B E H AV I O R G U I D A N C E T E C H N I Q U E I N P E D I AT R I C D E N T I S T RY
ARTICLE
ABSTRACT
This study compared the parental
acceptance of pediatric behavior guid-
ance techniques (BGT). Forty parents of
children without disabilities (Group A)
and another 40 parents of children with
disabilities (Group B) were selected.
Each BGT was explained by a single
examiner and it was presented together
with a photograph album. After that par-
ents evaluated the acceptance in: totally
unacceptable, somewhat acceptable,
acceptable, and totally acceptable.
Results indicated that in Group A, the
BGT based on communicative guidance
was accepted by most participants. In
Group B, just one mother considered
totally unacceptable the voice control
method and other two, tell-show-do. For
both groups, the general anesthesia was
the less accepted BGT. There was statis-
tically significant difference in
acceptance for protective stabilization
with a restrictive device in Group B.
Children’s parents with and without dis-
abilities accepted behavioral guidance
techniques, but basic techniques
showed higher rates of acceptance than
advanced techniques.
KEY WORDS: pediatric dentistry,
behavior management, intellectual and
developmental disabilities
©2013 Special Care Dentistry Association and Wiley Periodicals, Inc.
DOI: 10.1111/scd.12022
scd_12022.indd 213
Behavior guidance techniques in
Pediatric Dentistry: attitudes of parents
of children with disabilities and without
disabilities
Alessandra Maia de Castro, PhD; Fabiana Sodré de Oliveira, PhD;
Myrian Stella de Paiva Novaes, PhD; Danielly Cunha Araújo Ferreira, MS*
Universidade Federal de Uberlândia, Odontopediatria, Uberlândia, Minas Gerais, Brazil.
*Corresponding author e-mail: daniellycaf@hotmail.com
Spec Care Dentist 33(5): 213-217, 2013
In t r od uct ion
For some patients, dental treatment represents a threatening event, and generally
involves fear, anxiety, pain, and discomfort. This is no different for pediatric patients
who are neurologically challenged.1 The techniques that manage behavior and alleviate
anxiety in order to perform treatment safely and efficiently are very important.2
As children exhibit a broad range in stabilization, sedation, and general
their physical, mental, intellectual, emo- anesthesia (Figure 1).
tional and social development, and According to the recommendations of
diversity of attitudes, it is important that the AAPD (2010/11), communicative
dentists have at their disposal a wide management requires no specific consent.2
range of behavior guidance approaches All others BGT require informed consent
to meet the needs of each child.2 from parents or legal guardian, which
Some behavior guidance techniques must be documented in the patient record.
(BGT) are intended to maintain commu- In the past, parental consent about
nication, while others are used to the BGT technique selected was
extinguish inappropriate behavior and neglected. However, many pediatric den-
then establish communication.2 tists are concerned with the ethical and
According to guidelines of the legal issues regarding these techniques.3,4
American Academy of Pediatric Dentistry It has been recommended that it is nec-
(AAPD),2 BGT include basic and essary to obtain a specific consent for
advanced techniques. Basic BGT include behavior management techniques, espe-
communication and communicative cially for restraint.5 Several authors have
guidance (voice control, nonverbal com- documented that informed parents had
munication, tell-show-do, positive demonstrated significantly more accept-
reinforcement, distraction, and parental ance of BGT than uninformed
presence/absence) and nitrous oxide/ parents.4,6-9 For communicative guid-
oxygen analgesic. These techniques form ance, no specific documentation or
the foundation for all of the management consent is necessary prior to use
activities provided by the dentist. although it may be discussed with
However, some children require more parents, however dentists must obtain
advanced techniques, e.g., protective informed consent for advanced BGT.2
S p e c C a r e D e n t i s t 3 3 ( 5 ) 2 0 1 3 213
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 B E H AV I O R G U I D A N C E T E C H N I Q U E I N P E D I AT R I C D E N T I S T RY
Basic BGT
Voice control – VC
Non verbal communication – NVC
Tell-show-do – TSD
Positive reinforcement – PR
Distraction – DIS
Parental presence/absence – PP/A
Nitrous oxide sedation – NOS
Figure 1. Behavior guidance techniques.
Studies of parental attitudes toward
BGT present different methods to explain
the techniques some videotapes, with or
without explanations;6,7,9 and other writ-
ten or oral presentations.4 One study
used a photograph album with pictures
of a dentist, a child and a dental assistant
showing a sequence of tell-show-do,
voice control, physical restraint and
hand-over-mouth.10
Visual analog scale is one of the most
used way to assess the parental accept-
ance of BGT,3,6,7,11,12 but it can be also
evaluated in three or four criteria of
acceptance.9,10
The opinion of parents of children
with and without disabilities about the
use of BGT was compared by indicating
the level of acceptance of technical hand-
over-mouth, papoose-board restraint,
sedation and general anesthesia for a
check-up/cleaning, dental filling, or treat-
ment for toothache. There was not a
difference statistically significant between
the opinions of parents of children with
and without disabilities about their
acceptance of BGT.12
BGT may never be equally accepted,
and some are considered controversial
and unacceptable. Since developmental
delay, physical/mental disorder, and acute
or chronic disease are reasons for child
noncompliance, the purpose of this study
was to compare the attitudes of parents
of children with and without disabilities
toward pediatric dental BGT.
Mater ial and me tho ds
Subjects and methods
This study was carried out in the Faculty
of Dentistry of the Federal University of
Uberlândia (Brazil). At first, the project
214 S p e c C a r e D e n t i s t 3 3 ( 5 ) 2 0 1 3
scd_12022.indd 214
Advanced BGT
Protective stabilization with a restrictive
device – PSRD
Protective stabilization performed by
parent – PSP
Hand-over-mouth-exercise – HOM
Sedation – SED
General anesthesia – GAN
was submitted to the Committee of
Ethics in Human Research and was
approved (protocol number: 054/04).
The sample selection was a conveni-
ence sample. The parents that were
present at the reception room of the
Pediatric Dentistry Clinic with their chil-
dren were invited to participate in the
study. Then, a written informed consent
was read and parents signed it if they
were in agreement with the study.
Parents that were blind, deaf, with lan-
guage difficulties or unable to read and
those that did not accept to participate
were excluded.
Children selected, ranged from 4 to
8 years, were present at the Faculty of
Dentistry of Federal University of
Uberlândia (Minas Gerais- Brazil) for
preventive or restorative treatment. All
patients had already dental experience.
The dental treatment offered had no cost
for parents. All patients lived in an urban
and fluoridated area.
The sample consisted of 40 parents
accompanying their children to the
Pediatric Dentistry Clinic (Group A); and
another 40 parents were selected from a
Dental Care Program for Infants and
Children with Special Needs (Group B).
This group included children with a wide
range of disabilities; including Down
syndrome, cerebral palsy, aged between 3
to 10 years.
Demographic information about par-
ents was collected via a questionnaire
and included: age, gender, marital status,
and income level based on the economic
classification criteria of Brazil.
An album, containing colored photo-
graphs (15 × 18 mm), with pictures of a
dentist, a child, and a dental assistant
showing each one of BGT, was specifi-
cally produced and it was presented
Behavior guidance technique in pediatric dentistry
together with a standardized description
of techniques based on AAPD guidelines.2
Just one graduate student explained
each of the BGT to a corresponding
parent and showed the related photo-
graph. The BGT were presented in a fixed
order (voice control, tell-show-do, posi-
tive reinforcement, distraction, nitrous
oxide sedation, protective stabilization
with a restrictive device, protective stabi-
lization performed by parent and general
anesthesia). After viewing each photo-
graph, parents immediately evaluated the
BGT indicating in a form the acceptance
level according to the following criteria:
totally unacceptable, somewhat accepta-
ble, acceptable, totally acceptable. This
was carried out individually in a waiting
room of the clinic.
Analysis of data included tabulation
of frequency distributions for socio-
demographic information obtained from
the questionnaires. The Mann-Whitney
test was used to compare parental atti-
tudes toward each BGT.
R es ul t s
Demographic results
Participants were all female of low and
lower middle incomes (mean age = 33.7
in Group A and 32.0 in Group B). In
Group B, 42.5% of mothers were single,
and it was statistically different from
Group A (Table 1).
Parental attitudes toward BGT
Group A
In Group A, distraction and positive
reinforcement were considered totally
acceptable for 55.0%, and tell-show-do
technique for 52.5%. Voice control and
protective stabilization by parent was
acceptable for 52.5% of participants.
Nitrous oxide analgesia was totally
acceptable for 20.0% of mothers and
acceptable for 17.5%. The protective
stabilization with a restrictive device
was acceptable for 27.5% and somewhat
acceptable for 35.0% of mothers.
Protective stabilization performed by
parent was acceptable for 52.5% and
totally acceptable for 27.5% of mothers.
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General anesthesia was totally unaccepta-

Table 1. Sociodemographic information of parents participating
in this study. ble by 30.0% of mothers and somewhat
acceptable for 42.5% (Table 2).
Variable Summary
Group A Group B
Group B
Gender 40 female 40 female For Group B, distraction, tell-show-do,
Mean age 33.7 32.0 and positive reinforcement were totally
Socioeconomic status acceptable for 60.0%, 57.5%, and 55.0%,
A (high class) 0 0 0 0
respectively). The protective stabilization
with a restrictive device, immobilization
B (middle class) 8 20.0% 3 7.5%
performed by mother or legal guardian,
C (low middle class) 21 52.5% 24 60.0% and voice control were considered
D (low class) 11 27.5% 13 32.5% acceptable for 55.0%, 57.5%, and 40.0%
Marital status 33 (82.5%) married 21 (52.5%) Married of participants, respectively). Few moth-
ers (7.5%) assessed nitrous oxide
4 (10.0%) single* 17 (42.5%) single*
analgesia as totally unacceptable, just
3 (7.5%) divorced 1 (2.5%) divorced like general anesthesia (15.0%) (Table 3).
0 (0%) widowed 1 (2.5%) widowed
*p < .05. Comparison of parental
attitudes toward BGT
When acceptance rating of each BGT was
Table 2. Parental attitudes of children without disabilities toward compared between two groups, the sta-
behavior guidance techniques used in Pediatric Dentistry (Group A). tistical analysis showed that there was no
BGT T.U. n (%) S.A. n (%) A n (%) T.A. n (%) statistical difference for most of methods,
exception to protective stabilization with
VC 0 (0.0%) 1 (2.5%) 21 (52.5%) 18 (45.0%)
a restrictive device (p < .05).
TSD 0 (0.0%) 2 (5.0%) 17 (42.5%) 21 (52.5%)
PR 0 (0.0%) 1 (2.5%) 17 (42.5%) 22 (55.0%)
DIS 0 (0.0%) 0 (0.0%) 18 (45.0%) 22 (55.0%) D is cus s ion
NOS 3 (7.5%) 16 (40.0%) 13 (32.5%) 8 (20.0%) This study compared attitudes of parents
of children with and without disabilities
PSRD* 8 (20.0%) 14 (35.0%) 11 (27.5%) 7 (17.5%)
toward BGT used in Pediatric Dentistry.
PSP 3 (7.5%) 5 (12.5%) 21 (52.5%) 11 (27.5%) All participants were female, which
GAN 12 (30.0%) 17 (42.5%) 5 (12.5%) 6 (15.0%) can be justified, since mothers are the
*p < .05. main caretakers of children and who
T.U., totally unacceptable; S.A., somewhat acceptable. usually accompany their children on cus-
A., acceptable; T.A., totally acceptable. tomary activities, including dental
treatment.10
As dental literature has shown, par-
Table 3. Parental attitudes of children with disabilities toward ents who received a previous explanation
behavior guidance techniques used in Pediatric Dentistry (Group B).
showed more acceptance of BGT than
BGT T.U. n (%) S.A. n (%) A. n (%) T.A. n (%) uninformed.3,4,6-9 In this study, all parents
VC 1 (2.5%) 6 (15.0%) 17 (42.5%) 16 (40.0%) received the oral explanation. Each BGT
TSD 2 (5.0%) 3 (7.5%) 12 (30.0%) 23 (57.5%) was represented by photographs, like
Ramos et al.10 The videotapes were used
PR 0 (0.0%) 1 (2.5%) 17 (42.5%) 22 (55.0%)
in many studies,3,4,6,7,10-12 but Allen et al.4
DIS 0 (0.0%) 1 (2.5%) 15 (37.5%) 24 (60.0%) observed that handing parents a written
NOS 3 (7.5%) 8 (20.0%) 21 (52.5%) 8 (20.0%) form to read independently and sign or
PSRD* 1 (2.5%) 6 (15.0%) 22 (55.0%) 11 (27.5%) having them watch videos depicting the
techniques did not appear to be adequate
PSP 1 (2.5%) 4 (10.0%) 23 (57.5%) 12 (30.0%)
enough to ensure that parents were well
GAN 6 (15.0%) 15 (37.5%) 14 (35.0%) 5 (12.5%) informed and likely to consent. It should
*p < .05. be noted that questionnaire completion
T.U., totally unacceptable; S.A., somewhat acceptable. was performed individually, since it has
A., acceptable; T.A., totally acceptable. been demonstrated that group viewers of

de Castro et al. S p e c C a r e D e n t i s t 3 3 ( 5 ) 2 0 1 3 215

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 B E H AV I O R G U I D A N C E T E C H N I Q U E I N P E D I AT R I C D E N T I S T RY
BGT videotapes showed less acceptance
than the individual viewers.9,11
There is a trend of parents from the
low social status to be more accepting of
techniques than parents from high social
status. In our study, most mothers were
from low and lower middle incomes, and
they were receptive to most BGT.
However, it should be emphasized that
parents should be always informed about
BGT selected, irrespective of social status
or level education.
Few reports about BGT acceptance
by parents of children with disabilities
are published in the literature,10,12,13 one
was performed in 1995 and BGT evalu-
ated were papoose board,
hand-over-mouth, conscious sedation
and general anesthesia for different
dental procedures.12
In 2005, another study evaluated the
acceptance of four techniques employed
for dental treatment of children with cleft
palate. The results showed that there was
a large acceptance for all techniques, tell-
show-do (98%), voice control (96%),
physical restrain (81%), and hand-over-
mouth (85%). The reason for rejecting
the methods was the possibility of induc-
ing fear or trauma to the child. So, this
reinforced the need to provide previous
and detailed explanations to caretakers.10
More recently, parental attitudes
regarding behavior guidance of dental
patients with autism were evaluated. The
most acceptable techniques were positive
verbal reinforcement, tell-show-do, dis-
traction, rewards, general anesthesia, and
hand holding by parent. Parental percep-
tions of BGT were influenced by whether
or not they had been used for their child.13
In our study, acceptance of communi-
cative guidance techniques was also
evaluated. These techniques should be
used when dealing with children with
disabilities. It must be pointed out that a
practitioner should be able to assess a
child’s mental/physical disability, com-
prehension skills, oral and general health
conditions in order to select behavior
guidance approaches most appropriate to
each situation.
Tell-show-do, distraction, and posi-
tive reinforcement displayed a high level
of acceptance for both groups. Likewise,
216 S p e c C a r e D e n t i s t 3 3 ( 5 ) 2 0 1 3
scd_12022.indd 216
Alammouri13 also founded these tech-
niques were the most readily acceptable.
Voice control is a controlled altera-
tion of voice volume, tone, or pace to
influence and direct patient’s behavior.2
Although this technique does not
restrain the child physically, it is consid-
ered as an aversive method, mainly when
it is used to correct the child behavior,
and is less accepted if parents are not
totally informed about its real implemen-
tation. In one report,9 voice control was
the only technique highly rated as totally
unacceptable by all parents. Our data do
not support this finding, as both Groups
showed high acceptance by mothers. The
presentation of photographs instead of
videotapes could have influenced the
high acceptance of voice control.
In Brazil, only in 2003, the Federal
Council of Dentistry authorized the use
of nitrous oxide analgesic by dentists.
This technique was considered accepta-
ble or totally acceptable by most mothers
of two groups and there was not a differ-
ence statistically significant.
The physical restraint is one of the
least acceptable BGT.3,9,14 In this study,
there was a statistically significant differ-
ence (p < .05) of parental acceptance of
the protective stabilization with a restric-
tive device by Group B compared to
Group A. It is supposed that mothers of
Group B had already been informed
about the technique; perhaps their chil-
dren had been submitted to this kind of
restraint due to mental development
delay or involuntary movements. It has
been observed that parents whose chil-
dren did not cooperate with the
treatment showed more tolerance toward
“aversive” guidance techniques, despite
them being stressful for the child, but
necessary to perform treatment.14
The protective stabilization per-
formed by parent was totally acceptable
for 27.5% and acceptable for 52.5% of
mothers of Group A; and for Group B,
the percentages were 30.0% and 57.5%.
In Groups A and B, acceptance rates for
this technique did not show difference
statistically significant (Tables 2 and 3).
One study evaluated demographic
and cultural factors that influence den-
tists using restraint. It was concluded
Behavior guidance technique in pediatric dentistry
that the use of these techniques varied
depending on the age of the dentist and
the dental school from which the dentist
had graduated, because training time and
philosophy of the institution may influ-
ence professional conduct.15
It is important to note that hand-
over-mouth exercise was eliminated from
the American Academy of Pediatric
Dentistry’s clinical guidelines.2 A study
was made to discover an alternative to
substitute the hand-over-mouth (HOME)
technique after the elimination from the
clinical guidelines of the AAPD. A total
of 2,600 AAPD members answered the
electronic questionnaire about the
HOME technique, alternatives after the
elimination, concerns with its use, and if
the elimination had affected access to
care for children. Of the 2,600 members,
just 704 completed the survey, and the
techniques with more acceptances were
voice control and minimum/moderate
sedation, respectively. Fifty percent
believed that HOME is an acceptable
behavior management technique, and
41% believed it should be continued to
be recognized by the AAPD and 7%
believed that HOME eliminated affected
access to care for some children.16
Not surprisingly, mothers of children
with disabilities rejected less general
anesthesia than other group. It is sup-
posed that these mothers were conscious
about the need for treatment, and due to
systemic conditions, oral health status or
behavior they would agree to it, despite
the potential complications that are
involved during a general anesthesia.
Differences in the methodology do
not allow a direct comparison with other
studies, but findings are consistent with
those in the literature, as the basic BGT
showed high acceptability than advanced
behavior guidance in both groups.
Parents should be always informed
about the clinical procedure and the BGT
that will be used, so the informed con-
sent will be signed, guaranteeing more
acceptability, confidence, and support.
Conclusion
Parents of children with and without dis-
abilities accepted behavioral guidance
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techniques, but basic techniques showed
higher rates of acceptance than advanced
techniques. Parents of children with disa-
bilities showed a statistically significant
difference related to acceptance for a
protective stabilization with a restrictive
device.
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