A Successful Approach to the Management of Children Part 3

Parents, children, and the dental team. The kids are here! Now what?
For many dentists the scariest sight is a child in their waiting room. In fact, it’s a tossup as to who is more apprehensive: the child, the parent, or the dentist. Hopefully after reading the first 2 articles in this series, we have a little insight as to what is going through the minds of parents and children prior to a visit to the dentist, especially the all-important first visit. The parents are already carrying a bag full of preconceived notions about dentists and dental offices based on firsthand experience and hearsay, and these notions are readily conveyed to the child directly or indirectly.

Arguably, the single most meaningful factor influencing the child’s attitude and behavior is the parental attitude. An uptight, overly indulgent, well-meaning parent trying to ease the way for his or her child can often cause a child who is not in the least afraid to become apprehensive. The child senses the parent’s apprehension. “Don’t worry, he’s a nice man,” “I’ll be right here,” and “It’s just like a mosquito bite; it just hurts for a second,” are among a parent’s “helpful” offerings.
It has always been my contention that although the parent of a child-patient should be informed and must grant permission for treatment, it’s advantageous for all concerned if the caregiver separates the parent from the child at the earliest opportunity so that a direct rapport can be established between that caregiver and the child. The same reasoning can be applied to teachers, coaches, and babysitters.
My life experience as a pediatric dentist, a father, and a grandfather have led me to the conclusion that almost invariably, children are better behaved, more flexible, and more attentive in the absence of their parents. So I have operated my practice, which shuns the use of sedation, nitrous oxide, premedication, or papoose boards, with the proviso that the “temporary custody” of a child comes with the responsibility to keep that child safe.
If I wish to point something out to parents or demonstrate a child’s good behavior for a mom and dad, I can call them into the operatory for that purpose. A newborn infant or a baby less than a year old would be accompanied by his or her guardian, but should any kind of treatment be involved, the guardian would be asked to wait outside.
In a recent American Academy of Pediatric Dentistry (AAPD) survey of pediatric dentists, it was noted that over the past 10 years, there has been a more than 80% increase in the number of dentists that allow parents in the treatment room during treatment. But only 9% of those dentists felt the presence of the parent made for a more pleasant child, parent, and dentist experience. Why did they let the parent into the operatory? The overwhelming response was legal ramifications…the threat of litigation. As a participant in a panel discussion amongst fellow specialists at a recent AAPD meeting, one colleague stated, “Parents today don’t trust anybody. Just look at the situation with priests. You have to go with the flow.”
What a sorry state of affairs if we have to conduct our professional lives with a gun to our heads. To be a teacher, a coach, or a dentist in today’s world is difficult enough without having to deal with the impression that our intentions are anything but honorable and trustworthy. The parent may feel the need to be in the operatory with the child, but his or her motivation is based on some preconceived notion that the child needs to be protected from someone who would do the child harm. The keystone of our profession is trust. Any other kind of atmosphere is intolerable.
Moreover, the very fact that the parent makes an issue of being in the operatory sends a clear signal to the child that the dentist cannot be trusted and that the parent is there to protect the child against a dangerous person…No way!

THIS IS WHO WE ARE
Your patients must have a clear understanding of how your dental office operates: your policies, your philosophy, etc. It is to your advantage to develop a simple office pamphlet or brochure that serves as an introduction to your office. It should set out in a concise manner your particular philosophy about dentistry in general and dentist-patient relationships in particular. In our office booklet, we discuss issues ranging from why we fix baby teeth and why we take x-rays to who gets the afternoon appointments and how we handle financial issues such as insurance, co-payments, and fees.
It is in this booklet that the clear statement is made about doctor/child relationships and how we’d appreciate the parents’ support and their willingness to entrust their children to our care. When the parent calls for the appointment, the usual information is gathered: age, reason for the appointment request, referral source, and insurance details (if any). Then the front desk person makes the obligatory statement about children being the most important people at the first visit and that we believe the doctor and child should initiate their relationship without parental influence.
When the parent and child arrive for the appointment, an emphasis is placed on being attentive to the child in deference to the parent. We welcome the child and thank him or her for bringing mom along. An inscription on the door leading from the waiting room to the operatory reads “Children Only…Parents By Invitation.” Every effort is made to give the parent more than ample opportunity to question, to approve, or refuse. Remember, the parent is ultimately the decision-maker. Thus, when the dental assistant walks out to the waiting room and approaches the parent and child, the stage has already been set for the child to make the journey to the operatory without mom or dad.
There are a very few instances where parents cannot come to grips with their anxiety and will say to the front desk person, in an aggressive manner, “If I don’t go in, then she doesn’t go in!”
In these infrequent instances, I meet the parent and child in my private office in an effort to elucidate further the no-parent policy. Mind you, this is not the best of situations, because the child has picked up on the fact that there is some kind of misunderstanding or conflict. It’s most important that I don’t show any displeasure or irritation when addressing the parent. I walk in smiling, and I say “hi” to the child using the first name; eg, “Hi, Julie, I’m Dr. Berman. We’re going to have some fun together. But first I have to speak with mommy.” As I sit down, I turn to the parent with a smiling face and say, “Hi, Mrs. Wilson, I understand there’s a problem.”
The most amazing thing happens at least 90% of the time. The parent will say, “There’s no problem.” But to settle matters once and for all, I proceed to explain that Julie is the most important person today, and we want her to have a good time, that the issue is trust, and she has to feel comfortable that we will make every effort to treat her daughter gently and competently.
“But what if she cries?” the parent asks. “She may,” is the answer, “but we’re very good with children who are crying.” The fact is that because the parent has made such an issue of the situation, she’s almost guaranteed that the child will cry. Some parents will even say, “Okay, but if she starts to cry, I’m coming to get her.”
Crying is a trigger for parental apprehension and guilt. It never ceases to amaze me that these same parents who are living with their overindulged children and raising them in an overly permissive home environment, where whining and crying are the order of the day, attempt to blame us for their child’s chronic malcontent. Cry-ing should not be an indictment of our professional cap-ability. How vivid is the memory of my mother who, when we were crying about something, would say, “You wanna cry? I’ll give you something to cry about!”

THE MOMENT OF TRUTH
First impressions are everything. That first moment that the child-patient and the dental office denizens encounter each other sets the tone for the relationship. Body language and facial expression, though unspoken, speak volumes. So when the dental assistant goes out to the waiting room to escort the child back to the operatory, he or she must ooze the same enthusiasm and excitement that you would expect from a camp counselor, nursery school teacher, or rush-week chairman for a sorority. “Are we going to have fun today or what?” No question about it! This is going to be fun!
Say a quick “hello” to the parent, but focus on the child. In fact, kneeling down to the child accomplishes 2 goals. First, you’re getting down to the child’s level physically, and second, you are now, in the case of a young toddler, in position to pick the child up in your arms as you’re speaking. Don’t ask, “Would you like to come with me?” It’s a smiling statement: “Come with me!” And then, “We’ll be right back, mom. Don’t go away!” is always a good line, because you’re saying exactly what the child wants to hear. Don’t lose courage in the event the child is crying, screaming, or even kicking. This is not a kidnapping. Move with confidence…firm, but gentle. You’re simply picking up the child, and you’ll be bringing him back shortly. In my experience and according to the unsolicited testimony of dental assistants and dentists I’ve encountered these many years in venues all over the world, the overwhelming majority of children stop crying as soon as their parents are out of sight. It’s essential that the dental assistant be personable, physically agile, and verbally active, otherwise the trip to the operatory from the waiting room could resemble Dead
Man Walking. This is not a death march!

FIRST THINGS FIRST—THE FUN BEGINS
Let’s arbitrarily assume that our new patient is a 4-year-old girl named Julie who might exhibit any number of behavior patterns. For example, the child may come in happy, talkative, eager, and curious (mostly in your dreams). Or the child has come in quietly cooperative, but obviously apprehensive. This patient just needs the routine show-tell-do approach blended with tender care and gentle talk, without which the behavior of this child could deteriorate. Or the child may come in reluctantly, screaming, crying, and even physically antagonistic and belligerent. The belligerent, screaming child is the one that gets our attention. Don’t tell the child to be quiet. Don’t yell, “Shut up!” Don’t call names like “You bad boy” or “You brat.” Don’t say, “Look at you, acting like a baby!” Don’t take away the child’s dignity. Speak in a controlled, mannered voice, using her name. You say, “Julie, you’re not being nice! Your yelling is hurting my ears. What do you want?”
The magic words…“What do you want and why are you crying and why are you sad?” Most often the child will scream, “I want my mommy!” Don’t respond with “You’re not going to your mother until you brush your teeth!” Instead, say what both she and you want to hear. “Of course you’re going to mom. You can’t sleep over. You didn’t bring your pajamas. Hurry up and show me how you brush, and let’s go to mom.” Give Julie the feeling that you want her to leave as much as she does. All she has to do is take the toothbrush and show you how she brushes. Life is conditional, and the ball is now in her court. You then pick up the brush, hand it to her, and say, “Okay, hurry up, Julie. We have to go.”
In every case, we immediately embark on a program of show-tell-do governed by the principle of showing the familiar first and then taking the child to the unfamiliar. In other words, show them what they know and then take them to what they don’t know. So many dentists and their assistants and hygienists feel an urgency to immediately put the child in the chair, throw the napkin on, turn on the light, and give the young patient the traditional ride in the chair (which many kids hate, by the way).
Don’t rush to put the child in the dental chair. Let her just stand on the floor or sit in your lap. We merely hand her the toothbrush and say, “So show me how you brush.” If she doesn’t take the bait, then you take her hand in yours and move the brush for her. And the repartee proceeds in the following manner, give or take the personality of the dentist or assistant. “Wait a minute, we can’t brush ‘cause you didn’t bring any toothpaste! Don’t worry. I have some, but only the good-tasting kind.”
Put a little toothpaste on the brush and then…another discovery, “Where’s the water? We need some water, right?” The cup and cup filler are over on the dental unit. Pick her up and put her in the chair so she can reach the cup, and bring your stool in close to the chair and sit down. “But be careful, we don’t want to spill the water on your pretty sweater. We’d better put this napkin on.” Put the patient napkin on. “Now we can brush! But hold it! You can’t see because you don’t have a mirror. Guess what? I have one right here!” Get the face mirror and hand it to her. “Wait a minute, it’s too dark. We need a light.” Turn on the light. “Now we’re all set. Show me how you brush with your new brush.”
Move her hand with the brush if she doesn’t do it on her own. “Very good! Mommy will be so proud. Now, where’s Dr. Berman’s brush?” I pick up the handpiece and begin to run the prophy cup on my fingers. “But I can’t do it on you, just on my finger. Whooo, it tickles! Maybe I’ll give you a turn on your finger….but just one!” So that’s how it goes. First your brush, then my brush, your mirror, then my mirror. Step by step we introduce all of the elements in a logical progression, each step motivated by the previous one.
Once the child is under control, the parent is invited to look from behind through the glass doors of our multichair open operatory. Julie is unaware of her mother’s presence. Allow mom to stand for a couple of minutes and listen and watch. The amazed expression on the parent’s face is always so gratifying, and when the mother or father asks, “How did you get her in the chair? She won’t even open her mouth for us,” it makes the effort all the more worthwhile. Furthermore, the impression you’ve made on the parent is a long-term practice-builder.

REINFORCEMENT AND REVIEW
Before dismissing the patient, review what we did today and talk about what we’re going to do next visit. At the next visit, ask the child, “So what are we going to do today?” If she doesn’t remember, then quickly go through the routine again as a reminder.

THE RETURN TRIP TO THE WAITING ROOM
Returning the child to her parents is a very significant moment. If not managed effectively, the child could suffer a relapse or breakdown when united with her parent. In an effort to apologize to their little girl, the parents will resort to a range of expressions, all reversing the good effort you put forth.
“Oooooooh, what did they do to you? Are you all right? Does it hurt?”
 be surprised if a parent remarks, “Did you get all the cavities done? I don’t know how I’m going to get her to come back.” They obviously don’t appreciate the fact that cleaning the teeth and taking bite-wing x-rays were accomplishments, and that their worst expectations never materialized.
The dental assistant must override those remarks with an over-the-top display of unbridled enthusiasm before the mom can get going. “Show mommy your clean teeth! Tell mommy how we brushed them with the special toothpaste!” “Did we have fun or what?” Don’t give the parent room to poison the water. All positive! “Who’s the best dentist? Who’s the best girl?”
The brainwashing continues when I greet the parent in my private office with the child. “Hi, mom! Wasn’t Julie great? Julie, did you tell mommy how much fun we had?” I then proceed to talk to the parent about Julie’s teeth and discuss any interesting findings. If treatment is required, then I proceed to describe the procedures necessary, the what, how, and why details, and answer any questions the parent may have.
My experienced observation over these many years has convinced me to conclude that the combination of the separation from the parents and the “familiar to the unfamiliar” methodology is a recipe for the successful, quick conversion of the child from a reluctant dragon to a generally cooperative little patient. Essential to the success of this protocol, of course, are the enthusiastic, dedicated dental assistants and other auxiliaries who risk life, limb, and ego with me every day.
The final installment of our series will focus on clinical aspects of pediatric dentistry, including topics such as the deadly shot, pulpotomies, stainless steel crowns, and a potpurri of helpful tricks of the trade.

Dr. Berman is an internationally recognized pediatric dentist with a career as a successful practitioner and world-class lecturer spanning more than 4 decades. After hearing him speak or watching his videotapes, dentists (general practitioners as well as specialists) are using his straightforward, no-nonsense approach to patient management and practice organization. Dr. Berman has been an ambassador for dentistry as a health reporter on CBS (News Radio 78) and via media appearances as a consumer advisor for the ADA, the Chicago Dental Society, and the American Academy of Pediatric Dentistry. He is co-author of Essentials of Modern Dental Practice and has published numerous articles in the dental literature as well as practice materials and education videotapes. His public relations expertise is in demand when shows like OPRAH are tackling difficult issues such as AIDS, amalgam, dental phobia, and consumer rights, and he’s the principal dentist in a thriving practice in Chicago. For more information, he can be reached at (773) 764-0007 or marvy18@prodigy.net.