resources, and parent/patient values and preferences.
Children undergoing† For children and adolescents with positive baseline behavior needing dental local anesthesia, use of music Conditional Very Low
dental treatment visits distraction may have a large effect on reduction in anxiety and improving pain-related behavior. Evidence is
(dental local anesthesia) uncertain regarding the effect of music distraction on children with baseline negative behavior. Clinicians
may choose to implement music distraction considering their experience, child sensitivities, resources, and
parent/patient values and preferences.
For children and adolescents with positive baseline behavior needing dental local anesthesia, use of AVD Conditional Very Low
using 3D Glasses may have a large effect on reduction in anxiety, an improvement in pain-related behavior,
and a reduction in postinjection anxiety. Evidence is uncertain regarding the effect of audiovisual distraction
on children with baseline negative behavior. Clinicians may choose to implement AVDconsidering their
experience, child sensitivities, resources, and the parent/patient values and preferences.
For children and adolescents with positive baseline behavior needing dental local anesthesia, use of an Conditional Very Low
electronic Tablet may have a trivial or no effect on reducing pain experience; however, it has a small effect
on improving pain related behavior at the time of administration of injection. Clinicians may choose to use
a Tablet considering their experience, child sensitivities, resources, and the parent/patient values and
preferences.
For children younger than 12 years of age needing dental local anesthesia, use of VR glasses or VR box Conditional Very Low
may result in trivial or no benefit in reducing anxiety and pain perception. Clinicians may use VR
technology based on their expertise, assessment of risks and benefits, available resources, and after shared
decision making with parents while considering individual circumstances pertaining to the child’s sensiti-
vities, temperament, cooperativeness, anxiety/fear, systemic health, and past experiences.
undergoing preventive evidence, the Workgroup was unable to formulate a recommendation. The decision on use of mobile dental
or dental treatment apps or VR glasses should be made based on clinical expertise, individual patient factors and sensitivities, and
visits parent/patient values and preferences.
For children and adolescents with SCHN needing preventive or dental treatment visits, use of audiovisual Conditional Very Low
distraction techniques may have a trivial effect on reduction in anxiety, a trivial effect on improvement in
cooperative behavior, and a variable (trivial to large) effect on reduction in pain. Clinicians may choose to
implement AVD strategies considering their expertise, costs, resources, individual patient factors and sensiti-
vities, and parent/patient values and preferences.
Parental absence or presence
Children undergoing** For children and adolescents undergoing preventive or dental treatment visits, the presence of parents in Conditional Very Low
preventive visits the dental operatory may result in trivial or no effect on improvement in child’s cooperative behavior and
perception of treatment, or in reduction of anxiety and fear. Clinicians may choose to have parents in the
Children undergoing† operatory based on their expertise and shared decision making with parents while considering individual
dental treatment visits circumstances pertaining to the child’s temperament, cooperativeness, anxiety/fear, systemic health, past
experiences, and the treatment needed.
undergoing preventive or evidence, the Workgroup was unable to formulate a recommendation. The decision on presence or absence
dental treatment visits of parents in the dental operatory should be made based on clinical expertise, individual patient factors, and
parent/patient values and preferences.
Combined nonpharmacological behavior therapies
Children undergoing** For children and adolescents needing preventive or dental treatment visits, combined therapy of TSD and Conditional Very Low
preventive visits AVD may have a variable (trivial to large) effect on reduction in anxiety compared to no intervention. A
combined therapy of TSD with active parental presence may result in small effect on reduction of anxiety
and small improvement in cooperative behavior. Clinicians may choose to combine strategies considering
their expertise, costs, resources, and the parent/patient values and preferences.
Children with SHCN‡ For children and adolescents with SHCN needing preventive or dental treatment visits, given the lack of evidence,
undergoing preventive or the Workgroup was unable to formulate a recommendation. The decision on use of combined therapies should
dental treatment visits be made based on clinical expertise, individual patient factors, and parent/patient values and preferences.
Table continued on the next page.

Sensory-adapted dental environment (SADE)
Children undergoing** Given the lack of evidence, the Workgroup is unable to formulate a recommendation. The decision on use of
preventive visits SADE for healthy children undergoing preventive or treatment visits should be made based on clinical
Children undergoing† expertise, individual patient factors, and parent/patient values and preferences.
Children with SHCN‡ For children and adolescents with SHCN needing preventive or dental treatment visits, SADE may have a Conditional Very Low
undergoing preventive variable (trivial to large) effect on reduction in anxiety and a variable (trivial to large) effect on improvement
or dental treatment in cooperative behavior compared to regular dental environment. Clinicians may choose to implement SADE
visits strategies considering their expertise, costs, resources, the child’s sensitivities, individual patient factors and
the parent/patient values and preferences.
Animal assisted therapy (AAT)
Children undergoing** For children and adolescents needing preventive or dental treatment visits, use of AAT may have a variable Conditional Very Low
preventive visits (trivial to large) effect on reduction in anxiety, and a small effect on improvement in cooperative behavior
Children undergoing† compared to no intervention. Clinicians may choose to implement AAT considering their expertise, costs,
dental treatment visits resources, local regulations, and the parent/patient values and preferences.
undergoing preventive or evidence, the Workgroup was unable to formulate a recommendation. The decision on use of AAT should
dental treatment visits be made based on clinical expertise, costs, resources, local regulations, individual patient factors, and parent/
Picture exchange communication system (PECS)
preventive visits of PECS should be made based on clinical expertise, individual patient factors, and parent/patient values
and preferences.
Children with SHCN‡ For children and adolescents with SHCN needing preventive or dental treatment visits, there is limited Conditional Very Low
undergoing preventive evidence to support PECS. Current data suggests that PECS may result in a lesser reduction in anxiety
or dental treatment compared to mobile apps. Clinicians may choose to implement PECS strategies considering their expertise,
visits costs, resources, and parent/patient values and preferences.
* effect).
Assessment of effect=large effect, moderate effect, small important (statistically significant) effect, or trivial (small unimportant or statistically nonsignificant or no

Appendix 2. RECOMMENDATIONS ON USE OF ADVANCED NONPHARMACOLOGICAL BEHAVIOR GUIDANCE TECHNIQUES

Clinical question 3 In children and adolescents, does the use of advanced nonpharmacological behavior guidance techniques influence cooperative
behavior, dental anxiety, procedural pain, and treatment completion during the dental visit?
Statement * Strength Certainty

Cognitive behavior therapy (CBT)
Children undergoing** For children and adolescents needing preventive or dental treatment visits, use of CBT when indi- Conditional Very Low
preventive visits cated may result in a variable (trivial to large) reduction in anxiety, large reduction in phobia, and a
variable (trivial to large) improvement in cooperative behavior compared to no intervention. Clinicians
Children undergoing† may choose to implement CBT strategies for anxious patients in collaboration with a behavioral health
dental treatment visits professional considering their expertise, costs, resources, training, parent/patient values and preferences.
Children with SHCN‡ For children and adolescents with SHCN needing preventive or dental treatment visits, given the lack
undergoing preventive or of evidence, the Workgroup was unable to formulate a recommendation. The decision on use of CBT
dental treatment visits should be made based on clinical expertise, consultation with a behavioral health professional, individual
Hypnosis
Children undergoing** Given the lack of evidence and the unclear applicability, the Workgroup was unable to formulate
preventive visits a recommendation. The decision on use of hypnosis during preventive visits should be made based
on clinical expertise, individual patient factors, and parent/patient values and preferences.

Hypnosis - continued
Children undergoing† For children and adolescents needing dental local anesthesia, use of hypnosis alone or in com- Conditional Very Low
dental treatment visits bination with conventional behavior modification techniques may result in a variable (trivial
to large) reduction in anxiety and pain; however, there is no evidence of effect in improving
cooperative behavior or behavioral pain. Clinicians may choose to use hypnosis during treat-
ment visits considering their expertise, training and resources involved, and after engaging
parents using a shared decision model.
Children with SHCN‡ Given the lack of evidence and the unclear applicability, the Workgroup is unable to formulate
undergoing preventive or a recommendation. The decision on use of hypnosis for children with SHCN should be made
dental treatment visits based on clinical expertise, individual patient factors, and parent/patient values and preferences.
Protective stabilization
Children undergoing** Given the lack of evidence, the Workgroup is unable to formulate a recommendation. The
preventive visits decision on use of protective stabilization should be made based on clinical expertise, individual
patient factors including medical history, and parent/patient values and preferences.
* no
Assessment of effect=large effect, moderate effect, small important (statistically significant) effect, or trivial (small unimportant or statistically nonsignificant or
effect).
Appendix 3. Behavior guidance techniques for a pediatric dental patient
Abbreviations in figure:
AAT=Animal-assisted
therapy;
AV=Audiovisual;
CBT=Cognitive behavior
therapy;
PECS=Picture exchange
communication system;
SADE=Sensory-adapted
dental environments;
VR=Virtual reality.

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PEDIATRIC DENTISTRY V 45 / NO 5 SEP / OCT 23

RECOMMENDATIONS: CLINICAL PRACTICE GUIDELINE O

Nonpharmacological Behavior Guidance for the Pediatric Dental Patient

Plain language summary basic and advanced nonpharmacological behavior guidance

NONPHARMACOLOGICAL BEHAVIOR GUIDANCE 385

techniques), the use of animal assisted therapy, and combined

386 NONPHARMACOLOGICAL BEHAVIOR GUIDANCE

phobia), and procedural pain as

NONPHARMACOLOGICAL BEHAVIOR GUIDANCE 387

Table 1. AMSTAR 2.0 ASSESSMENT OF SELECTED SYSTEMATIC REVIEWS*

388 NONPHARMACOLOGICAL BEHAVIOR GUIDANCE

Table 2. GRADE INTERPRETATION OF STRENGTH OF RECOMMENDATIONS 21 *

Implications Strong recommendations Conditional recommendations

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Appendix 1. RECOMMENDATIONS ON USE OF BASIC BEHAVIOR GUIDANCE TECHNIQUES

Positive reinforcement and descriptive praise

** Preventive visits=included procedures such as examination, prophylaxis, fluoride, radiographs.

NONPHARMACOLOGICAL BEHAVIOR GUIDANCE 403

** Preventive visits=included procedures such as examination, prophylaxis, fluoride, radiographs.

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Table continued on the next page.

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** Preventive visits=included procedures such as examination, prophylaxis, fluoride, radiographs.

Appendix 2. RECOMMENDATIONS ON USE OF ADVANCED NONPHARMACOLOGICAL BEHAVIOR GUIDANCE TECHNIQUES

Statement * Strength Certainty

406 NONPHARMACOLOGICAL BEHAVIOR GUIDANCE

Appendix 3. Behavior guidance techniques for a pediatric dental patient

NONPHARMACOLOGICAL BEHAVIOR GUIDANCE 407

References 16. Liu Y, Gu Z, Wang Y, et al. Effect of audiovisual distrac-

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