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Hygienist's View of Children • Pediatric Dentistry and Rubber Dam • Treating Children

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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 or he can be reached by phone at (360) 413-5760 or e-mail at

This article was originally printed in Dental Equipment & Materials January, 2003

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