Shared Decision-Making in Pediatric Dentistry: Implementation and Challenges
Article information
Abstract
Shared decision-making (SDM) is a patient-centered care model in which healthcare professionals and patients jointly participate in treatment decisions based on the patient’s values and preferences. In pediatric dentistry, SDM has a characteristic triadic structure involving the child, the parent or caregiver, and the dental team. SDM is increasingly relevant in clinical situations such as decisions regarding sedation or general anesthesia, selection of behavior guidance techniques, timing and modality of orthodontic treatment, and preventive care choices. This review summarizes the concept and major SDM models (such as the Three-Talk Model and SHARE framework) and analyzes how SDM can be applied in pediatric dentistry and the challenges encountered during implementation. It discusses the evolving patient-clinician relationship, the current status of SDM in Korea and other countries, and the relevance of SDM within pediatric dentistry. The review also examines barriers to SDM adoption in Korean pediatric dentistry, including time and cost constraints, limited clinician training, cultural and legal considerations, and the scarcity of decision-support tools. In conclusion, this review recommends developing clinical guidelines, clinician training programs, and patient/parent decision aids to strengthen SDM in pediatric dentistry, emphasizing that SDM-based collaborative care can improve children’s oral health and enhance the quality of dental services.
Introduction
The medical environment continues to change rapidly due to shifts in social structure, including declining birth rates, population aging, evolving patient perceptions, and the widespread availability of health information. Correspondingly, clinical decision-making has been shifting from the traditional physician-directed paternalistic model toward a patient-centered approach. However, concrete discussion on how to operationalize patient autonomy within the decision-making process has remained limited[1]. In this context, shared decision-making (SDM) has gained prominence as an essential approach for translating respect for patients’ autonomous choices into clinical practice. SDM is a process in which healthcare professionals and patients work collaboratively to determine a treatment plan that integrates clinical expertise with the patient’s values and preferences[2]. Unlike the traditional clinician-driven model or the informative model, where clinicians merely provide information and patients decide alone[3], SDM requires that treatment choices be made together. In clinical settings, SDM enhances patients’ understanding of their options, increases satisfaction, aligns care with individual values, and helps clarify treatment goals[4]. It has been associated with positive behavioral change, reduced treatment duration, and lower costs[5]. However, because decision-making processes in clinical practice are diverse, the absence of a consistent definition of SDM has limited its translation into specific, observable clinical behaviors[6].
In pediatric dentistry, decision-making is particularly complex due to its triadic nature involving the child, the parent or caregiver, and the dental team. This setting combines the child’s limited decision-making capacity with the parent’s surrogate authority. The United Nations Convention on the Rights of the Child affirms that children have the right to express their views in all matters affecting them, including healthcare decisions, and that their opinions should receive appropriate consideration[7]. In general, involvement in decision-making should increase as children mature[8]. However, young patients face developmental limits in comprehension and judgment, and legal authority rests with the parents or guardians, who consequently make major treatment decisions[9]. For these reasons, SDM in pediatric dentistry must amplify the child’s voice to the greatest extent possible while fully incorporating parental concerns and preferences. SDM improves cooperation, satisfaction, and clinical outcomes[10]. A 2015 meta-analysis demonstrated that SDM interventions in pediatric care significantly improved parent and patient cooperation, and reduced decisional conflict[11]. Because of these benefits, SDM is widely endorsed internationally[12], and recommended in pediatric healthcare settings in the United States and Europe[13]. Nevertheless, its implementation in routine practice remains inadequate, and in Korean dentistry, SDM concepts and decision-support tools are still in early development. A central challenge in pediatric dentistry is determining how to meaningfully incorporate the child’s perspective while parents retain primary decision-making authority, and how to convey evidence, risks, and benefits across multiple treatment options in a manner that respects parental values. Precisely because of these challenges, SDM is especially important in pediatric dentistry, which involves diverse decisions related to behavior guidance, choices between sedation and anesthesia, preventive versus therapeutic interventions, and the timing and methods of orthodontic treatment. Many of these are preference-sensitive decisions in which several reasonable treatment options exist, and the optimal choice depends on the values of the child and parents. For example, in young children with limited treatment cooperation, selecting among general anesthesia, conscious sedation, or nonpharmacological behavior guidance, or alternative management strategies for decayed primary teeth—such as fluoride application, restorative treatment, or extraction with space maintenance—does not yield a single universally “correct” answer. Each option differs in side effects, costs, and expected outcomes. Therefore, the optimal choice reflects family priorities, such as the importance of dental esthetics, the desire to complete treatment in one session under anesthesia versus multiple shorter visits, or financial constraints. In these situations, the need for SDM becomes especially pronounced.
In Korea, interest in incorporating SDM concepts into dentist-patient communication and treatment planning has grown. Traditionally, treatment planning frequently involved parents simply ratifying the dentist’s expert recommendation. Recently, however, evolving parenting styles and heightened awareness of parental rights have led families to expect clear explanations of treatment rationales and available alternatives rather than unquestioningly accepting clinician authority. For instance, behavior management techniques such as protective stabilization (including parental holding or physical restraints), once considered necessary with consent, are now sometimes viewed as controversial or potentially abusive and may be strongly opposed by parents. Consequently, pediatric dentists must communicate more comprehensively to resolve misunderstandings and identify behavior guidance strategies that meet both the child’s best interests and family expectations[13]. Within this changing landscape, research and development of SDM in dentistry have begun in Korea. In 2023, the Ministry of Health and Welfare supported a project led by Yonsei University College of Dentistry to develop SDM approaches for dental care, including protocols and decision aids for periodontal treatment based on patient preferences. The research team highlighted the scarcity of SDM tools in current dental practice and announced plans to develop preference-prediction models, educational programs, and guidelines[14]. These initiatives reflect a growing recognition that shared decision-making is becoming essential in dentistry as well.
This review introduces the concept and principal models of SDM relevant to pediatric dentistry. Drawing on domestic and international literature, it examines how SDM is applied across clinical domains and the challenges encountered. The goal of this review is to offer practical implications for developing SDM strategies and guidelines tailored to pediatric dental practice in Korea.
Concepts and Models of Shared Decision-Making
1. Historical Background of SDM
“The meeting between patient and doctor is the core of medicine”[15]. This statement highlights the central role of the patient-physician relationship in shaping the nature of medical practice. How this relationship is conceptualized has historically influenced communication patterns between patients and clinicians[16]. Hippocrates, frequently cited as the father of medicine, is commonly associated with the paternalistic model, which holds that excessive information might harm patients. In this model, healthcare professionals make decisions on behalf of patients, assuming that expert judgment grounded in medical knowledge and beneficence is inherently superior to patient decision-making. Conversely, the informative model requires clinicians to present treatment options while patients independently choose among them. Although this approach allows patients to align decisions with their preferences and values, it is frequently considered impractical. Patients may struggle to evaluate the accuracy or relevance of medical information, and in urgent situations, delaying decisions can be unsafe. Therefore, while elements of healthcare consumerism support this model, it has limited applicability in routine clinical practice. Between these approaches lies the deliberative model, the practical expression of which is shared SDM. In this model, clinicians outline available options, and patients communicate their concerns, priorities, and values. Decisions are refined through dialogue rather than directed solely by clinicians[17]. SDM positions patients and clinicians as partners in the decision-making process, and represents a paradigm shift toward patient-centered care in contemporary healthcare.
2. Development of SDM
Until the mid-20th century, the paternalistic model dominated medical decision-making, with clinicians relying on professional authority to act in patients’ presumed best interests. Social change gradually increased recognition of patients’ desire for a more active role, leading to a stronger emphasis on clinician-patient communication. A pivotal development was the introduction of informed consent following the 1947 Nuremberg Code[18], which catalyzed the formation of legal and ethical frameworks requiring clinicians to provide adequate information about potential risks, and to obtain voluntary, uncoerced consent[19]. The late 20th century witnessed, as previously examined, greater attention to patients’ preferences, values, and needs which shifted the paradigm toward patient-centered care, and SDM emerged as a central concept. Unlike traditional informed consent, which focuses primarily on information delivery, SDM emphasizes integrating patients’ preferences with clinical expertise, reflecting a more active and collaborative approach to care. Since the mid-1990s, publications on SDM have increased across medicine, sociology, psychology, economics, and ethics[20]. International organizations such as the World Health Organization (WHO) and research agencies, including the U.S. Agency for Healthcare Research and Quality (AHRQ) and the UK National Institute for Health and Care Excellence (NICE), now recognize SDM as a core component of patient-centered care. Many medical associations and professional societies have subsequently incorporated SDM principles into clinical guidelines[21]. In Korea, discussions on SDM remain early in development, but the Patient-Doctor Shared Decision Making (PDSDM) research program has been established to create and evaluate Korean SDM models in collaboration with multiple academic fields[22]. In dentistry, related efforts include developing SDM models for patients with periodontal disease.
3. Conceptual Foundation and Models of SDM
SDM is a collaborative process in which patients and healthcare professionals exchange information, articulate preferences, and work together to reach a decision, making a shift toward patient-centered care. In SDM, clinicians present treatment options with clear explanations of benefits, risks, and supporting evidence, while actively eliciting patient values so these can be incorporated into the final choice[23]. The overarching goals are to improve patient satisfaction and adherence while reducing decisional regret or conflict[24]. Several structured communication models have been proposed to support the practical implementation of SDM. Among these, the Three-Talk Model and the AHRQ SHARE approach are widely referenced (Fig. 1). The Three-Talk Model, proposed by Elwyn and colleagues, divides the consultation into three phases. During ‘Team Talk’, clinicians explain that a decision is required, outline available options, and invite patient participation. This phase includes eliciting patient goals and reassuring them that decisions will be made collaboratively. The second phase, ‘Option Talk’, involves presenting balanced, comprehensible information on each option’s benefits, risks, and evidence. Finally, during ‘Decision Talk’, patients share their informed preferences, and clinicians help guide the discussion toward a decision that reflects those preferences while offering recommendations when appropriate[25]. By delineating the SDM process in sequential stages, the Three-Talk Model supports more natural and cooperative clinician-patient negotiation. A complementary framework is the 5-step SDM model developed by AHRQ, known as the SHARE approach. Similar to the Three-Talk Model, the SHARE approach promotes patient-centered communication but further specifies five distinct steps, each outlining core tasks designed to facilitate effective and shared decision-making. The five stages aim to foster meaningful conversations about what matters most to patients while comparing the benefits, harms, and risks of each treatment option. The steps are: Seek your patient’s participation, Help your patient explore and compare options, Assess your patient’s values and preferences, Reach a decision with your patient, and Evaluate your patient’s decision[26,27]. Detailed stage-specific content follows:
Schematic representation of the Three-Talk Model and the SHARE Model.
1) Seek your patient’s participation: Invite and prepare the patient to take an active role in the decision-making process. For example, clinicians might state, “There are several treatment options we can consider, and I’d like us to decide together what’s best for you,” to signal the need for collaboration.
2) Help your patient explore and compare options: Present the available treatment options and expected outcomes understandably, and assist the patient in comparing them. Decision aids can be used to summarize advantages, disadvantages, side effects, costs, and other relevant aspects, while encouraging patients to ask questions.
3) Assess your patient’s values and preferences: Ask how the patient perceives each option and what they consider most important, and listen carefully. These discussions help clarify values and guide the direction of the decision.
4) Reach a decision with your patient: Clinicians and patients (or caregivers) jointly determine the final choice. Clinicians may offer recommendations aligned with the patient’s preferences or provide additional support if the patient is uncertain, helping them move toward an informed decision.
5) Evaluate your patient’s decision: After some time, review the patient’s satisfaction with the decision and its outcomes. If necessary, the decision may be revisited or modified. This ongoing evaluation encourages continued patient participation.
Other efforts to conceptualize SDM include the MAGIC (Making Good Decisions in Collaboration) program, developed at the request of the UK Health Foundation, which outlines methods for embedding SDM in primary and secondary care[28]. The SEED (Seek, Elicit, Explain, Decide) model, developed at the University of British Columbia[29], was later adapted in Korea into the SEEDS model by adding a “support” component[30]. These developments have paralleled advances in digital technology, enabling the creation of SDM decision aids and online platforms that facilitate SDM in clinical settings.
When developing SDM models for pediatric patients, it is essential to incorporate the unique dynamics of triadic communication among children, caregivers, and clinicians. The American Academy of Pediatrics (AAP) proposed a four-step framework for applying SDM in pediatric care[31]. The steps include: (1) assessing whether multiple medically reasonable options exist, (2) determining whether one option is clearly superior based on medical evidence, (3) identifying parental or family values and preferences, and (4) integrating these factors to decide whether a clinician-led or parentled SDM approach is more appropriate. For example, if multiple options exist but one is clearly medically superior and does not conflict with parental values, a clinician-led approach with strong recommendations may be appropriate. Conversely, if no option is clearly superior and parental preferences are well-defined, clinicians may place greater weight on those preferences. This flexible approach acknowledges the challenges of either delegating all decisions to parents or disregarding their concerns, and emphasizes the importance of continued dialogue and trust-building. Overall, SDM in pediatric care can be viewed as a collaborative process in which the child, caregivers, and dentist work together to achieve optimal treatment decisions. The following section reviews how SDM is applied across core areas of pediatric dentistry, with illustrative examples and an analysis of its benefits and limitations in each context.
Recommendations for Implementing SDM in Pediatric Dentistry
Pediatric dentistry encompasses treatment decisional circumstances distinct from adult care. Since most dental pathologies manifest chronically and necessitate patient behavioral modifications, SDM approaches prove particularly requisite; moreover, as declining birth rates reduce children per household, children have become families’ paramount focus.
1. SDM in Behavior Guidance, Sedation, and General Anesthesia Decisions
Behavior guidance is an essential element in pediatric dental care, and in some cases, clinicians and parents must decide whether to use pharmacologic methods such as conscious sedation or general anesthesia. These decisions require balancing patient safety and treatment effectiveness with parental expectations, making them a key domain for SDM. Options range from nonpharmacological behavior guidance strategies (such as tell-show-do, distraction, and parental presence) to protective stabilization, conscious sedation, and general anesthesia (GA), each with distinct advantages, disadvantages, and risk profiles. For instance, minimal sedation such as nitrous oxide inhalation proves relatively safe yet may present limitations for complex treatments. Whereas GA ensures complete immobility and pain control but entails greater cost and medical risk[32].
Treatment choices should reflect clinical judgment, parental preferences, and the child’s condition. Recent studies have investigated which factors parents prioritize when selecting sedation or anesthesia for their children to support SDM[31]. These studies report that parents generally prefer options with a lower risk of adverse events, less intensive sedation, lower cost, shorter fasting and recovery times, and noninvasive administration routes such as inhalation. Understanding these priorities helps clinicians engage in more informed and collaborative discussions with families regarding sedation and anesthesia. SDM is also essential when determining how to manage early childhood caries using options such as silver diamine fluoride (SDF), conventional restorative treatment under local anesthesia, or treatment under GA. A recent cross-sectional study reported that when SDM was used, approximately 28% of caregivers selected SDF, 35% chose restorative treatment under local anesthesia, and 37% opted for GA[32]. Higher levels of dental fear in children increased the likelihood of electing GA, highlighting the importance of addressing patient-specific factors during SDM. These decisions—whether to use SDF, conventional restorative care, or GA—are classic preference-sensitive choices. Through SDM, caregivers are more likely to feel confident that they have made the best choice for their child after reviewing each option and its implications. In dental treatment under GA, unexpected intraoperative events may occur, leading clinicians to obtain comprehensive consent and exercise a degree of discretion during the procedure. While necessary for safety and efficiency, it can limit patient and caregiver participation from the perspective of ideal SDM. Therefore, clinicians should engage in thorough preoperative discussions with caregivers, review potential treatment scenarios, and seek agreement in advance.
2. SDM in Orthodontic Treatment
Pediatric and adolescent orthodontic treatment bears an elective character, constituting a domain wherein multiple alternatives exist regarding treatment implementation, timing, and methodology. Whether to pursue early orthodontic treatment during mixed dentition or observe until late growth for direct secondary orthodontics, whether to select fixed bracket orthodontics versus clear aligners versus removable appliances for adolescent malocclusion—such determinations depend substantially not merely upon clinical judgment but also patient and guardian treatment objectives and preferences. Thus, orthodontic domains manifest elevated SDM necessity.
The essential component of SDM implementation in orthodontic treatment lies in the active participation of the patient—the adolescent themselves. Adolescent patients possess the capacity for comprehension and opinion articulation regarding their treatment; therefore, harmonizing how patients and guardians embrace treatment objectives proves crucial. For instance, whether to emphasize aesthetic versus functional objectives, treatment duration tolerance, or pain endurance thresholds— acceptance parameters fluctuate individually. SDM processes require clinicians to explicate current malocclusion status and prognosis, meticulously conveying anticipated outcomes and risks across feasible treatment trajectories. Meanwhile, patients and parents must candidly disclose orthodontic treatment expectations, time and cost investment willingness, aesthetic considerations, and similar factors.
In practice, however, orthodontic consultations are frequently clinician-driven in information delivery, with patients and parents assuming passive listening roles before following recommendations. Establishing SDM necessitates systematically employing SDM-facilitating instruments during consultations (decision support booklets, visual materials) while introducing standardized consultation guidelines and education.
3. SDM in Preventive Treatment and General Treatment Planning
SDM concepts prove applicable within preventive dentistry and dental treatment planning. Preventive procedures commonly encountered in pediatric dentistry (fluoride application, sealants), alongside incipient caries management and treatment necessity determinations, all represent matters warranting patient/parental discussion and determination. Consider fluoride topical application: while dentists emphasize caries prevention efficacy and safety, some parents harbor vague anxieties or aversions toward fluoride. Under SDM approaches, clinicians explicate fluoride benefits and risks through evidence-based data while inquiring about children’s caries risk profiles, domestic oral hygiene conditions, and parental perspectives regarding fluoride. When parents comprehend sufficiently and consent, fluoride application proceeds; alternatively, when declined, collaborative preventive plans encompassing dietary modification, frequent examinations, and the fluoride-containing dentifrice recommendations emerge as alternatives.
Pit and fissure sealants likewise fail to garner uniform parental acceptance. SDM processes incorporate pediatric cooperation capacity, caries risk profiles, sealant insurance coverage and costs, and collaboratively determining which teeth receive sealants and timing thereof with parents. Additionally, upon caries diagnosis, choosing between immediate treatment versus observation, and per-tooth treatment modalities (resin versus crown, pulp therapy versus extraction)—SDM reflecting patient family treatment objectives proves crucial. Within pediatric dental preventive domains, effective communication among parents, children, and clinicians proves essential toward preventive intervention success. Reports indicate that when dentists engage both parents and children in social dialogue during preschool pediatric preventive treatment consultations, adequately attending to parental concerns while empathizing with children’s emotions, triadic collaborative alliances form, facilitating preventive treatment objective achievement[33]. Such staged communicative strategies constitute SDM forms—process-centered approaches enabling parental and pediatric comprehension and acceptance of treatment necessity[34].
Challenges in SDM Implementation
While the necessity and advantages of SDM across diverse pediatric dental domains have been discussed heretofore, several common difficulties exist in actualizing SDM pragmatically. First, difficulties arise from additional time and resource consumption. Explicating all options to patients and guardians while deliberating collaboratively extends consultation duration beyond unilateral explanations. Particularly within private practice environments necessitating numerous patient encounters within brief clinical timeframes or under low fee structures, dentists struggle to secure consultation time requisite for SDM. Additionally, preparing and providing decision-support materials (brochures, visual aids) used during SDM processes requires costs and effort. Addressing such pragmatic obstacles might encompass insurance fee improvements, communication with auxiliary personnel utilization, standardized patient educational material provision, and similar measures.
Second, deficient SDM competency among dental practitioners warrants attention. Traditional dental education predominantly emphasized clinical techniques and knowledge, with relatively scant training regarding conversational arts eliciting collaborative patient decision-making. SDM necessitates the capacity for extracting patients’ latent concerns or preferences through appropriate inquiries and attentive listening, alongside explanatory ability that translates dental terminology accessibly. Therefore, incorporating medical communication and SDM workshops within dental school curricula and continuing education proves crucial.
Third, cultural and ethical factors emerge. Patient or guardian perceptions regarding physician authority vary; particularly, elderly guardians may manifest attitudes of “following whatever the doctor prescribes.” Conversely, younger parents, familiar with internet intelligence, may withhold facile agreement with physician perspectives or adopt defensive postures guarding against overdiagnosis. Additionally, pediatric cases involve two or more guardians; when inter-parental opinion discordance exists, mediation proves challenging. Under such circumstances, allowing families temporal deliberation or, when necessary, furnishing decision support through specialists becomes requisite. When pediatric patients possess articulatory capacity, inquiring about and respecting their perspectives proves advisable.
Fourth, material and instrument insufficiency exists. Within Korean dental domains, decision-making tools or guidelines systematically supporting SDM remain virtually absent. While diverse Decision Aids have been developed internationally, language barriers and healthcare system disparities occasionally render direct application difficult. Therefore, centrally concentrated SDM information and tool development and dissemination through academic society initiatives prove necessary. The Korean Academy of Pediatric Dentistry might inform members regarding SDM concepts while furnishing support—including parental explanatory materials for exemplar scenarios and consent form improvements.
Finally, insufficient awareness regarding SDM efficacy poses a surmountable challenge. Some dentists may misconstrue SDM as “delegating responsibility onto patients” or, conversely, believe “extensive explanation merely induces confusion.” Yet research reveals that SDM enhances patient treatment comprehension and compliance, reduces dispute incidence rates, and ultimately elevates clinician trust. Increasing dental practitioner exposure to such affirmative evidence and sharing even modest success cases would fortify SDM motivation.
Conclusion
Within pediatric dental domains, Shared Decision Making (SDM) serves as a crucial approach capable of simultaneously elevating treatment efficacy and patient satisfaction. The process whereby pediatric patients, guardians, and dental practitioners forge partnerships determining optimal treatment modalities, though demanding temporal and effortful investments, yields numerous advantages—including enhanced treatment cooperation, amplified parental satisfaction, and improved clinical outcomes. Internationally, SDM establishes itself as a medical paradigm, with domestic movements initiating its dental domain introduction. As discussed throughout this review, SDM proves practicable across diverse circumstances—sedation/anesthesia selection, behavioral guidance, orthodontic treatment planning, and preventive treatment. While situation-specific challenges exist, these remain surmountable through systematic support and education. For instance, general anesthesia treatment might standardize preoperative consent and information-sharing parameters; orthodontic consultations might employ patient decision support instruments; and preventive treatment consultations might apply effective communicative strategies toward improvement.
Furthermore, dental practitioners bear ethical obligations toward cultivating superior trust relationships with patients through SDM while pioneering treatment cultures respecting patient rights and perspectives. Prospectively, the Korean Academy of Pediatric Dentistry and relevant health authorities must endeavor toward guideline development, facilitating SDM within pediatric dental practice, educational program establishment, and decision-making tool (checklists, explanatory materials) production and dissemination. Additionally, validating and establishing SDM models suited to domestic realities through diverse clinical investigations proves necessary. Through this approach, pediatric dental patients and their families are expected to experience more satisfying and safer dental care by being respected and actively participating in treatment decision-making processes.
Taken together, SDM philosophy can be crystallized into a single principle: “The best decisions for patients are made with patients (and guardians).” We envision a future wherein this tenet permeates every clinical setting in pediatric dentistry, advancing children’s oral health through collaborative efforts among clinicians.
Notes
Conflicts of Interest
The authors have no potential conflicts of interest to disclose.
CRediT authorship contribution statement
Soyeon Bak: Conceptualization, Writing – Data curation, Formal analysis, Investigation, Project administration, Visualization, Review and edition.