Pediatric Dentistry

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A small child on the schedule can make many a grown dentist tremble! Remember, the general medical surgeon operates on a completely anesthetized patient and pain and fear concerns are absent during their procedures. With the adult dental patient, at least we, the dentist, can explain the need for our treatments in a dialog that allows for a modicum of adult understanding and permissions before treatment begins.

With the child patient, especially the very young, we must become more childlike ourselves in approaching them (especially the very young) in a manner that will allow us to adequately diagnose and treat.

There are many excellent child behavior modification teachers and practitioners in dentistry today and we are truly lucky to have them but I want to add a few philosophies for you to consider in approaching the child patient that seem to work for me and maybe will help you too.

Prenatal: Tell Mom what hormones during pregnancy can do to her gums and to keep a healthy mouth for a healthy child.

Postpartum: Show mom what bottle caries are and what putting the child down with a bottle full of milk, apple juice, Kool-Aid, etc., can do to teeth before they even fully erupt (and that the adult teeth will most likely follow the same path).

8 Months: Upper incisors coming in and are already getting decay on the linguals. You tell Mom to cut out the bottle at sleep time and Mom says she “just can’t tolerate the squalling” if Junior doesn’t go down with his juice “ba-ba” and you tell her to just fill it with water then. Ha! Junior knows.

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Dilution solution. Tell Mom that each night add one tiny bit less juice and one tiny bit more water. Don’t let junior see her do it and take it in small increments. Maybe everybody can get some sleep.

2 to 5 year olds: The more of this age group you can get to visit your office in a group, the far better it will be when they come alone for actual treatment. Arrange for a Kindergarten or Head Start group of about 10 to 15 kids at a time to visit your office with their teacher. Do it in the morning when they are alert and it will only take 10 minutes out of your schedule. Great them at your office’s front door with a big “Howdy” and have your staff full of grins and enthusiasm (some will have to act more than others). Tell the kids you’re Dr. John have each staff member introduce themselves (first names are fine and positions like “tooth cleaner” and “dentist helper” work ok too) and that you’re going to show them a really neat place. Get them involved in the adventure immediately and ask What kind of office this is? One will invariable raise their hand and yell “The Dentist’s” then ask What do we play with here? and at least will proudly point to their mouth and say “Teeth!”

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Then gather them around a dental chair and have teacher keep them quiet with hands by their sides. Only have out a dental toothbrush, mirror, mask, and a pair of gloves. Tell them it is your office’s job to keep teeth HAPPY and that you clean teeth (grab tooth brush) and ask aloud who brushes their teeth every night (all hands will go up). Then tell them that you (the dentist) look at each and every tooth and counts their teeth with special instruments and hold up the mouth mirror. Ask an apparently attentive child in the first row to see if they can see themselves in the little tooth mirror and hand it to the child. It usually will be snatched out of your hand and eagerly inspected. Gently take it back and then say that dentists also count teeth and ask another child to hold up his hand. Using just the handle end of the mouth mirror , count the child’s five fingers out loud by touching each one lightly. The say, sometimes we even use our ABC’s when we count and do another child’s hand that way. Ask how many teeth do you think you have? and wait for a couple of answers, then remark Well, let’s see later! Then grab a glove and let the children reach out to feel how soft and nice it is. Tell them you wear it to keep their mouth very clean when your counting and nonchalantly don a pair. Then hold up the mask to your face (paint a little “Happy Face” on it beforehand) and tell them the dentist wears this so he doesn’t huff and puff in your face while he is counting.

Then announce that the dentist cleans and counts teeth in a special chair that moves like a ride. Ask who would like to ride in my chair today? and a few will fight for the chance. Select one of the bigger kids and have him climb up into the chair. First, just make it go up and down a little bit while commenting on how fun that must be. Then announce that your special chair even leans back like a couch and lean it back and forth just a little until the child seems to enjoy or wants more of it.

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Often the first warning of wariness to a child is to have a large chair suddenly flatten out and they will immediately spring upright. Boinggg! Let them always “ride” it down.

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Many Pediatric Dentists don’t even use dental chairs but padded tables, adjusted to their personal operating position (or chairs already adjusted flat) and simply tell the young’un to “climb up her on my special bed (or couch)”. Most do so without hesitation.

Then sitting in front of the child, and not behind him, say that the dentist needs to really see every tooth and needs some “sunshine” to see better. Then turn on the bright dental light and shine it on their feet. Remark how well you can see their shoes and then carefully bring the beam up to their chin only. (If you get it right in their eyes at first they will want no more of that thing!) Begin to examine with the mirror only and then slide your stool towards your normal operating position while their attention is on that mirror and don your mask. Proceed as the child allows, even to the point of looking at one tooth only and remarking how nice that one looks and asking “may I look at more of those pretty teeth? Turn the mirror around to the handle again and just point (or very lightly tap) as many teeth as possible while counting out load in numbers and letters while the rest giggle and want a turn. There is no need at this point to reveal the business end of an explorer until after you’ve counted some teeth with it and then can show it was harmless.

That is it for a first visit in a group and the whole process takes about 10 minutes. Now when you have a child back for a real examination and cleaning, chances are they will be 100 times less fearful and more cooperative then if it was all done cold turkey.

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Want to be really famous? Get your video camera and a friend with a steady hand. Film “A visit to Dr. Smith’s” by having the camera lens be the child’s eye view (a short cameraman would help) and go through the same visit sequence as above but address the camera just like that good child. Start outside your office building and be excited to see them and enthusiastic. You can even add a few portions like the x-ray “funny nose camera” or a close up of a “tooth tickling” prophy angle on your finger. Duplicate this 10 minute film on DVD or flash drive and post it on your dental website and/or mail or give it to the parent when they call or come by to make their child an appointment. The child will watch it because it’s on a screen and seems to be talking to them! They will arrive at your office feeling they have already met you and your staff because the faces will all be familiar, not to mention the equipment and surroundings. In quantity, this will cost you around a dollar and make your services sought after by child and adult.

6 to11 years old: “Show, Tell, Do is a fine philosophy for many child patients but a modified version seems to work better for me. If an older child says “What is that!” I show her the handle. If she persists, I show her the business end and downplay that it’s just to count with. If a decayed tooth needs a restoration I tell them that a sugar bug (use your imagination) has mad a bad hole in a tooth but I can fix it!

There are many terms to use for children but here are some new and used that work most of the time. Nancy, I am going to rub a little sleepy cream next to that tooth and it really tastes nice (bubble gum topical). Wait a few moments while you chatter away to her that you will be really quick. Then remark that you are going to squirt a little sleepy juice around that tooth so it will be asleep while you fix it. Then say Let’s practice how easy this is!

Position your hand for the block, infiltration, etc. and using the mirror handle direct it right to where you intend to inject. The child is familiar with this instrument already and you are teaching him what the positioning and wiggle sensation will be like. These little “dress rehearsals” take only seconds and acclimate the child patient to new steps in a procedure. Many children can be very suspicious of a new hand position and the sudden appearance of a large new instrument, like a loaded syringe, and a dangerous head jerk can result. Then after this short “behavior test, and using your best sleight of hand and wiggle fingers and chatter (not to mention an always safe technique), pick up the real syringe and most of the time the child will not be aware of your injection.

They may grow concerned about how their lip or tongue is beginning to feel and you just need to reassure them that it is perfectly normal and that the tooth is just falling asleep. Now say if you will be real still, like a statue, we won’t wake up that tooth and can fix it really quickly while it is sleeping.
Then show the highspeed handpiece to the child (WITHOUT the bur in it) and tell them you are going to blow that sugar bug out of the tooth, or clean that tooth with special whistle air, and then step on the air just enough for the child to feel that gentle breeze on their hand and hear the sound. Then do it one quick time on a tooth. Finally, back behind the child, load the bur and discreetly go to work.

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Never start at the worst part of the caries but only a small area of enamel in a few light touches only. Stop and ask if the child is doing ok and most of the time they’ll say “ok”. Then go back and remove a little caries far away from the pulp and ask again. You are raising the child’s pain threshold and building their confidence. This is not a slow process and is really only seconds but works wonders on their ability to undergo treatment (p.s. same for adults!)

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If the child starts to squirm whenever you touch the tooth, touch the head of the vibrating handpiece on an adjacent tooth (watch that bur!) and see if the same response happens. This can often distinguish between real pain and fear. If you are almost done, you need to make the clinical decision on whether to apply more anesthetic or not but tell the child that that bad old cavity is waking up the tooth and you need to give it more sleepy juice. Don’t put the cause of the pain upon yourself; blame the cavity so you stay one of the good guys trying to make it better. Nancy, did that cavity just hurt you then? I’ll put a little more sleepy juice on it so it won’t or if near completion I need to get just one last bit of that cavity out of there and then we’ll put a happy (strong) filling in that tooth and it will feel much better!

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Always caution the child (and parent) about not letting then chew or bite on the lip or tongue or eating or drinking too soon until the lip wakes up.

When to treat and when to refer: A general dentist needs to make that decision about every patent who comes into his or her office and no more so than with a young child. If the child is wary or fearful, but seems relatively cooperative during the “count your teeth trial” and the cleaning, then you may have a cooperative patient. If the child is crying/screaming and is terrified from the start then better to know that at the beginning than halfway through an open tooth (N.B. you must at least temporize an open tooth or stabilize a surgery no matter how suddenly things went South) (That is why the introductory play/assessment is so important!) Mom (or Dad) may be quite upset with you if you decline to treat their little darling but you can truthfully put it this way: Mrs Jones, safety is our first concern with any patient and I sincerely believe I could not safely perform treatment on little Billy here. There are specialists in dentistry called Pediatric Dentists, just like Pediatricians, who have additional training and methods to treat him and we can arrange for a referral.

Parent Back with child or not: Now here I have seen both work and it is a judgment choice. I know many schools teach that the dentist needs the child’s full attention and the parent is a distraction and a crutch and complicates the treatment. I have also seen offices where a parent is required to accompany a child and there is a stool at the foot of every chair for them to sit and hold hands with the child or just observe during treatment. They are diplomatically informed that they are not to talk or interrupt the doctor due to safety and I have seen a four chair pediatric bay with four small children and four adults all sitting in a row. Quietly. Amazing.
A well handled child today is your patient for life tomorrow.

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