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Treating children: A general practitioner's perspective

April 1, 2006
Over the last five years, I have been fortunate to treat children ranging in age from 2 to 16.
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Over the last five years, I have been fortunate to treat children ranging in age from 2 to 16. As a result, I have gained valuable insight into some key factors that are essential for successfully managing a pediatric patient pool. This article is not intended to address treatment regimens nor methodology for working with young patients, but simply to provide my own observations as a general practitioner providing treatment for children.

My interest in treating children has evolved over several years. It has been nurtured by many talented colleagues. Working with these dedicated professionals, I have learned that treating children is a unique, memorable, and important part of general dentistry. It affords the patient, the practitioner, and the parents with an opportunity to lay the foundation for future dental and systemic health. It also can cultivate the beginning of a long-term, healthy doctor-patient relationship.

Dental problems

The following is a list of the most common dental problems - with examples - that I have observed among a vast majority of children:

1. Infection: Toothaches/abscessed teeth

2. Trauma: Avulsed/fractured/chipped front tooth

3. Decay: Primary/adult teeth show signs of extensive decay

4. Growth: Over-retained primary teeth

5. Space management: Tooth/jaw size discrepancies

6. Dental anomalies: Missing teeth/Microdontia/Macro-dontia

The management of all these problems requires an understanding of the issues that impact the delivery and success of treatment.

Treating children

What is so different about treating children? There are several differences compared to the needs and characteristics of adult patients. These differences arise from challenges surrounding the behavioral, disciplinary, emotional, and parental issues impacting the delivery of treatment to children:

Expectations: Adults have preconceived notions of what to expect at the dentist’s office. Most children do not. However, those children who do have misconceptions and apprehensions usually have them due to the influence of friends and/or family members.

Parents who bring their little ones to their first dental visit often display a great deal of anxiety and nervousness surrounding this appointment. Typically, the parents’ expectations are very high. Parents want their child to be caries-freeor, at the very least, they want the child’s experience to go smoothly. Frequently, a negative experience a parent had as a child is reflected in his or her unfavorable attitude toward dental health and dental health providers.

Aside from performing the actual dentistry, the practitioner’s new goal then becomes to convert an apprehensive, dental-phobic child and parent into compliant and conscientious patients.

Communication: Adults generally can express themselves clearly about any fears they have or pain they are experiencing. Children are limited in their ability to do this. Fear of pain is a common denominator among all patients, and working towards alleviating that fear is one of the greatest challenges in children’s dentistry. Reducing the transmission of dental fear from parent to child is difficult. This obstacle can only be overcome by openly discussing the parents’ concerns prior to and after treatment. If an open channel of communication exists, it can serve to diminish anxieties and fears. Being able to transform a fearful visit into a trustworthy and enjoyable one for both the patient and parent is a positive achievement for all.

Patient reaction: Adults tend to react in a predictable fashion. A child’s reaction can vary from passive to uncontrolled, depending upon many variables and distracting factors, such as the presence of parents or family, time of day, health status, behavioral disabilities, and/or emotional disorders, to name a few.

Attention span: Most adults tend to have a reasonable attention span during treatment, and they follow instructions. Children have a very short attention span and need to be constantly engaged and directed. They can be easily distracted and misguided in the dental setting. If their energy isn’t guided in the most beneficial manner, it can wear out both the child and the dentist, inadvertently affecting the quality of service.

Behavior management: Children require the extensive use of effective behavioral-management techniques. They will carry any poor or traumatic experience with them into adulthood, thus creating a prejudice or biased attitude. Many nonpharmacological, behavioral-management techniques exist that can be applied to treating children. These techniques are easily available to general dentists. Through the years, I learned from colleagues that case selection, personal technique, and an open mind are critical to the success of any treatment.

Lessons learned

What follows is a summary of “lessons learned” to serve as a guideline for general dentists who may be interested in treating children.

1) Exercise patience: Avoid rushing the child or the parent. The pace of a first-time visit will be slow, since educating the patient (and the parents) and removing anxiety-causing stimuli must occur. Trust between the dentist and the child - and parental confidence in the dentist - must be established. The parents’ interpretation of “customer service” is in the context of the child, and a good impression will invariably serve to bring you further business. “Word of mouth” marketing is still the most effective way for enhancing your practice!

2)Practice precision: You usually have only one chance to change that scared patient into one who is more relaxed, and only one chance to do the whole thing the right way! Ninety-nine percent of the time, Little Johnny isn’t going to let you recontour your prep because you don’t like the line angle in your proximal box! The pressure certainly mounts as you must achieve an ideal prep, remain millimeters away from that pulp, be certain no caries still exists, and try to achieve perfect visibility in a tiny, fluid-filled environment! Let’s not forget that we also want Little Johnny to leave the office with an ear-to-ear grin and tell Mom about his positive dental experience!

3)Improve speed: This goes hand-in-hand with precision. Keep in mind that quality should be in direct proportion to speed. During a 30-minute appointment, it’s likely that Little Johnny will be restless after the first 10 minutes. Once your patient becomes restless, then try working on a moving target! Speed will be one of your antidotes for dealing with children who don’t have patience. Furthermore, the more you do, the better you get at it. So, don’t shy away from treating them.

4)Demonstrate flexibility and creativity: Adapt your style to suit the patient’s needs. Every child is unique and presents a different set of challenges. How about engaging the child with a song, or a discussion of sports, last night’s TV show or their favorite cartoon? Learn the “art of distraction” quickly. If you can keep their eyes and minds busy by either discussion or a form of media, they won’t realize time has passed. Before you know it, your treatment will be complete! Channelling their energy and diverting their attention can work to your advantage during treatment.

5)Use nonverbal communication techniques: In addition to having an understanding of the child’s dental needs, it also is helpful to be able to relate to their emotional needs. The ability to anticipate movement and interpret a child’s expression is an invaluable skill for any practitioner interested in increasing his or her pediatric patient pool. Holding their hand, giving them a “thumbs-up” signal, or turning the room lights off to set a quiet mood/tone will have an effect on the manner in which treatment is conducted, and the manner in which children respond. The trick is to determine the style of communication to which your patient is most receptive.

6)Exude a positive attitude and enthusiasm: Your energy and enthusiasm are contagious. They will help you to deal with a patient who is “wired” to be impatient and apprehensive, and build a sense of trust and fun. If a child senses that the procedure will be lighthearted, energetic, and fun, he or she will be more apt to try to work with you and cooperate.

7)Focus on teamwork: Performing treatment on children demands teamwork with assistants and staff members who are child-friendly and knowledgeable. Superior quality dentistry cannot be performed on a child without the help of a second set of experienced hands! Remember that “each child is precious to someone.” This means there must be a constant awareness that the patient’s needs come first, above and beyond all other office and personal issues.

Working with children can be joyful and rewarding because of the challenges and opportunities associated with creating an enjoyable and lasting first impression on an inquisitive mind. Apart from the chance to build a new and positive image associated with the child’s first-time dental experience, you are establishing the foundation for the child’s dental health, dental IQ, and overall self-image.


Success criteria

Here’s the acid test scenario for successful treatment:

The patient is happy.
The parent is satisfied that the necessary treatment was provided and that his or her child had a positive experience.
The treatment itself was successful.
The parent understands the postoperative directions.
The parent is willing to refer other patients to the office.
The office staff members feel satisfied that they put in their best effort.
Finally, the practitioner feels personal satisfaction, having rendered superior quality care and knowing his or her efforts were rewarded professionally and financially.

Achieving all of the above is akin to performing a tightrope balancing act while treating children. The presence of a fantastic support staff that enjoys working with children - and who has experience with them - is imperative to this success. Seeking help is a crucial part of the successful treatment formula. Following the principle of “do no harm,” knowing the limits of your capabilities, and drawing upon your staff and colleagues for their expertise and experience are some of the most critical and difficult judgments to be exercised in a general practitioner’s career.

Priya Kothari, DMD, graduated from Boston University’s School of Dental Medicine in 1997. Since completing an AEGD residency at the University of Pennsylvania, she has been practicing general dentistry and has developed a keen interest in improving office productivity and efficiency. She currently practices in King of Prussia, Pa., and also is a pediatric dental resident at Temple University. Dr. Kothari can be reached by e-mail at [email protected].

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