Written by Janet Hagerman, RDH Sunday, 30 November 2003 19:00
The crying started, then the wailing, then the screams. The patient was pediatric. I was in the office of a dentist who is often troubled when working on children. I, on the other hand, love treating kids because I know the secrets to perfect pediatric patients. There went the screams again. Little Jimmy could be difficult. More screams. Louder now. “No, I won’t do it. You can’t make me!” Feeling compelled to intercede, I peered around the corner asking, “Can I help you with little Jimmy?” Wide-eyed, the assistant proclaimed, “It’s not the kid screaming. It’s the doctor!”
|Table. Common pediatric expressions|
The following are core beliefs of outstanding pediatric healthcare providers:
(1) Children are excellent patients when properly introduced to the dental office. This belief must permeate all you say and do to result in a self-confidence that the child will perceive as authoritative yet supportive and nurturing.
(2) The first-time child patient, under normal preventive circumstances, has no reference to fear dentistry. Any fear has been introduced by another person or situation. This is important to establish at the beginning of an appointment. If a child who has never been to the dentist is fearful, ask the parent why the child is afraid, then listen carefully. Typical reasons may be prior unhappy experiences in another medical office/hospital or taunting from an older sibling. It’s important to learn these reasons so you can act accordingly. Sometimes parents project their fear onto the child. This needs to be addressed from the beginning. It’s important to be clear with the parents and child that your absolute expectation is for their child to have a fun and positive experience with you that will establish the foundation for a lifetime of productive, enjoyable dentistry.
(3) Praise is powerful. Take advantage of every single opportunity to praise your patient, always ending on a positive note.
(4) Children have short attention spans that must be occupied. Giving children the opportunity to become bored creates cranky, tired, apprehensive children. Don’t give them (and their parents) the opportunity to “wonder and worry” in anticipation of their appointment.
(5) Patient education regarding expectations and procedures must be accomplished quickly, effectively, and in a manner that is fun. Preparation, explanation, and flexibility are keys to accomplishing this.
Pediatric radiographic protocol is as follows:
•New patients 3 to 5 years old—2 anterior occlusal periapicals and 2 pedo bitewings.
•Recare patients—bwx annually
•Six-year-olds—panorex, then every 3 years to monitor development of permanent dentition and third-molar eruption pattern
•Posterior periapicals—taken to monitor specific problems
PROPHY, FLUORIDE, AND EXAMINATION PROTOCOL
The maximum time for a child rubber cup polish for deciduous teeth should be no more than about 3 to 5 minutes. The majority of chair time will be spent building rapport with the child and introducing equipment and procedures. Ask the child, “Do you brush by yourself or does your mom help you?” Kids are reliably frank, and this information will help you deliver appropriate home care instructions to the parents.
THE 5 GOLDEN RULES OF PEDIATRIC COMMUNICATION
(1) Explain each procedure. This is crucial for the first- time patient. The equipment and instruments can be very intimidating and frightening to a child. For example, tell the first-time patient, “My special chair is going to take you for a ride. Here we go, I’m going to count/tickle/take a picture of your teeth.”
(2) Establish clear expectations. Don’t beat around the bush pleading for cooperation. Tell children exactly what you want them to do. Some examples are the following: (1) “Bite on this (x-ray film) like a cracker.” (2) “Listen for the beep.” (3) “Give Mr. Thirsty a kiss.” (4) “Put your hands on your lap.” Children usually are eager to follow directions when expectations are clear.
(3) Solicit participation. Kids love to help. Utilize them as your assistant. Have them hold Mr. Thirsty in their left hand, provided you are approaching the chair from the right. Helping you keeps their attention occupied in a positive manner.
(4) Praise and encourage. It’s amazing how seldom people (young and old) get praised. It works wonders. Some examples: (1) “I’m so proud of you.” (2) “Your mommy will be so proud of you.” (3) “You took great x-rays!” (4) “Here’s a sticker for helping me so much.”
(5) Ask questions that require an acceptable response. Avoid yes and no questions. For example, never ask, “Do you want to get your teeth cleaned today?” Instead, ask, “Shall we count/tickle your top teeth first or your bottom teeth?” Questions like this give a child a feeling of choice while expediting their cooperation.
THREE KILLERS OF PEDIATRIC COMMUNICATION
(1) Mom in the room. Don’t do it. It’s imperative for you to establish one-on-one communication with your child patient, creating an independent, trusting rapport. This seldom occurs with mom present. Moms think they mean well but are almost always a destructive distraction to communication. A typical 3-year-old new patient, present for a preventive appointment with no pain, should be able to have a prophy, x-rays, and fluoride treatment with no mom present, provided that the hygienist knows how to handle the pediatric patient and the office is committed to– and prepared for–this philosophy. This appointment should be a new adventure for the child and fun for the hygienist too. Do invite mom to join for the exam. By this time, the child should be compliant and proud of the completion of the first visit. Now is the time to brag to mom about what a good helper the child was.
(3) The H word (“hurt”): Don’t say it. I never say, “This won’t hurt.” It plants a seed I don’t want even remotely considered. Instead, preframe your child patients positively with phrases like the following: (1) “You won’t feel this picture, but you’ll hear it.” (2) “You’ll hear a click/beep. I want you to listen for the click.” (3) “This might tickle a bit. Does it tickle yet?”
SUCCESS STRATEGIES FOR NONCOMPLIANT BEHAVIOR
Sometimes, circumstances dictate working with a totally uncooperative child. Examples may include babies with bottle mouth syndrome, traumatized children who have fallen or who have been in an accident, and behavior management challenges. In these instances, it is important to complete the necessary procedure quickly, efficiently, and safely, despite crying and sometimes screaming with flailing limbs. Always document the nature of noncompliant behavior and how it was handled in the patient chart. Here are 2 strategies to help you with the most common challenges.
(1) X-ray protocol with noncompliant child. Have the parent sit in the x-ray chair. Sit the child on the parent’s lap facing up, resting the child’s head on the parent’s chest. The parent crosses his or her arms over the child’s arms and crosses his or her legs over the child’s legs. Place the lead apron over child and parent. The parent’s embrace helps to soothe the child while securing him or her safely and unmoving for the x-ray. This sometimes requires the assistance of 2 dental healthcare professionals who should wear x-ray badges to monitor radiation exposure and lead aprons when applicable. If it becomes obvious that the child will need to be sedated for restorative work, x-rays can sometimes be postponed until that time.
(2) Exam protocol with noncompliant child. Have the parent sit on a chair opposite from and facing the doctor (or healthcare giver). Have the parent lay the child on his or her lap so the child is facing up with legs toward the parent and head resting on the parent’s knees. The parent can now hold the child’s arms while the clinician can look into the child’s mouth to diagnose dental problems.
TOOLS FOR PEDIATRIC DENTISTRY
Although the caries detection device Diagnodent (KaVo) benefits all types of patients, it is especially useful for the child patient. This procedure is quick and easy and should always be used prior to sealants to be absolutely certain there is no incipient decay present beneath the grooves you intend to seal.
TIME MANAGEMENT AND MARKETING TIPS
Manage your pediatric patients in a select time and space by creating Kid’s Day. Select 4 days per year (one per quarter or more if needed) and schedule only kids that day. Plan to restore as well as provide preventative treatment so patients get all dental treatment completed in the same day. Coordinate this with a holiday or create a seasonal theme (Halloween, sports, spring, etc). Promote and advertise this day. Decorate the office. Wear costumes. Have fun! Your adult (especially cosmetic) patients will appreciate the absence of child distractions, and your child patients and parents will love you for the special attention. You will significantly reduce your level of stress.
Once per year, contact a local nursery school to schedule a customized visit-the-dentist field trip. Promote and advertise. Also, use this as an opportunity to convert a previously noncompliant child patient by inviting the child and parents to join this day. Bring a group of no more than 35 children with their teacher for 2 hours in the morning. Do this when the office is closed, such as Friday from 9 to 11 am. Start in the reception room, where children can meet the dentist and hygienist. One staff member remains present and conducts story time about the dentist and oral health. Remaining children tour the office in groups of 5 to 6 with a staff escort, visiting such stations as the following: (1) operatory station–staff member provides show-and-tell with gloves, mask, glasses, and intraoral camera tour for 1 to 2 children; (2) photo station–staff member takes Polaroid of each child; and (3) toothbrush station–RDH or assistant demonstrates tooth brushing. Take-home bags can include toothbrushes and floss holder, stickers, coloring book, office business cards and/or brochures (children’s dentistry, sealants, etc), child’s Polaroid photo, certificate (“I visited Dr. Smith’s office”), and T-shirts with office logo.
Offer your patients a dental ID for safeguarding children. Toothprints (Kerr Corporation, kerrdental.com) are a wafer the child bites into under dental supervision. Like fingerprints, dental imprints are unique; they serve as accurate methods of identification. The parents keep the Toothprints record for quick access. Many offices are offering this quick-and-simple procedure for a minimal cost or as a complimentary service, while others use it as a marketing tool, practice builder, and community service.
Always take a Polaroid picture of the new child patient with the doctor for the patient to take home and put on the refrigerator or on a mirror. This can be easily done by the hygienist or assistant just prior to dismissing the child from the exam. Be sure to label the photo with the name of child and doctor.
Have T-shirts made up with office name and logo, with sayings like “We Love Kids,” “No-Sting Dentistry” (advertise air abrasion), or promoting your Kid’s Day theme.
Give away stickers and prizes for no cavities, best attendance, great home care, best improved behavior, and Kid’s or Nursery Day.
Handling children in the dental office doesn’t have to be intimidating for the child or for you. Use these success strategies to transform troublesome and terrifying children into children who are model dental patients who you love to see walk through your door.
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