Recent developments in dental materials, techniques, and technology are designed to ensure that GPs and pediatric dentists have everything they require to treat children’s oral care needs. This helps to put children and parents at ease in an environment that can cause anxiety.
But getting proper oral care from a young age can be critical in terms of building good habits early on. It helps educate children and their parents on the importance of a healthy mouth and healthy diet, and on protecting and keeping that smile for many years to come.
That’s why we applaud the many product and technique advances over the years that have helped make going to the dentist better for and easier on everyone—the patients, the dental team, and the parents or guardians of young patients. Many methods, treatment plans, technologies, and dental materials have come along that make going to the dentist less stressful, less painful, quicker, and more successful. Most of these enhancements help all patients, but many were developed specifically with young patients in mind.
Minimally invasive procedures have replaced some traditional methods of drilling and filling children’s teeth. Where many a clinician years ago might have watched for potential caries to occur in a youngster’s mouth, they now can turn to newer materials and methods designed to fight the spread of caries in its earliest stages. Materials such as glass ionomers, silver diamine fluoride (SDF), varnishes, flowable composites, and toothpastes with additional fluoride or calcium and phosphate offer caries prevention and less invasive treatment alternatives to help improve children’s oral health. These often prevent caries in cases that previously may have led to major oral health issues. Effective strides have been made in other areas. Better methods for the delivery and buffering of anesthetics and the delivery of nitrous oxide sedation, the increased use of dental lasers, as well as great-fitting pediatric crowns, have enabled general practitioners (GPs) and pediatric dentists to better serve children in their practices.
Although pediatric dentists now have a new armamentarium to better treat these youngsters, they know it’s imperative that GPs also are aware of each and every one of these newer, proven treatment methods.
“We would love to see every child, but that is not possible. We need the GPs’ help, and we need them to take good care of kids,” says Ben Curtis, DDS, a pediatric dentist in Dallas, Texas. “It takes all of us, the GPs and the pediatric dentists. I view it more as: How can we all work together to help the children be able to get the care they need?”
Dr Curtis, who did his residency in pediatrics at the Children’s Medical Center Dallas, began his career at a private practice that utilized lasers and that’s how he got started with using the technology. He regularly uses the Waterlase iPlus all-tissue laser from BIOLASE, and lectures to dentists on just how valuable a tool it is for pediatric patients. Many GPs are aware of the benefits to using a laser for soft tissue procedures such as frenectomies, but Dr Curtis stresses the added benefits of using a laser for hard tissue procedures. Many of those can be performed not only without the children having to get the “dreaded needle” but also more quickly and in fewer visits—huge plusses for both children and their parents.
“I use an all-tissue laser, meaning that I do both cavity preparations and soft tissue things like a frenectomy,” Dr Curtis explains. “In the pediatric world, when you say lasers, everybody thinks frenectomy, and really that’s one of the big things. I’m trying to help people appreciate all that the laser can do for you, not just frenectomies. So I’m speaking at the AAPD [American Academy of Pediatric Dentistry] this year in San Diego and my course is really all about lasers doing so much more.”
But Dr Curtis is the first to tell you that lasers are just one of the many more recent developments in pediatric dental care. These include SDF products, stainless steel primary molar crowns, glass ionomers, newer toothpastes and toothbrushes, varnishes, and even just the knowledge of techniques and methods designed to improve care for young patients. TVs, music, virtual reality headsets, and now even robots are being used to help distract anxious patients and keep children calm in the dental chair.
Minimally Invasive Methods
Jeanette MacLean, DDS, is a pediatric dentist at Affiliated Children’s Dental Specialists in Glendale, Arizona, who is internationally recognized as an expert and advocate for SDF, Icon resin infiltration (DMG America), and minimally invasive dentistry. The practice’s website (kidsteethandbraces.com) offers a wealth of information with videos illustrating SDF techniques, featuring Advantage Arrest by Elevate Oral Care and silver modified atraumatic restorative technique (SMART) minimally invasive treatment options for cavities treated with SDF and glass ionomer cement from GC America (Fuji TRIAGE, Fuji II LC, EQUIA Forte).
“In the United States, we’ve been late to the minimal intervention party, but I have tried to help raise awareness and increase adoption or utilization of noninvasive techniques,” says Dr MacLean, who was featured in a New York Times article on SDF as a pioneer of its use more than 5 years ago. “Compared to how I was trained in…the late ‘90s/early 2000s, it’s a big change because now people are starting to realize we don’t have to overdo it [with aggressive treatments] for every single situation. Tooth preparation can be more conservative; we don’t have to drill a big hole in every tooth. Not every kid with cavities needs sedation or general anesthesia.”
In recent years Dr MacLean has switched away from resin sealants to glass ionomer sealants with great success. She’s a big fan of the GC America line of glass ionomer products as well the company’s other products featuring MI Paste, the only products for professional use containing the active ingredient RECALDENT ™ (CPP-ACP), a special milk-derived protein that has a unique ability to release bio-available calcium and phosphate (and fluoride in MI Paste Plus) on tooth surfaces. MI Paste Plus offers the same benefits of MI Paste but is enhanced with a patented form of fluoride (900 ppm). Both products are safe and easy to use in office and at home, and are available in 5 flavors: melon, mint, strawberry, tutti-frutti, and vanilla.
“Everyone knows and loves Fuji TRIAGE [glass ionomer sealant and surface protectant], but GC enhanced that by adding the MI technology, RECALDENT, and now offer Fuji TRIAGE EP, which stands for ‘extra protection,’” she says.
These glass ionomers and pastes that can be used in office and at home have helped make a big difference in providing minimally invasive care to both pediatric and adult patients.
“That’s the secret sauce,” she says of RECALDENT. “They’re providing remineralization with fluoride as well as calcium and phosphate.”
Dr MacLean has used MI Paste products for years, but wants other practices to know there are some uses that they may not be aware of.
“We use MI Paste for obvious things like as a toothpaste, treatment of white spot lesions, desensitizer, and for dry mouth,” she says. “But we also use it to treat congenital enamel defects.” For example, she’s performed procedures on teenagers with “white frosty looking spots on their front teeth”. Dr MacLean will etch the surface and apply MI Paste as a noninvasive alternative to drilling them out and placing bonded fillings.
Another plus for glass ionomers over resins is that procedures can be performed without the isolation and rubber dam usage required for many resin procedures, something that can make working on children with small mouths and anxious movements a lot easier to deal with.
“If you don’t want to pull your hair out trying to do the kind of ridiculous isolation that you need for resin, glass ionomers are more user-friendly because they’re hydrophilic,” Dr MacLean adds. “But quite frankly, it’s just better for the teeth because we see less recurrent caries and reduced post-op sensitivity; it’s a win-win.”
Dr Curtis appreciates that pioneers like Dr MacLean have helped create awareness of these newer methods and materials. However, he believes there is still work to be done to help ensure that GPs are well aware of these options.
“Many GPs may not be very familiar with SDF,” Dr Curtis says. “They may have read an article or heard that it turns the teeth all black. But this black stuff is amazing.”
He adds that dentists’ only option used to be to just monitor small incipient caries and suggest the child lay off juices and the parents help brush and floss better. “We as the dentist would hope for the best and wait to see if it grows. But that’s not the case anymore. We should put SDF on this. That would be the bread and butter treatment at a GP office. You see an incipient, you don’t put a watch on the chart, you put SDF on the tooth. Rarely do I ever just mark a watch on a tooth for a potential cavity,” he says.
It was common maybe as recently as 5 years ago for dentists to watch several teeth in a child, but Dr Curtis considers this similar to “watching a bomb go off” when the caries worsen.
“Now we don’t just sit back and twiddle our thumbs and tell the parent, ‘Well, it’s up to you,’” he adds. “Now we’ve got a lot more skin in the game and that’s how we prevent it. We present this to the parents. We can be more proactive. We can be more helpful on our end of the deal by putting this medication down that’s going to help kill the bacteria right there at the source. It soaks into the tooth like a sponge; right where you need, it turns the little area that’s trying to be a cavity black, and it can either help stop [that] in its tracks or buy us more time.”
He adds that this method is especially effective with young patients, such as a 2-year-old who struggles to sit still in the dental chair and who is not yet capable of improving their brushing and flossing protocols.
Another technique gaining traction in the US is the Hall Technique, a noninvasive option for the placement of stainless steel crowns on primary molars with vital pulps. Dr MacLean describes this dental treatment as quick, painless, simple, and effective, with high levels of evidence, including 10 randomized control trials. It can help young or fearful patients avoid shots, drills, sedation and/or general anesthesia while allowing the dental team to treat caries. This treatment is standard of care in the UK, with its origins in Scotland more than a decade ago, and Dr MacLean and others are hopeful it will be more widely adopted as a minimally invasive option in the US.
Chad Jensen, DMD, a general dentist at Super Smiles in Harrison, Arkansas, who works exclusively with children and teenagers, also uses SDF and the Hall Technique, and he too has had great results.
“I started using silver diamine maybe 2 to 3 years ago. It [has] such a critical role in my office at this point for the short-term treatment of dental caries,” he says. “The SMART technique is basically silver diamine fluoride, and then you place glass ionomer cement over [the] top.”
The Hall Technique, which you can do with or without silver diamine fluoride as an initial caries treatment, involves placing orthodontic separators to create space between the teeth, instead of numbing and drilling the tooth, then a stainless steel crown filled with glass ionomer cement is placed overtop of the tooth, sealing off the caries lesion from the biofilm. The caries arrests and the odontoblasts in the pulp lay down a protective layer of secondary dentin. This technique has proven to be extremely effective for Dr Jensen.
“If I have the shape and the anatomy of the tooth is correct, and if the child is somewhat cooperative, all you do is very simple,” he says, noting that depending on the situation, they can be placed the same day. “You take a stainless steel crown, and you fill it with a glass ionomer cement and you firmly push it down over top of the crown and stainless steel crowns adapt to the tooth, and you can kind of snap it over top.”
Manny Friedman, BDS (WITS), BChD HONS (PRET), DDS, MSC, teaches endodontics at Schulich School of Medicine and Dentistry at Western University in Ontario, Canada, and has been using bioceramic dental materials with children for many years to provide vital pulp therapy (VPT). Advances in these types of dental materials, he explains, allow clinicians to keep the pulp nerves alive so the root can continue developing. In instances, for example, where a child has suffered a traumatic injury or the pulp is badly infected, products such as the MTA Repair HP from Angelus, a bioceramic reparative cement, can be quite effective. MTA Angelus features calcium ion release to enhance the formation of mineralized tissues, providing a biological seal of perforations and total repair of damaged periradicular tissues.
“Where I come in on pediatric dentistry is I…have a brother in London who is a pediatric dentist,” Dr Friedman says. “Essentially my interest was in endodontics, but any child that acquired any kind of root canal treatment, they would refer to me and I would look after them.”
Back in the 1990s, when mineral trioxide aggregate (MTA) dental materials with biocompatibility to oral and dental tissues first came around, Dr Friedman was using them to treat young patients’ permanent teeth rather than settling for extractions. MTA was developed for dental root repair in endodontic treatment and is formulated from commercial Portland Cement combined with bismuth oxide powder for radiopacity. Different from this initial Portland Cement–based material where the bismuth oxide showed to stain the dentin, the MTA Repair HP from Angelus uses calcium tungstate as radiopaquer, which prevents the dentin from staining.
“The whole idea with what we call vital pulp therapy is to keep that pulp alive so it can do its job and finish development of the root,” he says. “Why do we want to finish development to the root? Because the stronger the root, the longer it’s going to last.”
Before today’s bioceramic materials were developed, children who suffered trauma or had infected roots struggled to keep the pulp vital. Today’s calcium silicate cements have made treatment options so much better. These ceramic cements based on calcium silicate are commonly used in endodontics due to their good sealing ability, biocompatibility, and bioactivity, and as Dr Friedman states, they can help with treating children who might otherwise lose their teeth.
“Now with calcium silicate–type cements you’ve got something that creates a seal and prevents the bacteria from penetrating, which is why they are being used in children,” he says. “So the whole idea with this family of materials that have calcium silicate is it creates a good seal and…we can keep the pulp alive. The seal is the critical thing here so that you don’t get recurrent bacterial penetration or leakage.”
When it comes to choosing a bioceramic material, it’s often user preference that makes the difference. One clinician may just prefer how a material performs in their hands.
“I have used pretty much all the bioceramics that are available,” Dr Friedman explains. “There’s probably not one material that is better from a biologic point of view. In other words, is the Angelus product better than the one made by Brasseler [USA]? And then you’ll see a couple of manufacturers make these materials, change the label on it, and…provide [it] to a lot of distributors. But they all work equally as well.”
This is where handling properties and comfort in your hands play a role in your decision, he notes.
“For example, the Angelus root canal sealer in my hands is better than the Brasseler root canal sealer because, for me, it works,” he says. “That is the way I work now. If I see a new product, I personally try it out, and if it works better for me that’s fine. But overall, I haven’t found one that does a better job than another one.”
VOCO America manufactures a wide variety of dental materials, including a flowable composite that is ideal for dealing with small incipient decay. They also produce Profluorid Varnish, a 5% sodium fluoride varnish.
Canadian general dentist Carla Cohn, DMD, who limits her practice to treating children, is a longtime user of VOCO materials. She has received great results from the use of GrandioSO x-tra nano-hybrid bulk restorative and Admira Fusion x-tra single shade omnichromatic Nano-Ormocer restorative, along with glass ionomers.
“In terms of materials, …we’ve got improved dental materials…and we’ve got new, improved durability, particularly with GrandioSO,” says Dr Cohn, who has used this material since its inception a decade ago. “GrandioSO in its original format was a good product. And now with GrandioSO x-tra, because it’s a bulk fill, I’m not putting increments in tiny restorations for these kids. I want to get in there quickly and we want to get out fast.”
Using GrandioSO x-tra esthetic bulk restorative allows Dr Cohn to treat incipient decay in young patients quickly and efficiently. As all clinicians know, the longer a child sits in a dental chair, the more restless they may get and the more difficult the procedure can become. “The longer that we take in the chair, the more variables…with the cooperation of the parent and patient, and the more time we have for the procedure to turn south,” she adds. “If we can get in and out really quick, that’s great, and this material in particular helps me to do that. Also, I know that GrandioSO x-tra is very highly filled, so that’s not going to give me a shrinkage failure.”
Filling small cavities and repairing defects are recurring tasks in the dental practice. The primary goal is minimally invasive treatment to minimize the loss of healthy tooth substance. For these precise applications, dentists require a highly flowable material that at the same time displays the familiar strong physical properties and resilience of a packable restorative composite.
To accomplish this, VOCO expanded the GrandioSO product line with a low-viscosity nano-hybrid composite—GrandioSO Light Flow. The composite is thin flowing, precise, and strong. Above all, it enables a targeted and precise application with an extrafine cannula that is even finer than a periodontal probe. This makes it possible to avoid generating excess residue and save on material.
Dr Cohn suggests all clinicians who treat children should be familiar with products such as VOCO’s GrandioSO Light Flow and DMG’s Icon, which enables the immediate treatment of proximal and smooth surface lesions not yet advanced enough for traditional restoration.
“Things like Icon resin infiltration and now GrandioSO Light Flow are great minimally invasive products,” she says. “GrandioSO Light Flow has a really fine tip to the syringe, and when it came out, some people maybe [saw it as] just another flowable.”
But once she used GrandioSO Light Flow, Dr Cohn knew it was a great choice for her when treating children.
“VOCO developed it with the properties so that it is a flowable, but it still has a high filler content,” she adds. “It gets into these little, itty-bitty incipient caries, and I don’t have to make a great big preparation to be able to fill it. I can get in there minimally invasively, get the GrandioSO Light Flow in there, fill it, and have almost little to no finishing required because it’s so precise. It is really quick and easy and so I’ll use it in combination with GrandiSO x-tra. When something like GrandioSO Light Flow comes along, it’s a great product worth letting everybody know about for sure.”
Profluorid Varnish features an easy, nonmessy single-dose delivery system. It is transparent, causes no yellow discoloration of the teeth, and is available in 7 flavors. The varnish adheres well to moist surfaces, sets seconds after contact with saliva, and has a high immediate fluoride release to relieve hypersensitivity. Additionally, enhanced flow characteristics allow Profluorid Varnish to reach areas traditional varnishes may miss.
When the best choice for treating children is the use of pediatric crowns, there are choices, including NuSmile crowns and Hu-Friedy’s stainless steel crowns (Hu-Friedy is part of the HuFriedyGroup). In certain situations, these pediatric crowns can be the best long-term restorations for damaged or decayed teeth that can help to avoid multiple treatments as a child’s primary teeth develop.
Hu-Friedy’s stainless steel pedo crowns were developed to deliver consistent, accurate, and predictable clinical outcomes while allowing the practitioner to work more effectively and efficiently, ensuring more time for value-added services such as patient education and treatment planning. They feature a more narrow mesial-distal maxillary first primary molar width that allows for quicker adjacent crown placement. Pretrimmed, crimped, and contoured surfaces allow for less time spent chairside. The occlusal anatomy mimics the natural tooth while providing optimal occlusal thickness for superior resilience to abrasion and perforation.
Nitrous Oxide/Local Anesthetic
Clinicians know that there will always be anxious patients. No matter how much you try to make patients feel at ease, some of them will still have tremendous anxiety about dental care. One way to deliver treatment safely is to use nitrous oxide/oxygen sedation, which can make the patient’s experience much less stressful.
Nitrous oxide/oxygen sedation is especially useful for calming children’s fears of the dentist, and has been used for this purpose for many years to provide a positive and more relaxed experience. In the age of COVID-19, nasal masks are beneficial to patients in that they require patients to breathe through their nose and lessen their exposure to respiratory droplets. The American Dental Association’s published best practices for using nitrous oxide dictates using a single-use nasal mask and sterilizing tubing per the manufacturer’s recommendations.
The Accutron™ ClearView™ Nasal Mask from HuFriedyGroup uses a standard patient demand system for administering gas, which is designed to match the patient’s flow of breathing. The mask-in-mask design reduces ambient nitrous oxide and the clear outer mask shows patient “breathing through nose.” And the soft inner mask creates a better seal against the patient’s face for better administration of gas.
Another option is the Accutron Axess™ Nasal Mask, which operates on a positive flow system. With an even more low-profile design, it provides unencumbered access to the mouth while its small, lightweight scavenging system maximizes patient comfort. These nasal masks from HuFriedyGroup fit snugly without tape or uncomfortable tubes protruding into the patient’s nostrils, and are available at a lower cost than comparable single-use disposable options.
To help make patients even more comfortable and relaxed, both the ClearView and the Axess Nasal Masks come in scents and colors that appeal to patients, such as bubblegum and strawberry. Additionally, both of these nasal masks can be used with the Accutron Digital Ultra™ Flowmeter to deliver the right mix of nitrous oxide and oxygen to patients, featuring a completely flat surface for easy disinfection.
In procedures that require local anesthetic injections, the injection must cause children as little pain as possible and get to work rapidly. Because of this, some clinicians suggest the use of buffering agents. Dr Jensen believes sodium bicarbonate buffering is under-utilized in pediatric dentistry.
“I utilize sodium bicarbonate buffering…specifically because I want to make sure that I use that local anesthesia very effectively. I want to give [my pediatric patients] as little as possible so I want to make sure it’s effective,” explains Dr Jensen, who is also the founder of OCTOdent, an aerosol suction unit that was named one of Dental Products Report®’s Top 100 Products in 2021.
Two primary companies offer buffering supplies—Onpharma’s Onset and Anutra Medical’s Anutra Buffered Anesthetic. He says buffering is the norm in the medical world and that more dentists should use buffering agents in dentistry.
“Honestly, I feel like buffering is underutilized in dentistry. And largely, it’s really interesting to me because as I talk about buffering with my dentistry counterparts, I get a couple of responses,” Dr Jensen says. “The first response is usually ‘Yes, I’ve heard of that but I don’t know a lot about it and I didn’t ever use it.’ I’ve also [heard], ‘Buffering? I have no clue,’ and it’s a deer-in-the-headlights look; they’ve never heard of it at all before.”
Because dentists use so much local anesthetic, Dr Jensen believes it’s critical that buffering be indicated on a regular basis.
“In pediatric dentistry, you want to make sure that your buffering…increases the effectiveness, so if you max out on a patient with 1 carpule, you want to make sure that it’s as potent as possible without being toxic,” he explains.
Dealing With Anxiety
Many years ago dental offices attempted to make patients feel more comfortable in the operatory with artwork and wall colors designed to deliver a calming, soothing effect, and maybe even seating designed for better comfort and a less constrained feel. Music and later on TVs and computer monitors were introduced to further distract kids from dental treatments and any fears they may have when sitting in a dental chair.
As technology has evolved in every facet of our lives, it has brought more modern methods to stave off anxiety, including virtual reality goggles and even robotics. Now a child can sit in a dental chair, put on virtual reality goggles, and have a world of cool distractions to view and participate in while not even realizing the clinician is working in his or her mouth.
Then there’s Robin the Robot. Designed for children by scientists, engineers, and pediatric psychologists, Robin is the first emotionally intelligent robot used in pediatric dentistry. Standing at 47 inches tall, Robin’s curved body shape with smooth transitions along the frame’s edges ensures safe use and high levels of excitability.
Robin utilizes peer-to-peer interactions and engages children in various distraction techniques. These include interactive games, visual and auditory sensory modalities including images and music, and age-appropriate conversations to decrease stress about dental procedures. Study findings showed that children’s level of joy increased by 26% after they interacted with Robin and their stress level reduced by 34%. This resulted in a 40% decrease in the time of dental procedure preparation due to better cooperation with the dentists.
Amid the COVID-19 pandemic, Robin has become a reliable tool to meet children’s emotional needs when almost every child support method has been prohibited. The robot’s cutting-edge technology not only improves patient access to care but also helps dental practices provide a better patient experience. Clinics that use Robin leverage it in nonclinical areas as well, resulting in increased retention rates, new customers, and improved social media presence due to greater patient satisfaction.
Robin is also a great educational tool in pediatric dentistry. With its educational content, Robin increases children’s knowledge about various dental procedures, coping strategies, and healthy behaviors, which positively affects each child’s overall health. The robot also teaches children about dental hygiene, including correct brushing techniques and schedules, and which foods to avoid for better oral hygiene.
“Robin is changing the way our patients think about seeing the dentist by reducing their anxiety and increasing their excitement. Every young patient could use another friend and advocate at the dentist, and Robin improves the perception of ‘going to the dentist’ because it’s completely focused on patient experience and care. We’re so excited about the multiple ways we utilize this new technology in patient care, marketing, customer service, and, ultimately, brand differentiation,” says Matthew Schofield, DDS, MS, board-certified orthodontist and owner of Grapevine Kids Dental and Orthodontics.
Options Are Good
Although keeping every child and every parent happy may not be realistic, today’s clinicians do have more products, technologies, and methods at their disposal when it comes to providing dental treatments to young patients. Staying up-to-date on what’s out there is key, and confiding in colleagues and sharing ideas is also a plus.
“I think by having more options, I can satisfy more patients and their parents because we now have a variety of treatments available. Before I used to do very one-size-fits-all treatment planning,” says Dr MacLean.
A few years back much of the treatment for children meant sedation and crowns. Now some parents don’t want sedation or are looking for more cost-effective options or a minimally invasive approach that might benefit their children initially and in the long-term.
“Maybe you don’t like silver diamide because it’s black, but you don’t want zirconia crowns either because of the cost or the risks of IV sedation,” she adds. “Let’s compromise and do some of these other methods like glass ionomer strip crowns. We have more items on our ‘menu’, so we can satisfy more customers. By doing that, we’re able to retain patients better. We get a lot of internal marketing as the parents talk to other parents about the alternatives. Parents appreciate being involved in the decision-making and treatment planning process. I definitely think that helps keep people happy, and then they are more likely to follow through with treatment. They feel more in control, and lately in the pandemic, that’s a good way to keep people happy,” Dr MacLean says.
Another option, designed just for kids, is just around the corner from GreenMark Biomedical Inc., makers of LumiCare™ Caries Detection Rinse. The LumiCare rinse uses ionically-charged starch nanoparticles to identify early carious lesions. These particles are positively charged and attracted into negatively charged carious lesions. Once inside, they are activated by blue light and fluoresce a goldish green color. The early carious lesions can then be identified by the dental health professional.
Through early detection, dentists will better be able to diagnose and prevent disease. And the prevention of disease will lead to happier patients and better long-term oral health outcomes. The company is currently in the final steps of developing a children’s line of the LumiCare rinse called LumiKids™ Caries Detection Rinse. While the LumiCare rinse has been cleared by FDA for use on children ages 6 and above, GreenMark Biomedical wanted to adjust the quantity of rinse to make it more user-friendly for ages 6 to 11, and it added in more child-friendly flavoring and packaging.
Dr Jensen has similar beliefs on the importance of communicating available options to the parents or guardians of young patients.
“In the space of pediatric dentistry, I think it has made decisions a little bit more challenging because with some care situations there are a lot of people who are making a decision,” he says, noting that it’s no longer primarily the mother calling the shots for children’s dental care. “You know, in a traditional family home it’s just the mom, and dad would typically do whatever mom wants to do. But now I find more and more that I’m having to communicate with multiple people and multiple decision makers in the process, so that’s one of the big challenges. More and more I write down a lot of options and I really try and thoroughly communicate with the family.”