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How to make pediatric dentistry easier on patients, parents and you.
Children can be trouble in the dental chair. From toddlers to teenagers, all of the age groups have different challenges. W.C. Fields, an actor and entertainer from the early 1900s, once said, “Never work with animals or children.” Pediatric dentists, general practitioners, specialists and hygienists alike may have days where they see the wisdom in Fields’s words.
“When kids are relaxed and compliant, dentistry can be simple and fast. When they are not, that becomes a very different type of challenge,” says Dr. Jason Goodchild, DMD, director of clinical affairs for Premier Dental Products Company.
Common issues when treating children
The most common problems dental professionals face when working with children are behavior and fear management. Uncooperative children, especially demonstrative ones, parked in the chair can have detrimental effects on your practice experience.
“When you have a screaming child in the back operatory, everyone can hear it. It certainly can affect the energies of everyone in the office,” says Katrina M. Sanders, RDH, a dental hygiene educator and international speaker.
Dr. Jeffrey Lineberry, DDS, is a private practice dentist and educator in Mooresville, North Carolina. He agrees that uncooperative children can disrupt the patient flow.
“If you are trying to do a procedure on a pediatric patient and you are having behavioral issues, then it slows the procedure way down and you get behind, and it snowballs from there,” Dr. Lineberry says.
Ramifications of poor early dental experiences
The stakes are high in pediatric dentistry. The American Academy of Pediatric Dentistry recommends that all children establish a dental home by their first birthday, a time when children are notoriously difficult to manage. When those early experiences are negative, it can have repercussions for the rest of the child’s life.
Dr. Nathaniel Lawson, DMD, Ph.D., division director of the division of biomaterials at the UAB School of Dentistry, doesn’t treat children anymore but sees the effect of poor dental experiences in his adult patients.
“I still see adults that come in who had a bad experience early in their life that now gives them dental anxiety. Sometimes, they delay treatment. They will delay a filling to the point that they need a root canal because they didn’t want to come into the dentist,” Dr. Lawson says.
Dr. Lineberry says delaying treatment to the point where there’s a significant problem only reinforces the cycle of fear.
“When adults delay treatment and the problem worsens, we have to do more of the challenging, difficult and more expensive procedures because we are either trying to save a tooth or replacing a tooth,” Dr. Lineberry explains.
Without a doubt, practicing pediatric dentistry takes, well, practice. Also, some good advice from people who know best. We spoke with several industry experts to learn how they address the challenges they encounter when practicing pediatric dentistry. Here’s what they had to say.
Up next: 10 ways to simplify pediatric dentistry...
1. Work from the outside in
Tina Clarke, RDH, MEd and the academic program director for the Oregon Tech Dental Hygiene Program at Chemeketa Community College, teaches her students to concentrate on young patients’ extremities to get them used to the dental professional coming into contact with them. Patients 18 months to age 4 center their identity around their mouth, head and chest. However, their hands and feet are more distant from their identity than those areas. Clarke recommends concentrating on the extremities when talking to them for the first time. For example, she likes to notice the patient’s shoes to diffuse anxiety and give the patient time to warm up to her.
“When you meet a dog, you don’t go right up and scratch their ears or put your head in their face. You have to let them smell your hand to let them know you are okay. Then, you can love and squish on them,” Clarke explains, “With kids, something extremity-related will get them used to the idea of you coming in contact with their space. That’s huge.”
2. Rethink your restoration materials
Dr. Lawson recommends reconsidering your materials. Since time is of the essence with pediatric patients, having simpler and faster ways to do similar procedures can help to improve the experience. When he was treating pediatric patients while previously working at a dental service organization (DSO), Dr. Lawson wishes he had used more flowable composites.
“Flowable composites got a bad rap in the ’90s, but now they are not that different from packable composites,” Dr. Lawson explains. “Flowable composite is a good option for restoring primary teeth a little more quickly and achieving good adaptation with small cavity preparations.”
He also says he would’ve used more glass ionomers instead of composite restorations because glass ionomers are more moisture tolerant and they release fluoride and reduce the risk of recurrent caries.
Dr. Jeanette MacLean, DDS, DABPD, FAAPD, a private practice pediatric dentist in Glendale, Arizona, and an international lecturer on minimally invasive dentistry, agrees that glass ionomer cement sealants and restorative materials are great in pediatric dentistry. Using GC Fuji TRIAGE® glass ionomer sealant has been incredible for her practice, since it allows her to apply sealants on children who she couldn’t before.
“The material is hydrophilic, so it needs moisture to set. You can do sealants on moist surfaces and you don’t use the traditional, caustic 37% phosphoric etch. You use a gentler 20% poly-acrylic acid cavity conditioner. It’s a whole different ball game,” Dr. MacLean says. “Most importantly, glass ionomer sealants release fluoride, creating a more caries-resistant enamel surface.”
Dr. Lawson also recommends TheraCal LC® light-cured pulp capping material for indirect and direct pulp casts. It’s quicker than the conventional calcium hydroxide and glass ionomer method. He would also reconsider performing permanent restorations on certain deep carious lesions. Biodentine® is a calcium silicate-based liner and temporary material that can form reparative dentin next to the pulp and also function as a temporary for up to six months.
“If a kid comes in with a deep cavity on a permanent tooth and you don’t know if they need a root canal, Biodentine temporizes it while you wait to see how the tooth responds without a permanent restoration,” Dr. Lawson says.
Silver diamine fluoride (SDF) is another option for treating caries that Dr. Lawson recommends. SDF arrests caries until a more permanent restoration is possible or until the primary tooth falls out.
Dr. MacLean also likes using SDF for treating caries in young patients, especially on a first encounter when you’re building trust because it’s quick, simple and painless. Moreover, it’s a desensitizer. Dr. MacLean says that SDF used in combination with glass ionomer cement has opened up “a whole new world” of minimally invasive treatment options that can be accomplished without the need for local anesthetic.
“We have so many more tools in our armamentarium now than before. So, we can care for more patients and give more comfortable, easier and faster treatments,” Dr. MacLean says.
3. Let products do the dirty work
Sanders is an international lecturer on the delivery of local anesthesia. She recognizes the general fear of getting a shot is widespread and pervasive. “The syringe is scary looking, even for an adult. It is important that we, as dental professionals, are mindful of the fears our pediatric patients may have simply upon seeing our dental equipment,” she says.
That’s why he likes Kovanaze®, a nasal spray on the market that replaces the shot and delivers anesthesia to the entire maxillary arch, including the palatal aspect.
“Anyone who is a dental provider knows they are never prepared to give a palatal injection to a pediatric patient. The intranasal delivery of Kovanaze is incredibly useful for non-injectable anesthesia techniques,” Sanders says.
Another challenge hygienists face is flossing patients in full orthodontic gear. Between hormone changes and the poor nutrition common among teenagers, their inflamed gums make flossing difficult. However, the Platypus Orthodontic Flosser simplifies matters for Sanders.
“Recommending a product like the Platypus Ortho Flosser for your orthodontic patients makes it easier for them to be compliant with their home care recommendation,” she says.
Kim Miller, RDH, BSDH, says an additional area challenging dental professionals is keeping the patient’s mouth open. She likes using different types of bite blocks as well as the JawDropper device. “They hook it over their lower front teeth and it supports the downward movement of the jaw to help them keep their jaw open,” Miller says.
Up next: Introduce kids to the tools...
4. Introduce kids to the tools
Kids have never seen anything like the objects in a dental office. Miller, who has practiced for 36 years and coached practices since 1992, thinks you should introduce children to the various tools and even let them touch them.
“I always took time to show them what the tools were. So, when I picked them up and started coming at their face with them, the kids knew what they were. Most of the reason children are afraid is that it’s an unknown. If you can eliminate the unknown, the fear goes away,” Miller says.
When Alyssa Aberle, RDH, works for a community health center with kids in a school-based setting, she also takes the syringes for sealants and pokes the blunt tip of the sealant/etch syringe to her glove to show that it’s not a needle and doesn’t poke through her glove.
“I call it my little squirt gun that is just the size of their teeth,” Aberle explains. “Taking some of the unknown out of the situation always helps with kids.”
5. Tell, show, do to earn trust
Dr. Goodchild is a general practitioner, but he treats many kids and at one time considered specializing in pediatric dentistry. He uses the tell, show, do concept to build trust:
Tell: Tell the patient what you’re going to do.
Show: Show the patient how you’ll do it.
Do: Do it.
Dr. Goodchild says if you can get compliance and then do it, it’s the old “I say what I do and I do what I say” message to earn their trust. He finds it especially useful with handpieces and dental instruments - but not the needles. “You never show them the needle,” he says.
6. Don’t underestimate the power of distraction
Dr. Jennifer Sanders, a private practice general dentist in rural Frenchtown, Montana, treats families, which works out to around 10 percent children. Many challenges with her pediatric patients stem from fear of the unknown. Dr. Sanders uses many methods to manage their anxiety, including the tell, show, do technique. However, if that doesn’t work, she tries to distract them with conversation.
Many operatories have TVs that play kids’ programming. However, distraction techniques don’t have to be fancy or high-tech.
“As much as I would love to have TVs in our rooms, we don’t. So, we talk to them and try and get them to move their toes or focus on something else,” Dr. Sanders says.
7. Pick up the pace
Dr. Goodchild says pediatric dentistry isn’t that different from adult dentistry for the most part. The significant difference is that you don’t have the same amount of time.
“Adults can sit there and can open their mouth. They can work with you a little bit,” he says. “Kids, that is not always the case. Sometimes you have to be really on your game to work within their timeline. If they are going to be compliant for a little while, then you better get it done in that little while.”
Aberle agrees. “Some offices like to get you into the office and then wait for the dentist to come in after a while. Then, the dentist comes in and has to get things situated, so more waiting. With kids, minimizing that buffer time is helpful,” she says.
Up next: Develop a kid-friendly office...
8. Develop a kid-friendly office
A kid-friendly office, from the staff to the office décor, can do a lot to make children feel comforted, and it sets the tone for the appointment. Sanders works one day a week in a pediatric practice with a train station theme. “We attract quite a few kids,” she says.
A kid-themed office not only looks fun but it’s non-threatening, putting the child at ease. Dr. MacLean, a mother of two, co-owns her private pediatric practice with another female dentist and mom. Together, they’ve built a team of assistants and hygienists who love working with children. The right environment and staff improve the experience for everyone, from patient to parent to staff.
“We have a movie theme in our office. When you walk in, there is a marquee that says, “Welcome new patients,” with each new patient’s first name listed. The kids get so excited when they see their name up there,” Dr. MacLean says, “Parents tell us that their kids are actually excited to come here because we’ve made it child-friendly.”
Dr. MacLean’s office features bright colors, toys, books, play areas and features that are at the kids’ eye level. They have lots of TVs and even a video game room. “That’s pretty common in pediatric offices but not all of them. Sometimes they look kind of sterile. To a kid, a sterile office can trigger a little anxiety.”
Clarke says one way to be kid-friendly is for dental professionals to speak their language and to be up on the current trends for kids. “It creates this connection where you can have a conversation with them about something that interests them at their level,” she says.
9. Brush up on your behavior management skills
Kids will be kids, but as the authority figure in the practice, you’re responsible for managing their behavior in the chair. Dr. MacLean thinks good behavior management skills are the No. 1 way to make pediatric dentistry easier.
Dr. MacLean notes that over the past decade, due to changes in parenting styles and pediatric dental training programs with a heavy emphasis on hospital dentistry, there has been an increase in the use of sedation.
“Anybody can work on a kid who is unconscious,” Dr. MacLean says. “What makes a pediatric dentist special is their training in child development and psychology, along with their ability to develop trust with children and their families.
We need to work with these small people and build their confidence. Sometimes I feel like behavior management is a dying art form”
Dr. MacLean thinks that working with children requires patience, getting down to their eye level when you communicate with them, and keeping them entertained with your words. “I like to tell silly stories and I even sing to them,” she explains. Investing in the patient experience creates a fun and pleasant appointment that not only benefits the child but also the practice’s bottom line.
“When you are patient and kind and spend the extra time to develop trust, you give the kids an experience where they beg their parents to come back,” Dr. MacLean says. “Nothing can give you better word-of-mouth, free advertising than a happy customer who tells all their friends, ‘My kids love going to the dentist!’”
Aberle says timing the appointment is another way to make it easier to have a successful experience. Whoever schedules for the practice should work with parents to find out what might be the best possible time to foster cooperation with their kids.
“Parents will know better than anyone what the best time of day is for their kids where they are the freshest, or at least a time when they are not hungry, not tired, and they don’t have a million things going on in their head,” she says.
10. Know when to quit
There are times when even your best efforts may not work. Some patients need a specialist who can sedate them so that the treatment won’t be as traumatic. Acknowledging when it’s time to refer a patient to a trusted pediatric office well-equipped to manage some of these challenges can improve the outcome for patients. Sanders says that all dental professionals need to know where that line is in their practice.
“Have the conversation with the parent. Tell them that you are not giving up on their kid and that you want this to be a positive experience. Tell them you don’t want their kid to panic every time he or she hears a dental drill or sees a dental chair. It shouldn’t be that way,” Sanders says.
Clarke agrees, emphasizing the importance of those early positive experiences to prevent adverse effects later. Sedation could be the best option for some fearful young patients.
“Don’t be afraid to use nitrous oxide with them because it helps chill things out a little bit,” Clarke says. “The more positive experience a person has in a dental office minimizes any negative impact. If we can start with positive experiences early on, that can make a tremendous impact.”