AAPD behavior guidance for the pediatric dental patient (2024 revision): the basic techniques, the advanced ones, and what the chart has to show

What it says#

Behavior Guidance for the Pediatric Dental Patient is a 21-page best practice in the Reference Manual of Pediatric Dentistry, adopted by the Clinical Affairs Committee Behavior Management Subcommittee in 1990, last revised in 2020 and carrying a latest revision date of 2024. The 2024 pass was a collaborative effort of the Councils on Clinical Affairs and Scientific Affairs, built on proceedings from the AAPD's behavior guidance conferences, a PubMed search with a date limit of August 2023, a narrative review, and 50 hand-searched articles on mind-body therapies. It is written to align with the AAPD's separate 2023 clinical practice guideline on nonpharmacological behavior guidance.

The framing matters more than any single technique. Behavior guidance is described as a continuum of interaction involving the dental team, the patient and the parent, directed toward communication and education before and during care, with six goals: establish communication, alleviate fear and anxiety, promote awareness of the need for good oral health, promote a positive attitude, build a trusting relationship, and provide care in a comfortable, minimally restrictive, safe and effective manner. Behavior is never meant to be punishment, power assertion, or any strategy that hurts, shames or belittles a patient. Only a minority of children with uncooperative behavior actually have dental fears, and not all fearful children misbehave; about 15% of pediatric patients have persistent anxiety or develop dental anxiety as adults, which is the document's argument for getting the early visits right. A federal mandate requires translation services at no cost to the family in health care facilities that receive federal funding.

Before any technique is chosen, the document lists what should be considered and documented: medical history, temperament, informed consent including risks, benefits and alternatives, pain assessment, acuity of treatment needs, previous behavior during treatment, previous techniques used, and alternatives including no treatment or deferred care. The Frankl behavioral rating scale sits in Appendix 2, four categories from definitely negative to definitely positive, and the document suggests adding a descriptor such as "+, nonverbal" to help plan the next visit.

Basic behavior guidance is the bulk of the recommendations, each technique given a description, objectives, indications and contraindications: communicative guidance, positive previsit imagery, direct observation, tell-show-do, ask-tell-ask, voice control, nonverbal communication, positive reinforcement and descriptive praise, distraction, memory restructuring, desensitization, enhancing control, and parental presence or absence. Almost all are indicated for any patient with no contraindications; the exceptions are worth knowing. Voice control is contraindicated for patients who are hearing impaired. Ask-tell-ask is for any patient able to dialogue. Parental presence or absence is contraindicated where parents are unwilling or unable to extend effective support. Enhancing control has no contraindication, but the document warns that using it prematurely may increase fear by implying concern about the procedure. Descriptive praise is singled out over generic praise: "Thank you for sitting still" rather than "Good job."

For anxious patients and those with special health care needs, four more options are described: sensory-adapted dental environments (dimmed lighting, moving ceiling projections, soothing music, a wrap providing deep pressure), animal-assisted therapy with a temperament-tested, trained and certified animal, picture-exchange communication systems, and mind-body therapies including biofeedback, breathing exercises and hypnosis. Nitrous oxide and oxygen inhalation is described here too, on the basic list, with a pointer to the AAPD's separate nitrous oxide document and the warning that concentrations above 50% or combination with benzodiazepines or opioids increase the likelihood of moderate or deep sedation.

Advanced behavior guidance is three techniques: protective stabilization, sedation and general anesthesia, described as commonly used and taught in advanced pediatric dental training programs. The document says skillful diagnosis of behavior and safe implementation of these techniques require knowledge and experience generally beyond predoctoral dental education, and that dentists considering them should seek a residency, a graduate program, or an extensive continuing education course with both didactic and experiential mentored training.

Protective stabilization gets the most specific treatment. It is the physical limitation of a patient's movement by a person or by restrictive equipment for a finite period, active when a person does the restricting and passive when a device does. Devices placed around the chest may restrict respiration and must be used with caution, especially with medications that depress respiration. The dentist should always choose the least restrictive safe and effective option, and continuous monitoring of physical and psychological well-being is mandatory. A mouth prop in a compliant child is not protective stabilization. Indications include a patient needing immediate diagnosis or urgent limited treatment who cannot cooperate, a previously cooperative patient who becomes uncooperative mid-procedure, an uncooperative patient with limited treatment needs where sedation or general anesthesia is not an option, a sedated patient needing limited stabilization, and a patient with special health care needs whose uncontrolled movements would be harmful. Contraindications include a cooperative nonsedated patient, an uncooperative patient with no clear need for treatment that visit, a patient who cannot be immobilized safely, a patient with a history of physical or psychological trauma including abuse, non-emergent full-mouth or multiple-quadrant rehabilitation, a practitioner's convenience, and a dental team without the requisite knowledge and skills. Precautions name specific medical flags (cardiac or respiratory instability, musculoskeletal alignment issues or weakness, joint hypermobility, bone fragility, cutaneous vulnerability, psychological instability, thermoregulation disorders, psychotropic medications), require tightness and duration to be monitored and reassessed at intervals, forbid restricting circulation or respiration, and require stabilization to be terminated as soon as possible in a patient experiencing severe stress or hysterics.

Consent is the thread running through all of it. Decisions about anything beyond communicative management cannot be made by the dental team alone and include the parent, and the child when possible. Communicative guidance requires no specific consent; all other techniques require informed consent consistent with the AAPD's Informed Consent document and applicable state laws. A signature on a consent form does not necessarily constitute informed consent: the document defines it as information provided, including risks, benefits and alternatives, questions answered, and permission obtained before treatment. If a parent refuses after that conversation, an informed refusal form signed by the parent and kept in the record is prudent. If an unanticipated behavioral reaction forces a new plan, a new informed consent for the alternative method is indicated. For protective stabilization specifically, consent must be obtained and documented before use, and when the patient can reasonably understand, the need should be explained with a chance to respond.

Documentation for protective stabilization is an eight-item list: indication, type, informed consent, reason for parental exclusion when applicable, duration of application, behavior evaluation or rating during stabilization, any untoward outcomes such as skin markings, and management implications for future appointments.

Who it applies to#

Any dentist who treats children, not only pediatric specialists, and the assistants and hygienists who work chairside while the technique is being used. The document is explicit that dental practitioners are expected to recognize and effectively treat childhood dental diseases within the knowledge and skills acquired during their professional education, and equally explicit that the advanced techniques sit beyond predoctoral training.

The exemptions are narrow. Communicative guidance is the only technique that needs no specific consent. A mouth prop in a compliant child is not protective stabilization. And the document repeatedly defers: pain management, protective stabilization, sedation, office-based deep sedation and general anesthesia each have their own AAPD best practice, and the monitoring rules for sedation come from the joint AAPD and American Academy of Pediatrics guideline.

What changed#

The previous revision was 2020. The 2024 text is built to align with the AAPD's 2023 clinical practice guideline, Nonpharmacological Behavior Guidance for the Pediatric Dental Patient (Dhar and colleagues, Pediatric Dentistry 2023;45(5):385-410), which assessed eight systematic reviews using GRADE. That guideline's conclusion is the useful context for anyone quoting technique effectiveness: overall, basic nonpharmacological techniques produced trivial to small effects on behavior or anxiety, while modeling, positive reinforcement, biofeedback and breathing relaxation, animal-assisted therapy, combined tell-show-do, audiovisual distraction and cognitive behavior therapy showed large reductions in anxiety during treatment visits; for children with special health care needs, audiovisual distraction and sensory-adapted dental environments showed large reductions. All the recommendations were conditional and mostly based on very low certainty of evidence. This entry did not compare the 2020 and 2024 texts line by line.

Where the source is#

The link under the title is the AAPD's page for the best practice, which opens the Reference Manual PDF, Behavior Guidance for the Pediatric Dental Patient, latest revision 2024, printed at pages 379 to 399 of the 2025 manual; the How to Cite line on the document is the citation above. The AAPD web page currently labels it for the 2026-2027 edition of the Reference Manual, with the page range not yet assigned, so the pages quoted here are from the PDF the site serves today. The companion documents quoted in this entry, the 2023 nonpharmacological clinical practice guideline, the protective stabilization best practice and the Informed Consent best practice, are separate open-access PDFs on the same site. All four PDFs were downloaded and read in full for this entry. The AAPD's materials are free to read and free to download, but they are copyrighted by the Academy, so quote rather than reprint them in a staff manual.