The reality of working with kids
Believing each child will have an "ideal
visit" sets the stage for pediatric success
By Greg Psaltis, DDS
When fellow dentists find out that I am a pediatric specialist, it's
common for them to express either amazement, pity, or, at times,
unbelievable gratitude that I "do what I do." I always marvel at the
popular misconceptions surrounding pediatric dentistry and even find
amusement in the usual image that it evokes for other dentists — a day
full of out-of-control screaming monsters, vomiting and struggling from 8
a.m. until 5 p.m. According to the what I hear from my peers, it seems as
if they view pediatric dentistry as a never-ending wrestling match with
alligators in piranha-infested waters! This couldn't possibly be farther
from the reality of working with children. In fact, most visitors who come
to observe my practice invariably comment on the calmness of the office in
spite of fifty or so patients that we see in a normal, non-hectic day. Of
course it helps to have a team of talented professionals — including
assistants and a restorative hygienist. My team consists of fifteen women
who make my job wonderfully easy. However, the cornerstone of the practice
is one simple tenet — we believe each child will have an ideal visit each
time he or she comes to see us. If we come to the task with a positive
mindset and we truly believe that the outcome for the patient will be both
successful and safe, treatment of the young patient becomes not only
simple, but also gratifying far beyond the remarkable financial rewards
that accompany the delivery of that care.
To be certain, there are "tricks of the trade," but if that first
essential piece is not firmly entrenched in the minds of the team, there
is no way that "cute" terminology, reasonable treatment planning,
judicious sedation, or distraction techniques can overcome the negative
assumption that "children are a problem." My experience is that children
(who usually don't have any expectations) are far easier to treat than
adults, who have often made up their minds about dentistry, how they
relate to it, whether or not it will be "painful," and a multitude of
other attitudes. By capturing a child in an unbiased state, we can create
a positive first experience and thereby set the tone for all future dental
visits. Achieving this is a function of the doctor's attitude plus the
appropriate use of skills that will enable all parties to have a mutually
fulfilling and successful visit.
Critical elements for success
It is beyond my intentions here to enumerate all the facets of behavior
management of a child patient, but the elements that I feel are critical
to the successful presentation of dental care to a young child are as
follows: Use terminology that is
age-appropriate and positive — In our practice, we don't give "shots," we
"put teeth to sleep." We don't feel this is deceptive. It is descriptive
and avoids labels for which the child may have previous experience and,
therefore, negative connotations. By giving the child an accurate
expectation, we create a bond of trust when our description matches the
experience. When we tell a child her lip will start feeling fat and then
it does, the child learns that she can trust us.
Explain everything — One of the most effective distraction techniques is
to provide a running commentary to the child so that nothing comes as a
surprise. By telling the patients (in simple, understandable words) what
is happening, they can anticipate the next instrument, sensation, or
procedure with minimal anxiety.
Focus on what is going well — Don't be phony about it and don't sugar-coat
it, but keep your attention on the aspects of the appointment that are
working. Be specific in your feedback to the child. Avoid general
statements like, "You're being a good helper" because the child may not
even understand what she is doing right. Be clear by saying, "It's very
helpful when you hold your mouth open because then I can see better," or
"When you keep your head still like that, I can work more quickly." This
provides definite teaching to the child so that she will better know how
to help you. Keep appointments
short — This is somewhat dependent on age, but we rarely have restorative
visits that are longer than 45 minutes to an hour unless they are
accompanied by sedation. Avoid
pain — While some practitioners I have met often treat primary teeth
without local anesthetic, we use it routinely for a number of reasons. We
do not know ahead of time whether or not the child will experience
discomfort with a "routine" procedure. I have seen many children maintain
that a rubber cup for a prophy is agonizing while other children will sit
through multiple extractions, pulpotomies, stainless steel crowns, etc.,
and never say a word. I am unable to determine which children will have a
pain-free experience for a given procedure, so I prefer to anesthetize to
insure comfort. We use topical anesthetics routinely and nitrous oxide
when indicated to ease the injection process, and we do not routinely
encounter responses to the actual procedure. Rubber dams are routine — This affords a better view, keeps debris from
falling into the child's mouth and provides a more controlled field in
which to place the compomer materials that we use for primary posterior
teeth. When doing primary root canals (pulpectomies) and/or stainless
steel crowns, it also affords us the safety of preventing things from
being dropped into patients' mouths and potentially being aspirated.
Having the appropriate clamps is essential for successful dam placement
and retention. (See the
article on rubber dam armamentarium.)
What about the parents? One
of the more controversial aspects of pediatric dentistry obviously has to
do with the parents. There is an enormous range of thought on this topic,
but it is my opinion that the "misbehaving" parent (that is, the one who
causes more problems than solutions) is behaviorially similar to the child
— they simply don't know what is expected of them unless told. With the
legal atmosphere being as it is these days and parenting philosophies
spanning such a broad range of possibilities, it is my belief that having
informed parents present is safer for the practitioner.
Here are some critical elements for having parents be an asset and not a
liability for the dental treatment visit: Explain your philosophy in specific terms, including the management tools
you will employ in treating the child, the child-friendly terminology you
will use, and the role you expect the parents to play in the appointments. When the parents accompany the child into the operatory, tell them up
front that it is important for you put your entire attention on the child.
Tell them you expect the child to listen to you and not to the parents. In
support of this, the parents must be informed that they are not to speak
to the child. Ask the parents
for their support of the practice's terminology. Give them a handout with
sample words so that they will not inadvertently frighten their child with
words or phrases like shot, drill, yank a tooth, or other negative images. Advise the parents to not prepare the child for the restorative visit. I
explain to the parent that I will prepare the child literally on the spot.
I then launch into my preparation by making direct eye contact with the
child, explaining that during my examination that I found "x" number of
"sugar bugs" and that I will make them go away at the next appointment. I
then ask the child if she can help me at that visit in the same way she
did for the checkup. In virtually every case, the child will agree to
this. I then tell the parent that the preparation is complete. Be realistic about your expectations about the child's next visit. If you
believe that the child will not handle the visit easily, it is unwise to
tell the parent that you expect everything to go smoothly. Parents know
their children better than you do and most come into the dental setting
with low expectations about how the child will do. You are far better off
being clear and honest.
Obviously there are many tools that facilitate a successful pediatric
dental appointment. I have found that focusing on the behavioral side of
dentistry has provided as much satisfaction for me as the technical side.
It's a "given" that excellent technical dentistry must accompany the
management. My experience has taught me, though, that if a child is
misbehaving, it becomes an extreme challenge to provide the high quality
of care that we all strive for. In this way, I view management as a
critical aspect of proper dental care for young patients.
About the author: Dr. Gregory Psaltis has been in private
pediatric dental practice in Olympia, Wash., since 1981. In addition, he
has lectured nationally and internationally on a variety of topics, both
clinical and business. He is actively involved in consulting with other
offices to create more enjoyment and profit in the workplace. His Web site
is www.psaltis.info or he can be
reached by phone at (360) 413-5760 or e-mail at
drpsaltis@orcalink.com.
This article was originally printed in
Dental Equipment & Materials January, 2003 More articles
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