By Greg Psaltis, DDS
When my fellow dentists discover that I am a pediatric specialist, it is not unusual for them to express either amazement, pity, or, at times, incredible gratitude that I "do what I do." I always marvel at the misconceptions about my specialty and 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 feedback I hear from my peers, it's as if they view pediatric dentistry as a neverending 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 50 or so patients being seen in a normal, non-hectic way. Of course it helps to have a team of talented professionals — both assistants and a restorative hygienist. My team consists of 15 women who make my job remarkably easy. However, the cornerstone of the practice still evolved from one simple tenet — we believe each child will have an ideal visit each time he or she comes to see us. When the mindset is positive and the operator's belief system is based on the conviction 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 fiscal rewards that accompany the care.
To be certain, there are "tricks of the trade," but if that first essential piece is not firmly entrenched in the mindset of the providers, there is no way for "cute" terminology, reasonable treatment planning, judicious sedation, or distraction techniques to overcome the negative assumption that "children are a problem." In my experience, I have found 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 myriad 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. This is a function of the doctor's attitude, plus appropriate use of skills that will enable all parties to have a mutually fulfilling and successful visit.
Critical elements for success
It is beyond the scope of this article 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 is very helpful when you hold your mouth open because 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 routinely use it 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 visit for a given procedure, so I prefer to anesthetize to ensure comfort. We use topical anesthetics and nitrous oxide when indicated to ease the injection process, but 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 nothing being dropped into patients' mouths and potentially being aspirated. Having the appropriate clamps is essential for successful dam placement and retention.
What about the parents?
It goes without saying that one of the more controversial aspects of pediatric dentistry 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 behaviorally 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 in your practice:
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 sheet with sample words so that they will not inadvertantly 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 manage this by explaining to the parent that I will prepare the child literally on the spot. I do this 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 placing my focus on the behaviorial side of dentistry has provided as much satisfaction for me as the purely technical part. It must be 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 to which dentists strive. In this way, I view management as a critical aspect of proper dental care for young patients.
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.