Pediatric Dentists’ Use of Nonpharmacological Behavior Guidance Techniques and Experiences with Caregiver Acceptance: A National Survey

Abstract

Purpose:

The purpose of this study was to determine: (1) which nonpharmacological behavior guidance techniques outlined in the American Academy of Pediatric Dentistry’s (AAPD) best practice statement are currently routinely used by pediatric dentists, and (2) their perception of caregiver acceptance of the techniques.

Methods:

All active AAPD dentist members were invited to participate in this cross-sectional study. Participants (N equals 518) completed an online questionnaire that queried use of each nonpharmacological behavior guidance technique listed in the AAPD best practice, frequency with which caregiver hesitancy/refusal is encountered for each, and practice characteristics and demographics. Data were analyzed using descriptive statistics and tests of group difference.

Results:

Nearly all participants endorsed routine use of the foundational techniques tell-show-do (98.6 percent), counseling skills to build rapport (97.7 percent), and positive reinforcement (95.6 percent). Fewer endorsed using more complex techniques like desensitization (75.3 percent), memory restructuring (22.6 percent), and cognitive behavioral therapy (4.4 percent). There were significant differences in mean years of clinical experience between those who used and did not use some of the more complex techniques. Of the 26 techniques queried, caregiver hesitancy/refusal was encountered most frequently for parental absence, physical restraints, and voice control, and never to rarely for the others.

Conclusions:

This first-ever study of all nonpharmacological behavior guidance techniques outlined in the AAPD best practice suggests that pediatric dentists routinely use foundational techniques but less frequently use more resource-intensive or complex techniques. With few exceptions, these techniques are accepted by caregivers.

Behavior guidance is a cornerstone of pediatric dentistry. The American Academy of Pediatric Dentistry (AAPD) defines behavior guidance as “a continuum of interaction involving the dentist and dental team, the patient, and parent directed toward communication and education, while also ensuring the safety of both oral health professionals and the child, during the delivery of medically necessary [dental] care.”¹ Along that continuum, dentists and the dental team use techniques that range from basic to advanced, and selection of appropriate techniques requires understanding and appreciation of each aspect of the continuum.^2,3 Generally, the most basic techniques of what the AAPD terms “basic behavior guidance” are rooted in education (e.g., tell-show-do), communication (e.g., counseling skills to build rapport and trust, non-verbal communication), and basic psychological and behavioral phenomena (e.g., direct observation, positive reinforcement, distraction).¹ Moving along the continuum, more complex “basic behavior guidance” techniques draw on more complex psychological and behavioral phenomena (e.g., desensitization, memory restructuring, sensory-adapted dental environments).¹ What the AAPD terms “advanced behavior guidance” involves physical restraint (e.g., protective stabilization)⁴ and pharmacological behavior management (e.g., sedation, general anesthesia).^5,6 Nonpharmacological techniques toward the advanced end of the continuum may also include cognitive behavioral therapy or its components. Across the continuum—and most simply—behavior guidance is intended to facilitate safe, effective, and efficient dental care while ensuring the best possible experiences with dentistry.⁷

Among others, specific goals of behavior guidance include establishing communication, building trust, promoting a positive attitude toward oral health care, alleviating fear and anxiety, encouraging appropriate behavior, and providing quality oral health care as safely, minimally restrictive, and comfortable as possible—all of which can have lifetime benefit for pediatric patients.^1,2 Thus, undesirable or unsafe behavior is not a prerequisite for the use of behavior guidance techniques, and basic techniques such as communicative guidance and positive reinforcement are indicated any time a dentist interacts with pediatric patients. Depending on a child’s treatment needs, developmental stage (including physical, intellectual, emotional, and social), temperament, fear/anxiety, special healthcare needs (SHCN), and other individual case-related factors, more complex or advanced techniques may also be indicated. Effective behavior guidance requires the integration of multiple appropriate techniques that are selected and applied in manner tailored to the individual patient.^1,2 Importantly, behavior guidance is understood to be a continuous process, as well as a skill that requires ongoing practice and effort on the part of dentists.^1,7

The AAPD provides best practice recommendations for behavior guidance, outlining numerous specific basic and advanced techniques and offering considerations for selecting and applying them based on patient needs and practitioner skills.¹ Numerous published studies have aimed to describe dentists’ use of these techniques, but many of them involved surveys from 20 or more years ago.^8–12 Those older studies may not be relevant today given there have been well-documented shifts in the use of certain techniques over time.^13–16 For example, there has been movement away from aversive behavior guidance techniques (e.g., hand over mouth, voice control) and toward communicative techniques and pharmacological behavior management.^15,16 Moreover, the AAPD’s best practice recommendations have been updated/revised four times since they were originally formally developed and adopted in 1990 (in 2003, 2013, 2015, and 2020),¹ further limiting conclusions that can be drawn about contemporary practice from the older surveys. More recent studies have reported on dentists’ use of specific recommended behavior guidance techniques.^14,16–19 However, only three of those studies surveyed AAPD members and they—like the other recent studies—were noncomprehensive in their assessment of techniques used.^14,16,19 That is, the questionnaires administered in those studies queried only 6–7 basic/nonpharmacological behavior guidance techniques each and not the complete list of such techniques outlined in the AAPD best practice statement.

Among the many factors that influence selection and use of specific behavior guidance techniques, caregiver acceptance of the technique ranks second only to the provider’s comfort in using the technique.¹⁴ Thus, it is important to understand caregiver attitudes, preferences, and influences as related to behavior guidance. Early work on this topic indicated that pediatric dentists have perceived changes in parenting practices and caregiver preferences over time,^20,21 which may partially explain some of the previously noted shifts in the use of certain techniques.^22,23 Since then, several published studies have investigated caregiver attitudes about and acceptance of some techniques.^24–29 Many of those studies were relatively narrow in scope, for example focusing specifically on children with SHCN such as autism spectrum disorder^25–27 or addressing only advanced behavior guidance techniques.²⁹ The other studies were noncomprehensive in their assessment of caregiver attitudes and acceptance across the range of available basic/nonpharmacological techniques and focused disproportionately on advanced/pharmacological techniques,^24,28 similar to the previous studies of dentists’ use of behavior guidance techniques. As a result, caregiver acceptance is not understood for all the nonpharmacological techniques outlined in the AAPD best practice recommendations.

Understanding current provider behavior is essential for describing contemporary pediatric dentistry practice and may be useful for informing future implementation efforts to improve evidence-based clinical practice. Likewise, understanding current caregiver acceptance of clinical practices in pediatric dentistry may be useful for informing future practice recommendations or guidelines. Because previous studies are noncomprehensive, the goals of this study were to determine: (1) which nonpharmacological behavior guidance techniques are currently routinely used by AAPD-member pediatric dentists, across the entire range of techniques listed in the AAPD best practice recommendations; and (2) the frequency with which caregiver hesitancy, reluctance, or refusal is encountered when using the techniques.

METHODS

Data for this cross-sectional descriptive study were collected via an online questionnaire administered in July and August 2022. All procedures were caried out according to the study protocol approved as “exempt” by the University of Washington Institutional Review Board. Per the exempted protocol, and as indicated on the survey invitation and landing page, completion of the online questionnaire constituted informed consent.

Participants and Setting

Any pediatric dentist who was an active member of the AAPD at the time of study invitation was eligible to participate. There were no exclusion criteria. Thus, participation was open to pediatric dentists from any of the AAPD-defined districts in the United States and Canada as well as AAPD pediatric dentist members working outside the United States and Canada, and regardless of practice setting (e.g., rural, urban), type of practice (e.g., private, dental service organization, community clinic), days per week spent providing clinical care, and years of experience (see Table 1). In completing the online questionnaire, participants were prompted to think broadly about their clinical practice, no matter these contextual features. All study procedures, including recruitment and completion of the questionnaire, were carried out electronically.

Table 1.

Practice, Training, and Demographic Characteristics of Participating Pediatric Dentists (N^*=518)

Practice, training, and demographic characteristics**	N* (%) or Mean±SD†
Practice district‡^
Western	158 (30.5)
Northeastern	177 (22.6)
Southeastern	93 (17.9)
Southwestern	78 (15.1)
Northcentral	70 (13.5)
Outside US or Canada	2 (0.4)
Practice setting
Suburban	296 (57.1)
Urban	165 (31.9)
Rural	52 (10.0)
Other	5 (0.9)
Practice type (not mutually exclusive)
Private, group	245 (47.3)
Private, solo	167 (32.2)
Academic	67 (12.9)
Hospital	57 (11.0)
Community clinic	40 (7.7)
Dental support organization	30 (5.8)
Other	8 (1.5)
Days per week in clinical practice	3.82±1.11
Board certified
Yes	409 (79.0)
No	109 (21.0)
Years in practice	17.5±12.3
Gender
Woman	310 (59.8)
Man	198 (38.3)
Prefer not to answer	9 (1.7)
Gender not listed	1 (0.2)
Race and ethnicity (not mutually exclusive)
White	322 (62.2)
Asian or Asian Indian	85 (16.4)
Hispanic or Latino	35 (6.8)
Prefer not to answer	31 (6.0)
Black or African American	27 (5.2)
Middle Eastern or North African	12 (2.3)
Mixed	9 (1.7)
Other	7 (1.4)
American Indian or Alaska Native	6 (1.2)
Native Hawaiian or Pacific Islander	2 (0.4)
Age (years)	47±12.2

Note.

^*N=number of participants.

^**All variables presented in Table 1 were self-reported by participants via the study questionnaire.

^†SD=standard deviation.

^{‡^}AAPD-defined practice districts are: Northeastern (CT, DE, DC, ME, MD, MA, NH, NB, NJ, NL, NS, NY, PA, PE, QC, RI, VT); Southeastern (AL, FL, GA, KY, MS, NC, PR, SC, TN, VA, VI, WV); Northcentral (IL, IN, IA, OH, ON, MB, MI, MN, NE, ND, SD, WI); Southwestern (AR, CO, KS, LA, MO, NM, OK, TX); and Western (AB, AK, AZ, BC, CA, HI, ID, MT, NT, NU, NV, OR, UT, WA, WY, YT).

Study Questionnaire

Administration of the study questionnaire was included as part of a larger survey project aimed at understanding pediatric dentists’ practice behaviors with respect to both acute pain assessment and behavior guidance. Because no such extant questionnaire items could be identified in the literature, questions were developed by the study team specifically to assess behavior guidance techniques utilized by pediatric dentists and the degree to which caregiver hesitancy or refusal is encountered when they are utilized. Given the scope of the larger project, and due to notable gaps in the literature on basic techniques in particular, the questionnaire intentionally focused on nonpharmacological behavior guidance. As part of the development process, the questionnaire was pilot tested with practicing pediatric dentists to ensure that intended meaning would be understood by the target participants.

First, the questionnaire asked, “which of the following nonpharmacological behavior guidance techniques do you currently routinely use in your clinical practice?” For this item, participants were instructed to check all that apply from a list of 27 response alternatives (see Table 2). The response alternatives included all distinct behavior guidance techniques described in the AAPD’s Behavior Guidance for the Pediatric Dental Patient best practice statement, as well as others identified in the literature (see the best practice statement for detailed descriptions of and indications for each technique).¹ Because “distraction” is a particularly broad category, several specific types of distraction were included as response alternatives (e.g., distraction by imagination, distraction by audio-visual effects). Next, the questionnaire asked, “how often do you encounter hesitancy, reluctance, or refusal by parents or caregivers when attempting to use the following nonpharmacological behavior guidance techniques?” Using electronic questionnaire branching logic, participants were prompted to answer this question only for the techniques they endorsed routinely utilizing in the preceding question. For each, participants responded using a 5-point Likert-type scale with anchors ranging from “never” to “always” (0 equals never, 1 equal rarely, 2 equals occasionally, 3 equals often, 4 equals always). Last, the study questionnaire queried the following practice, training, and demographic variables: AAPD-defined practice district (Northeastern, Southeastern, Northcentral, Southwestern, Western, outside the United States and Canada; see Table 1 for detail); practice setting (rural, urban, suburban, other); practice type (solo private practice, group private practice, dental support organization, community clinic, academic institution, hospital, other; selecting all that apply); days per week in clinical practice; board certification in pediatric dentistry (yes, no); years in clinical practice; gender (woman, man, non-binary, other); race/ethnicity (10 categories, selecting all that apply; see Table 1 for detail); and age.

Table 2.

Proportion of Participating Pediatric Dentists Endorsing Routine Use of Specific Behavior Guidance Techniques and Frequency of Caregiver Hesitancy, Reluctance, or Refusal (N^*=518)

Behavior guidance technique**	n* (%) endorsing routine use	Mean±SD† hesitancy frequency rating‡^
Tell-show-do	511 (98.6)	0.55±1.06
Verbal communication, counseling skills to build rapport and trust	506 (97.7)	0.67±1.05
Positive reinforcement, descriptive praise	495 (95.6)	0.48±1.07
Parental presence	451 (87.0)	0.80±1.00
Distraction by imagination (e.g., stories)	429 (82.8)	0.46±0.92
Direct observation/modeling	415 (80.1)	0.57±0.87
Distraction by audio-visual techniques (e.g., television, gaming)	399 (77.0)	0.78±1.05
Desensitization to dental setting, procedures	390 (75.3)	0.69±0.93
Nonverbal communication	375 (72.4)	0.56±1.07
Relaxation techniques (e.g., deep breathing, muscle relaxation)	348 (67.2)	0.54±0.97
Enhancing control (i.e., allowing patient to assume active role)	344 (66.4)	0.53±0.82
Pre-visit preparation (i.e., provision of information)	324 (62.5)	0.67±0.96
Voice control	309 (59.7)	1.21±0.88
Parental absence	293 (56.6)	1.86±0.84
Distraction by audio effects (e.g., music)	264 (51.0)	0.59±0.95
Distraction by clinic design	259 (50.0)	0.56±1.08
Ask-tell-ask	255 (49.2)	0.54±0.94
Post-visit debrief/preparation	177 (34.2)	0.56±0.98
Positive pre-visit imagery	175 (33.8)	0.73±1.07
Physical restraints	160 (30.9)	1.82±0.77
Memory restructuring	117 (22.6)	0.48±0.75
Animal-assisted therapy	40 (7.7)	0.90±0.98
Sensory-adapted dental environments (SADE)	37 (7.1)	0.49±0.73
Picture Exchange Communication System (PECS)	27 (5.2)	0.67±0.83
Cognitive behavioral therapy	23 (4.4)	0.87±1.05
Distraction by virtual reality effects	11 (2.1)	0.82±0.98
None listed	1 (0.2)	-

Note.

^*N=number of participants.

^**The list of behavior guidance techniques from which participants could endorse use includes all distinct techniques described in the AAPD’s Behavior Guidance for the Pediatric Dental Patient best practice statement (see the best practice statement for detailed descriptions of and indications for each technique).¹

^†SD=standard deviation.

^{‡^}Frequency that caregiver hesitancy, reluctance, or refusal is encountered was rated by participants on a 0–4 scale, where 0 is “never” and 4 is “always.”

Study Procedures

A list of all active pediatric dentist members (n=7013) and their email addresses was obtained from the AAPD. To recruit participants, an email invitation was sent to all pediatric dentists on the list. The invitation described the purpose of the study and scope of the study questionnaire, and it included a link to the online survey landing page, where additional details about the survey and indication of IRB exemption were provided. To ensure the survey was completed only once per participant, each email invitation included a unique link that expired upon completion. Reminder emails were sent to non-responders one, two, and three weeks after the initial invitation email was sent. Using a blinding feature of the electronic survey software, email addresses and survey links were not connected to participants’ questionnaire responses. In appreciation for their time, participants who completed the survey had the option to enter a drawing for one of 25 $100 gift cards.

Data Management and Statistical Analysis

Survey data were collected and managed using Research Electronic Data Capture (REDCap), hosted at the University of Washington.^30,31 REDCap is a secure, browser-based electronic data capture software that includes email invitation, questionnaire administration, and database management tools. Data were downloaded from REDCap and inspected for accuracy. Statistical analyses were completed using SPSS 28. Descriptive statistics, correlations (i.e., Pearson correlation coefficients), and tests of group difference (i.e., chi-square and t-tests) were calculated to characterize participants, their approaches to behavior guidance, and their perceptions of caregiver acceptance of those approaches. The threshold for statistical significance was set at P<.05.

RESULTS

Of the 7013 member email addresses provided by the AAPD, 58 returned undeliverable study invitations; thus, invitations were transmitted to 6955 members. Following all rounds of invitation reminders, 518 pediatric dentists completed the study questionnaire in full (7.45 percent response rate). All AAPD-defined practice districts were represented, with the largest proportion of participants practicing in the Western district (30.5 percent). Most participants reported practicing in a suburban setting (57.1 percent), with fewer practicing in urban (32.0 percent) and rural (10.0 percent) settings. Most participants endorsed working in private practice (47.3 and 32.2 percent in group and solo practices, respectively); far fewer endorsed working in academic (12.9 percent), hospital (11.0 percent), and community clinic (7.7 percent) settings. Participants reported spending almost four days per week in clinical practice (mean equals 3.82±1.11 standard deviation [SD]). All but one participant endorsed completion of a pediatric dentistry residency, and most participants reported being board certified (79.0 percent). The mean number of years of clinical practice reported by participants was 17.5±12.3. Most of the participants were women (59.8 percent). Nearly two-thirds of participants were white (62.2 percent), with fewer Asian or Asian Indian (16.4 percent), Black or African American (5.2 percent), Middle Eastern or North African (2.3 percent), and Native American or Alaska Native (1.2 percent) participants; 6.8 percent of participants endorsed Hispanic or Latino ethnicity. The mean age of participants was 47.0±12.2 years. A complete summary of practice, training, and demographic characteristics of the entire sample is presented in Table 1.

Behavior Guidance Techniques Utilized

All but one participant endorsed routine use of at least one of the listed behavior guidance techniques, with most participants endorsing routine use of many techniques. The three most commonly endorsed techniques were tell-show-do (98.6 percent), verbal communication and counseling skills to build rapport and trust (97.7 percent), and positive reinforcement and descriptive praise (95.6 percent). The three least commonly endorsed techniques were Picture Exchange Communication System (PECS) (5.2 percent), cognitive behavioral therapy (4.4 percent), and distraction by virtual reality effects (2.1 percent). The proportion of participants endorsing routine use of each technique is presented in Table 2.

For 12 behavior guidance techniques, there were significant differences in mean years of clinical experience between participants endorsing and not endorsing routine use (Table 3). On average, participating pediatric dentists who routinely use the following techniques had more years of clinical experience than those who do not: cognitive behavioral therapy, PECS, sensory-adapted dental environments, and voice control. Mean years of clinical experience was lower for those who routinely use versus do not use distraction by audio-visual techniques, relaxation techniques, memory restructuring, distraction by imagination, enhancing control, parental presence, desensitization to the dental setting or procedures, and post-visit debrief/preparation.

Table 3.

Mean Years of Clinical Experience of Participating Pediatric Dentists Using and Not Using Specific Behavior Guidance Techniques

Behavior guidance technique*	Mean±SD** years of clinical experience† and (N‡)		t §	P-value
	Do not use†	Use†
Cognitive behavioral therapy	17.2±12.1 (495)	23.3±14.6 (23)	2.34	0.02
Sensory-adapted dental environments (SADE)	17.2±12.1 (481)	21.6±13.8 (37)	2.10	0.04
Picture Exchange Communication System (PECS)	17.2±12.4 (491)	22.2±8.0 (27)	2.06	0.04
Voice control	16.1±10.6 (209)	18.4±13.2 (309)	2.06	0.04
Distraction by audio-visual techniques (e.g., television, gaming)	23.2±13.3 (119)	15.8±11.4 (399)	5.92	<0.001
Relaxation techniques (e.g., deep breathing, muscle relaxation)	22.0±12.8 (170)	15.3±11.4 (348)	6.07	<0.001
Memory restructuring	19.0±12.4 (401)	12.3±10.3 (117)	5.35	<0.001
Distraction by imagination (e.g., stories)	22.3±13.9 (89)	16.5±11.7 (429)	4.06	<0.001
Enhancing control (i.e., allowing patient to assume active role)	21.3±12.8 (174)	15.6±11.6 (344)	5.12	<0.001
Parental presence	22.1±13.5 (67)	16.8±12.0 (451)	3.33	0.001
Desensitization to dental setting, procedures	20.3±13.0 (128)	16.6±11.9 (390)	3.04	0.002
Post-visit debrief/preparation	18.8±12.6 (341)	15.1±11.3 (177)	3.27	0.001

Note.

^*The list of behavior guidance techniques from which participants could endorse use includes all distinct techniques described in the AAPD’s Behavior Guidance for the Pediatric Dental Patient best practice statement (see the best practice statement for detailed descriptions of and indications for each technique).¹

^**SD=standard deviation.

^†Years of clinical experience and use of behavior guidance techniques were self-reported by participants via the study questionnaire.

^‡N=number of participants.

^§t-test; level of significance is set at P<.05.

For two behavior guidance techniques, there were significant differences in the proportion participants who were board certified in pediatric dentistry versus not board-certified endorsing routine use. Participants who routinely use ask-tell-ask were less likely to be board-certified (chi-square equals 7.21; P=0.007). Participants who routinely use distraction by audio-visual techniques were more likely to be board-certified (chi-square equals 4.11; P=0.04).

Caregiver Acceptance of Behavior Guidance Techniques

For all but three behavior guidance techniques, mean frequency of caregiver hesitancy, reluctance, or refusal encountered by participating pediatric dentists was between “never” and “rarely.” The mean frequency with which caregiver hesitancy, reluctance, or refusal is encountered was between “rarely” and “sometimes” for parental absence, physical restraints, and voice control. Mean frequency ratings for all techniques are presented in Table 2. Years of clinical experience was significantly positively associated with frequency of encountering caregiver hesitancy, reluctance, or refusal for the following techniques: direct observation/modeling (Pearson correlation coefficient [r] equals 0.30; P=0.001); post-visit debrief/preparation (r=0.18; P=0.02); distraction by clinic design (r=0.14; P=0.03); enhancing control (r=0.13; P=0.01); and, direct observation/modeling (r=0.10; P=0.04). Years of clinical experience was significantly negatively associated with frequency of encountering caregiver hesitancy, reluctance, or refusal for physical restraints (r=−0.16; P=0.04). There were no differences in frequency of encountering caregiver hesitancy, reluctance, or refusal for any technique based on board certification status.

DISCUSSION

This cross-sectional descriptive study surveyed AAPD-member pediatric dentists about their routine use of nonpharmacological behavior guidance techniques and the frequency they encounter challenges with caregiver acceptance when using those techniques. This is the first study to assess these practice behaviors across the entire range of nonpharmacological techniques outlined in the AAPD best practice recommendations.¹

Participants commonly endorsed using techniques related to education (i.e., tell-show-do), communication (i.e., verbal communication and counseling skills to build rapport and trust), and basic psychological or behavioral phenomena (i.e., direct observation/modeling, positive reinforcement and descriptive praise, and various forms of distraction). In fact, the top quarter of techniques endorsed as routinely used can be characterized this way. This finding is consistent with results from previous studies, which have found frequent use of tell-show-do, positive reinforcement, distraction, and parental presence.^14,16 Clustered toward the more basic end of the behavior guidance continuum, such techniques are foundational, broadly applicable, and relatively easy to implement; thus, routine use is expected. Perhaps also unsurprisingly, the least commonly used techniques included those that are more complex and/or resource intensive (e.g., animal assisted therapy, PECS, distraction by virtual reality effects), require special training (e.g., animal assisted therapy, PECS, cognitive behavioral therapy), or may be indicated only for children with certain SHCN (e.g., sensory-adapted dental environments for children with autism spectrum disorder, cognitive behavioral therapy for children with profound dental fear). This may explain the finding that there were no differences in years of clinical experience between those routinely using and not using foundational techniques, while those routinely using PECS, sensory-adapted dental environments, and cognitive behavioral therapy had more years of clinical experience than those not using the three techniques.

Though nearly all the behavior guidance techniques queried in this study are often referred to as “basic,” their application is not necessarily simple. This study adds to the literature a description of practice behaviors specifically related to the more complex “basic” techniques, the use of most of which has not been assessed in prior studies. While most participants endorsed routine use of many nonpharmacological techniques, the percentage of participants endorsing use of more complex “basic” techniques—such as relaxation techniques, enhancing control, distraction by clinic design, positive pre-visit imagery, and memory restructuring—was much lower than for the more foundational “basic” techniques. Even desensitization approaches, for which implementation can be complex, were reported as routinely used by only three-quarters of participants. Thus, such techniques are not part of the integrated behavior guidance process for many pediatric dentists. Interestingly, for many of these techniques (e.g., relaxation techniques, enhancing control, memory restructuring, desensitization) the mean years of clinical experience was lower for those endorsing routine use compared to those not using the technique. This may be reflective of changes in training over time as the guidelines have been iteratively updated,¹ and it may also be partially explained by changing trends in clinical practice over time^14,15,22,23 or comfort with technology, such as for distraction by audio-visual techniques.

A main finding of this study is that pediatric dentists rarely if ever encounter caregiver hesitancy, reluctance, or refusal when using most of the behavior guidance techniques queried, including those not previously assessed in past studies. This finding suggests that current AAPD best practice recommendations for nonpharmacological behavior guidance are generally acceptable to caregivers. Three techniques stand out as potentially less acceptable: parental absence, physical restraints, and voice control—which is consistent with results from other studies^28,29,32 and likely reflective of broader changes in caregiver preferences over time.^22,23 Of note, any lower-than-expected ratings of frequency of caregiver hesitancy, reluctance, or refusal may be due to questionnaire design, as participants were asked to rate caregiver acceptance only for techniques they routinely use (and they may not currently routinely use certain techniques precisely because they have previously encountered poor acceptance).

Study results should be interpreted in the context of potential limitations. First, the response rate was only 7.45 percent, likely due in part to the electronic nature of the invitation and survey completion processes as well as the length of the questionnaire administered as part of the larger project with which this study was associated. Such an outcome is perhaps consistent with a more global trend in declining (electronic) survey response rates, especially following the onset of the COVID-19 pandemic.^33,34 However, the sample size still is large, and the make-up of the sample is comparable to previous similar research^14,16 and generally reflective of the profession in the US and Canada and the AAPD membership overall. Second, though practice behaviors were assessed across a wider range of behavior guidance techniques than in any previous study, the study questionnaire was relatively limited in the variables queried. For example, there are numerous factors that may represent barriers to or facilitators of the use of specific techniques^14,16,35 or may influence caregiver acceptance, and these necessarily could not be included. Future research should address how such factors are related to use of nonpharmacological techniques from the comprehensive list. Future research should also address the relation between caregiver acceptance of behavior guidance techniques and providers’ use of those techniques. Third, this study relied entirely on participants’ self-report data, which can be prone to bias. For instance, there may be differences in how participants interpret “routine use” and in what participants believe constitutes each specific technique queried (and the ways in which they implement the technique—which may mean study results more precisely describe utilization versus use). Future research should adopt multimodal data collection to more fully understand practice behaviors. Last, though a strength of the study is providers’ report of their actual experiences with caregiver acceptance of nonpharmacological behavior guidance techniques (versus their or caregivers’ ratings of hypothetical scenarios), there is an opportunity in future research to more comprehensively account for caregiver (and patient) perspectives and the factors that drive those perspectives.

CONCLUSIONS

1. In this first-ever study of all nonpharmacological behavior guidance techniques outlined in the current AAPD best practice recommendations, pediatric dentists were found to routinely use multiple techniques and to more frequently endorse use of foundational techniques rooted in education, communication, and basic psychological and behavioral phenomena; future research should address the drivers of these practice behaviors and ways to improve implementation for the most appropriate application of evidence-based techniques.

2. Pediatric dentists use more resource-intensive (e.g., audio-visual or virtual reality distraction) and more complex (e.g., enhancing control, memory restructuring, cognitive behavioral therapy) techniques much less frequently than they use foundational techniques; however, more complex techniques may be particularly clinically useful (and most appropriate) as case- and patient-related acuity and complexity increases.

With few exceptions—notably parental absence, physical restraints, and voice control—nonpharmacological behavior guidance techniques are accepted by caregivers, which should be considered in everyday clinical practice and in future guidelines and recommendations.