Impact of protraction or orthognathic surgery for class III malocclusion on longitudinal quality of life in patients with cleft lip and palate.

OBJECTIVES: This study assessed overall quality of life (QoL) over time in youth with cleft lip and palate (CLP) undergoing maxillary protraction treatment or orthognathic surgery for class III malocclusion to identify any differences in QoL based on treatment group and outcome success. MATERIALS AND METHODS: A prospective longitudinal cohort study was conducted in two pediatric hospitals. The Short Form Health Survey (SF-12) measured physical and mental QoL prior to treatment, at maximal correction, at treatment completion, and at 1-year post treatment. Analyses included one-sample, two-sample, and paired t-tests and analyses of variance and covariance. RESULTS: Participants (N = 91) either completed protraction (n = 53) at age 11-14 or surgery (n = 38) at age 16-21. Participants were mostly Latinx (67%) males (55%) born with unilateral CLP (81%) and there were no demographic differences between the two groups other than age. The total sample's QoL was in the average range and significantly higher than national norms. No significant differences were found in QoL-based outcome success; however, the protraction group showed a gradual physical QoL improvement over time, while the surgery group experienced a temporary drop in physical QoL postoperatively. At treatment completion, higher physical QoL was associated with higher socioeconomic status. At a year post treatment, mental QoL was significantly higher for males. CONCLUSION: Both protraction and surgery appear to be acceptable treatment options in terms of overall QoL for youth with CLP. While treatment success did not impact QoL, there were some differences in physical QoL coinciding with the treatment phase as well as individual factors.

Does Mandibular Distraction Osteogenesis for Robin Sequence Create Altered Craniofacial Morphology and Disrupt Tooth Development?

BACKGROUND: Robin Sequence (RS) infant patients may require mandibular distraction osteogenesis (MDO) to improve airway. The distracted mandible may grow vertically and the developing dentition may be disrupted. PURPOSE: The study purpose was to measure the association of MDO on craniofacial morphology and tooth development in RS subjects. STUDY DESIGN, SETTING, SAMPLE: This was a retrospective cohort study of RS infants treated with/without MDO. Inclusion criteria were RS diagnosis, complete imaging, and treatment at our pediatric regional hospital. Exclusion criteria were treatment elsewhere and insufficient imaging. EXPOSURE VARIABLE: Exposure was airway management; subjects were grouped by use of MDO or not. Subjects were compared to age-matched normal infants presurgically and to age-matched normal controls at follow-up. MAIN OUTCOME VARIABLES: Main outcome variables were craniofacial morphology measured using cephalometric gonial angle and ramus height to mandibular body length ratio presurgically (T1), postsurgically (T2), and at the mixed dentition (T3). Disrupted tooth development was assessed by absence/abnormality of teeth on radiographs at T3. COVARIATES: Covariates were age, sex, body mass index, comorbidities, and cephalometric measurements. ANALYSES: Appropriate univariate, bivariate, and regression models were computed, and significance level was set at P < .05. RESULTS: The sample contained 14 RS-MDO subjects with median age of 1.1 months and 10 (71.4%) were female. Presurgery, RS-MDO subjects had significantly more obtuse gonial angles (145° vs 137°, P = .04) and shorter mandibular bodies (32 vs 41 mm, P < .01) than the 37 unaffected controls. Increased ramus height (P < .01) and mandibular body length (P < .01) and forward rotation of the mandible were seen in 12 subjects with post-MDO imaging compared to their presurgical condition. At mixed dentition, 12 post-MDO subjects had more obtuse gonial angles (P < .01) and steeper mandibular planes (P < .01) than 19 non-MDO RS subjects. Both RS groups had different cephalometric values and more vertical measures than matched cephalometric norms. Thirty-one percent of 12 RS-MDO subjects had ≥1 teeth with abnormal development compared to none of 19 RS subjects without MDO (P = .02). CONCLUSION AND RELEVANCE: MDO increased mandibular size in infants but can disrupt the developing dentition. Postdistraction growth may result in more vertical mandibular morphology with large gonial angles.

Factors Contributing to Canine Impaction in Patients With Unilateral Cleft Lip and Palate Undergoing Alveolar Bone Grafts.

BACKGROUND: Patients with unilateral cleft lip and palate (UCLP) undergo alveolar bone grafting (ABG) to unite the bony segments before eruption of the maxillary permanent canine. PURPOSE: This study assessed the frequency of canine impaction after ABG in the UCLP patient population and identified associated demographic, anatomical, and operative factors. STUDY DESIGN, SETTING, SAMPLE: This retrospective cohort study included 257 patients with UCLP who received ABG surgery at a single craniofacial center. PREDICTOR VARIABLES: The variables were cleft characteristics, pre-ABG procedures, operative factors, and dental anomalies identified through electronic health records, radiographs, and intraoral photographs taken before ABG and at least 2 years after ABG. MAIN OUTCOME VARIABLE: The primary outcome variable was the presence of an impacted maxillary canine, defined as malposition of a fully developed canine following ABG with full eruption of the contralateral canine. ANALYSES: The t tests, χ2 tests, and logistic regression analysis were used to evaluate frequency of canine impaction and test for associations with the predictor variables. RESULTS: Of 257 patients, 56% were male with a mean age of 9.2 years at the time of ABG. The frequency of canine impaction was 27% (n = 69, 95% confidence interval 22 to 33%). Significant associations were found for: complete clefts (30 vs 12%, P = .017), hypodivergent facial patterns (low angle: 46%; high angle: 29 vs 22% normal angle, P = .042), females (adjusted odds ratio [aOR] = 2.1, P = .015), early grafting with less than 1/3 developed canine root (aOR = 3.36, P = .024), pregraft extraction of primary canine (aOR = 2.3, P = .009) and greater permanent canine angulation (odds ratio = 1.1, P < .0001). No significant associations with pregraft orthodontic expansion or regrafting were detected. CONCLUSION AND RELEVANCE: In this study, about one in four patients with UCLP had an impacted canine. Multiple factors including pregraft extraction of the primary canine and increased canine angulation were associated with impaction of the permanent canine.

Diagnostic Protocols for Alveolar Clefting and Barriers to Acquiring Imaging: A Survey of ACPA-Approved Cleft Teams in the United States.

OBJECTIVE: To report current diagnostic protocols, practices, and barriers related to imaging of alveolar clefting among American Cleft Palate-Craniofacial Association (ACPA)-approved cleft/craniofacial teams. METHODS: An electronic survey was sent to 162 ACPA-approved teams in the United States. Key items were team location, venue of orthodontic treatment, imaging modality(s) and access, barriers to imaging, billing, imaging protocols including team members involved in decisions pre- and post-alveolar bone grafting (ABG), and craniofacial fellowship status of team orthodontist(s). RESULTS: A total of 66 responses were received (40.7%). Responding teams were university-based (47%), hospital-based (42.4%), and independent clinics (10.6%). Orthodontic treatment for most patients was in private practice (53%). On-site 2-dimensional (2D) and 3-dimensional (3D) dental imaging capabilities were reported by 42% of teams; 29% have no on-site imaging. One or more barrier(s) to acquiring imaging were reported by 67%, with insurance challenges reported by 47%. Most teams bill medical payors for cleft-related dental imaging (58%). Pre- and post-ABG imaging was most frequently 3D (35% and 36%, respectively). Surgeons and orthodontists commonly evaluate ABG timing and outcome together (53%-65%). Periapical radiographs were included significantly more often in cleft imaging protocols by orthodontists with versus without fellowship training (P = .011, P = .04). CONCLUSIONS: Barriers to acquiring imaging are frequent. 3D is the most common imaging pre- and post-ABG. Our study endorses multi-level advocacy for improved medical insurance coverage of diagnostic cleft-related dental imaging to decrease barriers to providing timely care.

Oral health in children with chronic kidney disease.

The review summarizes the current understanding of dental health in children with chronic kidney disease (CKD). Oral conditions associated with CKD and its medical and surgical management have been described in cohort studies. Children with CKD may present with severe developmental defects of enamel (DDE) including discoloration, pitting, and reduced hardness leading to extensive tooth wear with normal function. The alkaline oral pH resulting from the uremia of CKD inhibits cariogenic bacteria, reduces dental caries risk, and increases accumulation of dental calculus. The malnutrition, acidosis, growth hormone resistance, anemia, and renal osteodystrophy in CKD provide multiple mechanisms for abnormal craniofacial growth and delayed tooth eruption. Following successful kidney transplant, caries risk increases due to normalization of oral pH in the presence of DDE; optimized diet and oral hygiene become critical in caries control. Post-transplant medications including cyclosporine A and calcium channel blockers may cause gingival overgrowth which in severe cases requires gingival surgery to allow tooth eruption, improve appearance, or permit orthodontic treatment. Immune suppression with sirolimus or everolimus may cause severe debilitating oral ulcerations. Long-term immune suppression increases the risk for development of oral candidiasis and oral cancers. Dental examinations and treatment are recommended for children with all stages of CKD to mitigate adverse oral outcomes of the disease and its management.

Pediatric Odontogenic Infections.

Odontogenic infections are a broad group of head and neck conditions that arise from the teeth and surrounding periodontium. These largely preventable infections disproportionately affect members of ethnic and racial minorities and low-income/uninsured groups, and result in significant costs to our health care system. Left untreated, odontogenic infections can spread to deep spaces of the head and neck and can result in life-threatening complications. The mainstay of treatment includes timely treatment of the affected teeth. These infections are a global public health concern that could be diminished with improved access to routine dental care.

Association Between Social Determinants of Health and Receiving Timely Dental Treatment With General Anesthesia.

Purpose: To describe social determinants of health (SDOH) in a group of children with special health care needs (CSHCN) planned for dental procedures with general anesthesia (GA) at a pediatric hospital and explore associations between SDOH and completing this treatment in the recommended timeframe. Methods: SDOH were recorded for all patients planned for dental treatment with GA in 2019. Outcomes were treatment completed in the recommended timeframe or treatment not completed within two years of planning. Results: Dental surgery plans were made for 390 CSHCN: 190 were completed in the recommended timeframe, and 119 were not completed within two years. The SDOH associated with completing/not completing surgery were parents (guardian/caregiver)/household, and documentation of social work involvement with the family. Patients receiving optimally timed surgery more frequently had two parents/one household and/or an active social work plan on the record. Those not receiving surgery frequently had two parents/two households, single parents, and/or had no social work plan. Ethnicity, payer, and the need for an interpreter were not associated with receiving timely surgery. Conclusions: Multiple studies have found that social determinants of health contribute to disparate health outcomes. In this study, children with two parents in one household appear to be advantaged in receiving care in the recommended timeframe. Families with SDOH challenges who had a social work plan were frequently able to overcome SDOH barriers and receive dental treatment with general anesthesia in the timeframe recommended.

Does surgical sequencing influence the accuracy of maxillary positioning in bimaxillary cleft orthognathic surgery?

PURPOSE: To evaluate whether the sequence of osteotomies influences the accuracy of maxillary positioning in patients with cleft palate ± cleft lip undergoing bimaxillary orthognathic surgery (OGS). METHODS: This was a prospective study of patients with Veau 2-4 clefts who underwent bimaxillary OGS at tertiary-care children's hospital over a 3-year period. The primary predictor variable was the sequence of osteotomies (maxilla-first versus mandible-first). The primary outcome of interest was the concordance between the planned and achieved maxillary position, as assessed using linear and angular measurements. Secondary study predictors were demographic and surgical variables. Differences between groups were compared using non-parametric independent samples tests for continuous measures (data reported as median and interquartile range, IQR) and chi-squared tests for categorical measures. For all analyses, p≤ 0.05 was considered significant. RESULTS: Subjects who underwent maxilla-first (n=15) and mandible-first (n=16) operations were comparable with regard to age, gender, cleft type, skeletal classification, segmental maxillary osteotomy, and magnitude of maxillary movement (p ≥ 0.09). The planned sagittal and vertical positions of the maxilla were similarly accurate between the two groups (p ≥ 0.68). Angular accuracy was also comparable (p ≥ 0.56) between the study groups. CONCLUSION: In patients with CP ± CL undergoing bimaxillary orthognathic surgery, use of mandible-first sequencing, when compared to maxilla-first sequencing, does not impact accuracy of maxillary positioning in the immediate post-operative period in well-selected patients.

Dental and Dentoalveolar Injuries in the Pediatric Patient.

Dental and dentoalveolar injuries are common in the pediatric population. Management is predicated on the type of tooth injured (primary or permanent), extent of injury, the dental and behavioral age of the patient, and ability of the patient to tolerate treatment. Although many dental injuries occur in isolation, a systematic evaluation of the patient is mandatory to confirm the absence of basal bone fractures of the maxilla or mandible, traumatic brain injury, cervical spine injury, and/or facial soft tissue injury. Long-term follow-up is paramount to achieving a functional occlusion and optimal dental health following injury.

Orthodontic treatment protocols in patients with alveolar clefting: a survey of ACPA-approved cleft teams in the United States.

OBJECTIVES: To describe pre- and post-alveolar bone graft (ABG) practice protocols of orthodontists associated with American Cleft Palate-Craniofacial Association-approved cleft and cleft/craniofacial teams. MATERIALS AND METHODS: Electronic survey responses from team orthodontists were evaluated regarding pre-ABG orthodontic treatment type(s), timing of post-ABG imaging and post-ABG orthodontic treatment, and craniofacial orthodontic fellowship training status of the team orthodontists. A P value of <.05 was considered significant. RESULTS: Of 31 responding orthodontists, 54.8% had fellowship training and 45.2% did not. Pre-ABG orthodontic preparation ranged from solely maxillary expansion for alveolar segment alignment (35.5%) to a combination of maxillary expansion for both alveolar segment alignment and posterior crossbite correction, anterior tooth alignment, and anterior crossbite correction (19.4%). Most captured post-ABG radiographs prior to orthodontic tooth movement (90.3%). Orthodontists began treatment at least 6 months (35.5%), 2-4 months (32.3%), or 4-6 months (29%) post-ABG. No significant differences were found when comparing fellowship subgroups. In addition, 47.1% of fellowship-trained orthodontists deferred post-ABG orthodontic treatment to at least 6 months post-operatively, vs 21.4% of non-fellowship trained orthodontists (P = .14). CONCLUSIONS: A large variation in approaches is evident in pre-ABG orthodontic treatment types and timing of post-ABG treatment. Post-operative imaging is pursued by most orthodontists to assess graft status prior to initiating orthodontic treatment. Additional clinical research is needed to support providers in their decision-making with regard to evidence-based approaches.

COVID-19 Pandemic Emergency Department Utilization for Pediatric Dental.

PURPOSE: Early in the COVID-19 pandemic, restrictions from mid-March to mid-May 2020 curtailed community dental practice. The study purpose was to analyze the utilization of a pediatric hospital emergency department (ED) for dental emergencies over six months of practice disruption compared to two previous years. METHODS: Records of patients presenting to the ED were analyzed for volume, demographics, dental emergency type/acuity, and treatment. Study patients presented between March and September 2020; controls presented between March and September 2018 and March and September 2019. RESULTS: A total of 138 study patients (mean age equals 6.4 years) and 171 controls (mean age equals 7.0 years) were assessed. Emergency types were trauma (68 percent), caries (25 percent), and "other" (seven percent) for both periods (P=0.997). Nearly all patients triaged as "urgent." Medical radiology (P<0.001), laboratory tests (P<0.001), medication administration (P=0.016), ketamine sedation (P=0.014), and procedures by the medical team (P=0.014) increased for trauma patients in the study versus control period. Significantly more study patients with caries identified as persons of color: 69.7 percent versus 36.8 percent of controls (P=0.006). CONCLUSIONS: The emergency department medical and dental teams served as a safety net for both public health and the private practice dental community during the early pandemic. The effect on tertiary medical facilities should be considered when closing venues for the management of routine emergencies; it is more time-efficient and cost-effective and less resource-intensive to manage patients with dental emergencies in dental clinics.

Comparison of Pediatric Dentistry Under General Anesthesia in a Surgery Center vs a Hospital.

OBJECTIVE: Pediatric patients who undergo general anesthesia (GA) for dentistry may be treated in different venues. This retrospective study compared patients treated in an ambulatory surgery center (ASC) to those treated in a hospital operating room (H-OR). The 2-venue model was also compared with a historical hospital-only model. METHODS: Twelve months of data were collected via records review: patient demographics, American Society of Anesthesiology (ASA) classification, and medical comorbidities. Data from patients treated at the H-OR 10 years prior were referenced for comparison. RESULTS: Between July 2017 and June 2018, 1148 patients were treated: 635 at the ASC and 513 at the H-OR. The most common age range for both venues was 3 to 8 years. Of all the ASC patients, 78% were ASA I, while 48% of H-OR patients were ASA III (P < .001). The number of patients treated with the 2-venue model represented a 240% annual increase compared with those treated historically using the hospital-only model. CONCLUSION: Because of differences in patient medical comorbidities, both the ASC and H-OR are needed to adequately address the needs of pediatric dental patients who require GA. Treating healthy patients in an ASC also creates increased capacity in the H-OR to better accommodate those with higher medical acuity.

Transition to adult dental care from a pediatric hospital dental home for patients with special health care needs.

AIMS: This study describes patients with complex Special Health Care Needs (SHCN) transitioning from a pediatric hospital clinic dental home to adult care and evaluates effectiveness of transition practices. METHODS AND RESULTS: Demographics, medical/behavioral complexity, and documentation of transition processes were collected for patients graduated from the service in 2018/2019. An invitation to complete a survey assessing transition was sent to patients/guardians ≥ 14 months after the final visit. Seventy-nine patients graduated and 94% required accommodation for SHCN: 47% medical, 42% medical + behavioral, and 5% behavioral only. Of 63 eligible patients/guardians, 29 completed surveys. While 90% of surveyed patients had established some/all adult medical care, only 41% completed a dental visit, and less than 28% established a dental home. Medical/behavioral complexity, payer, and time since graduation did not impact having a visit. CONCLUSIONS: This study found ineffectiveness of departmental protocol for transition to adult dental homes for patients with SHCN. Developing an optimal transition process is complex and will require collaboration of all stakeholders. Introducing transition in early teen years, tracking progress at subsequent visits, assessing patient readiness, summarizing history for receiving providers, and verifying transition are elements of medical transition programs that should be included in dental transitions.

Inpatient dental consultations at a pediatric hospital: A single center 1-year review.

AIMS: Inpatient dental consultations done at a pediatric hospital in 2017 were analyzed to determine consult reasons, requesting departments, and patient characteristics. Findings were compared to a 2007 study from the hospital. METHODS AND RESULTS: Data were collected from medical records. Descriptive statistics and logistic regressions were calculated. In 2017, 300 consults were performed for 211 patients (1.8% of inpatients). hematology-oncology requested the most consults (63%). Evaluation prior to cancer treatment, cardiac surgery, or organ transplantation was the most common reason for consult requests (52%). Fifty-eight percent patients had a dental home; older patients were more likely to have a dental home (P < .001). Patients with a dental home were less likely to have caries (P = .047). Many patients with a dental home had caries (33% in 2007 and 29% in 2017); more patients without a dental home had caries (46% in 2007 and 38% in 2017). CONCLUSIONS: This study both supports the dental home concept and reveals that many children with a dental home have treatment needs. This indicates that medical providers should not equate having a dental home with having dental health and emphasizes the value of an in-hospital dental service to support the management of critically ill children.

Caries-risk assessment and caries status of children with autism.

PURPOSE: This paper's purpose was to describe the caries status of children with autism and explore associations with the Caries-risk Assessment Tool promoted by the American Academy of Pediatric Dentistry. METHODS: Data was collected from children with autism, their parents, and dentists using interviews, surveys, and treatment records. Descriptive statistics and bivariate analysis explored the association of new caries activity and caries experience with oral health measures. RESULTS: Subjects were 75 males and 24 females with a mean age (+/-SD) of 9.7 years (+/-3.7), (range=2.7 to 19 years). Children < or =7 years old had more new caries (60%) than older children (34%; P=.05). Although not statistically significant, all children who brushed less than once per day had new caries and a mean t-DMF-T (def + DMF) of 73. Children with poor oral hygiene had more new caries (59%) than those with good/excellent hygiene (28%; P=.06). Caries status was not associated with gender, socioeconomic status, medical history, appointment type, dental home, food rewards, restricted diets, and some hygiene habits. CONCLUSIONS: This study confirms the validity of considering autism as an indicator of high caries risk. Oral hygiene may be the most influential risk indicator associated with new caries in children with autism.

Analysis of One- to 21-Year-Old Patients Preplanned for Hospital Admission After Dental Surgery.

Purpose: The purposes of this study were to: (1) describe patients preplanned for admission to the hospital after dental treatment under general anesthesia (GA) and compare patients who were admitted to those not admitted; (2) describe patients with unplanned admission to the hospital after dental treatment under GA; and (3) refine the criteria used for preplanning patients for admission.
Methods: Records of patients preplanned for admission following dental GA at a major children's hospital between January 1, 2015, and June 30, 2017 were reviewed.
Results: Pediatric dentists treated 948 patients. Most patients (84 percent) were planned for day surgery (n=792; two were admitted postoperatively [0.3 percent]). Sixteen percent (n=156 patients) were preplanned for hospital admission after surgery and 62 percent (n=97) of these patients were admitted. Anticipated challenges with analgesia, nutrition, or hydration were reasons for preplanned admission significantly associated with hospital admission (P <.01). Demographics, body mass index, physical status classification, and apnea-hypopnea index were not significantly associated with admission. Significant differences in medical support provided in the admitted versus non-admitted cohorts were: non-opiate analgesics (P <0.01); opiates (P =0.02); antiemetics (P =0.01); airway support (P =0.05); and intravenous hydration (P <0.01).
Conclusion: Among patients preplanned for admission to the hospital following dental surgery, 62 percent were admitted; these patients received significantly more intravenous fluids, antiemetic and/or analgesic medications, and airway support than patients not admitted.

Body mass index of children with severe early childhood caries.

PURPOSE: The purpose of this retrospective case study was to describe the body mass index (BMI) of children with severe early childhood caries (5-ECC) receiving dental rehabilitation under general anesthesia. METHODS: Demographics, BMI percentile, decoyed, missing, or filled teeth (dmft), and the number of pulp-involved teeth were analyzed for 293 healthy 2- to 5-year-olds (mean = 47.2 months). Weight groups were assigned using current Centers for Disease Control (CDC) BMI-for-age and gender definitions. Descriptive statistics were calculated and multivariate analysis used to evaluate BMI's association with oral health measures. BMI distribution of the subjects was compared graphically and with the use of confidence intervals to a reference population with similar demographics. RESULTS: The distribution of subjects' BMI percentiles was: underweight=11l%; normal weight=67%; at risk for overweight=9%; and overweight=11%. The mean dmft was 11.8; BMI percentile did not correlate with dmft or the number of pulp-involved teeth. Significantly, more children in the sample were underweight than in the reference population (11% vs. 5%). CONCLUSION: In this sample of S-ECC children, the BMI percentile was not correlated with dmft or the number of pulp-involved teeth, even After adjusting for confounding factors. Thirty-two percent had unhealthy weights, as currently defined by the Centers for Disease Control and Prevention.

Children with Autism Spectrum Disorder Are Able to Maintain Dental Skills: A Two-Year Case Review of Desensitization Treatment.

Purpose: The purposes of this study of children with autism spectrum disorder (ASD), who had successfully accepted a dental examination seated in a dental chair following desensitization interventions, were to: (1) determine if ability to accept an examination was maintained two years following initial success; (2) quantify new dental skills acquired; and (3) analyze the use of advanced behavior guidance techniques. Methods: This retrospective two-year case series included 138 ASD children. Data were obtained from dental records. Descriptive statistics were calculated, and Fisher's exact test was used for comparisons of interest. Results: Most children (92 percent) maintained the ability to receive minimum threshold examinations once the initial exam had been achieved. New basic dental skills attained by most children included receiving toothbrush prophylaxis (83 percent) and accepting fluoride varnish (77 percent). Few children required oral sedation or protective stabilization, but 22 percent received general anesthesia. Conclusions: Most children with autism spectrum disorder who learned to accept an examination maintained that skill over time, and many accepted toothbrush prophylaxis and fluoride varnish. Sensory-invasive skills, such as radiographs and rubber cup prophylaxis, were acquired with lower frequency. Therefore, when treating ASD patients, it is important to consider that some will require advanced behavior guidance techniques. (Pediatr Dent 2019;41(5):397-403).

Parental attitudes regarding behavior guidance of dental patients with autism.

PURPOSES: The purposes of this study were to evaluate: (1) parents' ability to predict dental treatment cooperation by their autistic child; (2) behavior guidance techniques (BGTs) used during treatment; and (3) parental attitudes regarding basic and advanced BGTs. METHODS: Data were collected from 85 parent/autistic child pairs and their dentists using surveys and treatment records. RESULTS: Parents most accurately predicted if their child would permit an examination in the dental chair (> or = 88%) and would cooperate for radiographs (> or = 84%). BGTs utilized most often (> 50%) were positive verbal reinforcement (PVR), tell-show-do (TSD), mouthprops, and rewards. In general, basic BGTs were more acceptable (> 81%) than advanced BGTs (>54%). The most acceptable techniques (>90%) in order were: PVR, TSD, distraction, rewards, general anesthesia, hand-holding by parent, and mouth-props. When parents evaluated only BGTs used for their child, all BGTs, including a stabilization device, were highly acceptable (> 91%), except for staff restraint (74%). CONCLUSIONS: Parents were accurate in predicting cooperation for some procedures. The most acceptable and efficacious BGTs in order were: PVR, TSD, distraction, rewards, and hand-holding by parent. Parental perceptions of BGTs were influenced by whether or not they had been used for their child.