Dentistry for Kids E-Book

Ulrike Uhlmann

• Herausgeber: Quintessence Publishing Co, Inc
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 359

Veröffentlichungsjahr: 2020

Beschreibung

The practice of pediatric dentistry requires a broad knowledge of dentistry, orthodontics, nutritional sciences, and last but not least, psychology. The goal is to enable our young patients to live with the healthiest teeth possible, and this involves understanding how to embrace the opportunity, challenge, and responsibility of ensuring an ideal start for even the tiniest of our patients. This book presents the fundamentals of pediatric dentistry and explains how to incorporate them into an existing dental practice. Because parents are a crucial part of the equation, particular focus is given to educating and managing parents to be the best advocate for their children's oral health. While the book is a useful reference for everyday practice in terms of examination, diagnostics, and findings, it goes further to include tips on how to create a child-friendly environment, how to communicate with young patients, and how to handle difficult situations with uncooperative patients or parents. The second half of the book is given over to treatment considerations, spanning from preventive treatment like fluorides and sealants to filling and crown therapy. This final chapter also includes sections on antibiotic use, managing trauma, sedation, and other particular challenges in everyday practice. This book is an essential resource for anyone working with kids in dentistry.

Leseprobe

Dentistry for Kids

Rethinking Your Daily Practice

Dedication

I would like to dedicate this book to Dr Christiane Gleissner. She was the first and only one who read the complete and raw manuscript, dedicating many hours while contributing some important suggestions from the viewpoint of a general dentist. She always motivated me and dispelled doubts. She will forever be an inspiration for me. May she rest in peace.

Library of Congress Cataloging-in-Publication Data

Names: Uhlmann, Ulrike, 1986- author.

Title: Dentistry for kids : rethinking your daily practice / Ulrike Uhlmann.

Other titles: Kinderzahnheilkunde. English

Description: Batavia, IL : Quintessence Publishing Co, Inc, [2020] | Translation of: Kinderzahnheilkunde : Grundlagen für die tägliche Praxis / Ulrike Uhlmann. [2019]. | Includes bibliographical references and index. | Summary: “This book offers professional and practical tips on communicating with parents and sets out to illustrate the responsibility involved in treating children”-- Provided by publisher.

Identifiers: LCCN 2020007937 | ISBN 9781647240134 (hardcover)

Subjects: MESH: Dental Care for Children | Child | Infant | Oral Hygiene | Dentist-Patient Relations | Pediatric Dentistry--methods

Classification: LCC RK63 | NLM WU 480 | DDC 617.60083--dc23

LC record available at https://lccn.loc.gov/2020007937

This book was originally published in German under the title Kinderzahnheilkunde: Grundlagen für die tägliche Praxis by Quintessenz Verlag (Berlin) in 2019.

© 2020 Quintessence Publishing Co, Inc

Quintessence Publishing Co, Inc

411 N Raddant Road

Batavia, IL 60510

www.quintpub.com

5 4 3 2 1

All rights reserved. This book or any part thereof may not be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, or otherwise, without prior written permission of the publisher.

Editors: Leah Huffman and Samantha Smith

Design: Sue Zubek

Production: Sarah Minor

About the author

Ulrike Uhlmann studied dentistry at Leipzig University from 2005 to 2010. Even during her studies she showed a keen interest in children’s dentistry. After her examinations in 2010, she worked in Halle/Saale for 4 years, during which time she learned about and came to love the whole gamut of pediatric dentistry. Interdisciplinary work with midwives, pediatricians, and speech therapists was and is a cornerstone of her professional ethos. At present she works on the staff of a family dental practice in Leipzig. As a speaker, she is also involved in the continuing professional development of midwives, speech therapists, educators, and other related professional groups in the field of pediatric dentistry. Together with a Leipzig midwives practice, she has also launched a parents workshop where relevant topics concerning children’s oral health are explained to pregnant women and parents, raising their awareness. She is married and has four children.

Courtesy of Sabrina Werner, smirkART Photography.

contents

Foreword

Preface

Resources

1

Introduction and Basics

2

Successful Communication with Kids and Parents

3

Educating Parents: Oral Hygiene and Prophylaxis

4

Dental Examination and Tips for Increasing Compliance

5

Diagnostics in Pediatric Dentistry

6

Findings

7

Treatment Considerations and Approaches

Epilogue

Index

foreword

So it’s 8 am on a Monday morning, and you get into work early to help the staff prepare for the day and to review the schedule. All good so far. Then you see at 10 am you have a new patient who is 2 years old, the child of a great patient of yours. You digest this and then start to sweat and get a bit stressed. You are not great with children, and the back door is blocked—you cannot escape! You would love to have a drink, but that is an after-work thing. You take a deep breath and call in your head assistant to help you with prep. She is amazing, as is the rest of the staff, because you trained her. Your procedures are all set up, so now what?

The child comes in and is a bit nervous, as are you. Well, fortunately you read this book and so did your staff, and you are ready to go ahead with the appointment. You smile and bend down to greet the child and hand him a sticker and ask for a hi-five. You get one in return and you now calm down—you’ve got this, and you will be great! Now you can take the time to enjoy the whole experience.

Working with children should not be an ordeal but a fun, rewarding experience for you and your team. Play kid music, make a balloon, and be silly like you are with your own kids. Remember that sometimes it is a slow process and you may need one or two appointments to get things done. That is fine. Also, remember that if you are good with this little one, your favorite patient will now be an even better referrer and will extol your virtues as the best dentist in town. Oftentimes, too, parents will test the waters of your office with their children, and if they do well you now have two parents as patients for life. It’s helpful to appoint someone in your office to be the children coordinator. This person’s job is to be the direct point of contact and help the parents and the child to have a great time and prepare them for their visit. This is the person who calms you and the patient down and is the one in charge of the fun!

This book will help prepare you for all the potential challenges and energize you for all the fun of pediatric dentistry. Remember: You would rather have a child make some noise and have no decay than have a mouth full of decay that could have been avoided. Read the book, and it’s that easy. With every child you can handle, there are parents who will become your raving fans. Ulrike Uhlmann is a dear friend and colleague, and her pediatric skills and knowledge are beyond reproach. She has spent many hours creating this book to help inspire you, reward you, and help you have some fun at the same time. Take your time reading it, and make notes or highlight it when and where you can. Let your staff read this as well, as this is a great resource for them. I had a staff meeting in my practice to review it, and the response was a unanimous GREAT!

Lee Weinstein, DMD, FASDC

Pediatric Dentist and Consultant

Scottsdale, Arizona

preface

I was more or less pushed into pediatric dentistry in 2010, shortly after starting to work as a general dentist. The early stages were fraught with a succession of small challenges. Of course we had learned how a pulpotomy works in our studies, but hardly any of us really had the opportunity to treat young patients ourselves.

A lot of questions do not come to light until the little kid is sitting there right in front of you. As an inexperienced dental practitioner, you constantly face situations that take you well outside your comfort zone. Children, in particular, have a keen sense of the person facing them, and you very quickly notice as a practitioner that the more confidently and purposefully you conduct yourself, the more likely you are to be successful. Back then, I benefited first and foremost from colleagues who shared their many years of experience through observation sessions and continuing education.

This book is intended as an introduction to one of the most fulfilling areas of activity in dentistry. It cannot and should not replace continuing professional development but aims to offer insight into this highly varied field. I hope I have managed to bring together fundamental knowledge that will make it easier for people taking their first steps into the field of pediatric dentistry. The structure of the book is based chronologically on a treatment session. The outcome of any treatment stands or falls by proper communication, and parents HAVE to be educated as to their vital role on the team. Examination and diagnosis then take place, followed by various treatments.

Child patients are something of a bête noire for many colleagues, whether they are recently qualified or have had many years on the job. Recent years have seen more focus shift to our youngest patients, with the American Academy of Pediatric Dentistry recommending a “dental home” by the time a child reaches their first birthday (see page 2). This group of patients, which is new to some dentists, raises a few questions: How do you examine a 6-month-old baby? What issues do you address with the parents? What’s the appropriate fluoride prophylaxis? From what age is it reasonable to take radiographs? How do I deal with difficult children? The parents also bombard the practitioner with a host of questions—from when teeth will erupt to teething pains and advice on pacifiers to tips and tricks for daily oral hygiene in the different age groups.

Pediatric dentistry brings together a wide variety of topics encompassing all facets of dentistry, orthodontics, nutritional sciences, and, last but not least, psychology. It involves opportunity, challenge, and responsibility all at the same time. We as clinicians must ensure that even our tiniest patients get the ideal start to enable them to live with the healthiest possible oral cavity. The special challenge, of course, is not just children’s compliance but primarily the fact that children can’t be the ones responsible for their (oral) health. It is therefore our task to educate and motivate parents and guardians and make them our allies. A good relationship with the parents not only guarantees long-term loyalty from patients beyond their childhood years, but it is also absolutely crucial to children’s good oral health. It is only when dentists manage to treat young patients properly and educate their parents that they will succeed in making a long-term contribution to children’s oral health. This book therefore offers professional and practical tips on communicating with parents and sets out to illustrate the responsibility involved in treating children. Above all, it aims to garner enthusiasm in readers for this diverse field of dentistry.

Acknowledgments

Many people have played a part in the creation of this book. A big heartfelt thank you must go to Dr Lee Weinstein. He has sacrificed many hours in order to adapt the content to American guidelines and recommendations. Besides that, he contributed so many thoughts and ideas. I appreciate his work on this book very much because he is such an experienced pediatric dentist. His compassion is absolutely inspiring. Also a big thank you to Leah Huffman, Samantha Smith, and Sarah Minor, who did not become tired in view of my comments and suggestions. Thank you for putting this together. I would also like to thank Sue Holmes, who did flawless work translating the book while keeping the narrative character. Huge thanks to Anita Hattenbach and Dr Viola Lewandowski for the editing of the German version, for constantly being accessible, and for always lending a sympathetic ear to questions or ideas.

My thanks also go to those colleagues who provided numerous images from their daily practice and were thus an immense support in the production of this book. These include Dr Gabriele Viergutz (Dresden), who contributed not only several illustrations but also some important suggestions, as well as Dr Richard Steffen (Zurich), who kindly supplied photographic material from his online atlas without hesitation. My thanks also to Dr Jorge Casián Adem (Poza Rica de Hidalgo), whose high-quality photographs provided excellent documentary records. In addition, heartfelt thanks to Dr Nicola Meissner (Salzburg) for her series of photographs and her contribution. Thank you to Prof Dr Katrin Bekes (Vienna), Claudia Lippold (Halle), Dr Juliane von Hoyningen-Huene (Berlin), dental technician Peter Schaller (Munich), Dr Bobby Ghaheri (Oregon), Dr Matthias Nitsche (Leipzig), and Prof Dr Roswitha Heinrich-Weltzien (Jena) for their photographs. An enormous thank you to Sabine Fuhlbrück (Leipzig) for providing illustrations and for her tireless work on myofunctional therapy. I also owe thanks to Dr Silvia Träupmann (Leipzig) who, with her passion for pediatric dentistry and her experience, was always ready to listen to young colleagues and willingly shared her knowledge. Thank you to Manuela Richter, a highly experienced dental assistant in pediatric dentistry, who guided and supported me so much in my first cautious steps in the field. Warmest thanks to Birgit Wolff for motivating words whenever they were needed.

During the development of this book I was in contact with many inspiring colleagues, and, as a result, I was able to expand my horizons constantly and learn a lot—for which I am extremely grateful.

Last but not least, thank you to my husband who supported this project from the outset, who motivates me continually, and lightens the burden for me time and time again. Without him this book and many other accomplishments would never have been possible. Thank you.

resources

Because this book was originally published in German, much of the literature cited comes from German sources. Therefore, included below is a list of helpful resources in English for navigating the waters of pediatric dentistry.

American Academy of Pediatric Dentistry: www.aapd.org

The AAPD has many resources available on its website from scientific research on specific topics to medical history forms that can be downloaded and adapted for clinical use.

ADA MouthHealthy: www.mouthhealthy.org

This website sponsored by the American Dental Association offers practical information and resources for clinicians and parents, including free posters and activity sheets. Tips for healthy habits and a baby eruption teething chart are available at www.mouthhealthy.org/en/babies-and-kids/healthy-habits.

FDI World Dental Federation: www.fdiworlddental.org

The FDI World Dental Federation represents more than a million dentists worldwide and develops health policy and continuing education programs to promote global oral health.

American Academy of Pediatrics: www.aap.org

Dedicated to the health of all children, the AAP is a great source for new policies and guidelines for pediatric care.

US Department of Health and Human Services: www.hhs.gov

While each state has its own health and human services department, this federal branch is a good resource for information regarding social services, child or domestic abuse, and mental health.

US National Library of Medicine: www.nlm.nih.gov

Under the umbrella of the US Department of Health and Human Services, the US National Library of Medicine includes MedlinePlus, ClinicalTrials.gov, and PubMed, among other databases, all of which provide access to the latest research in all fields of medicine.

1INTRODUCTION AND BASICS

“Only those who attempt the absurd can achieve the impossible.”

ALBERT EINSTEIN

No matter the age, children can be at times challenging, enriching, a reason to smile, as well as the cause of the odd bead of sweat on a dentist’s brow! In dental prophylaxis and treatment, it is essential to adapt to these young patients in order to achieve the best treatment outcomes, guarantee long-term patient loyalty, and, perhaps most importantly, ensure that these patients of tomorrow do not grow up anxious under our care. According to estimates, around two-thirds of anxious adult patients link their anxiety to a traumatic experience with a dentist in their childhood.1

In dental school, we are faced with a lot of theory, but there is virtually no discussion of the practical aspects of treating children. Because it is sometimes impossible to reconcile theory and practice without a degree of compromise, especially in pediatric dentistry, the treatment of young patients often poses a challenge in everyday practice. In many practices, seasoned dentists prefer that treatment of children is performed by the newest hire just out of dental school or with the most junior status; however, they often do not have the necessary communication skills to improve or maintain compliance from young patients. Nonetheless, provided the diagnostic steps run smoothly and none or only minor findings become apparent, no one involved has to leave their comfort zone. But what if measures become necessary that demand more from the patient and practitioner than their individual comfort zones will allow?

Children are incredibly receptive and attuned to the people interacting with them. Uncertainties are easily transmitted to young patients, which commonly results in stress and refusal. Specialized pediatric dentists are often called in too late and then laboriously have to regain the child’s trust. But it can be different! With a few tricks in organization, communication, and treatment; proper diagnostic testing; and realistic recognition of one’s own capabilities and limitations, treatment of children can become established as a successful element of a practice concept.

The concept of a family dental practice yields benefits for all those involved: Parents can combine their preventive care appointments with their children’s to save time, while dentists can gain a whole new patient base and duplicate their range of treatments and that of their team. Treating children also provides dentists with more variety in everyday work, opens up new prospects, and creates trust. Parents who know their children are in good hands with a dentist will be happy to become or remain patients themselves.

The great challenge in pediatric dentistry is determining which treatment approach and technique is most appropriate for each individual patient. Not every young patient is suitable for classic filling therapy, and the wait-and-see approach after fluoride application is not appropriate for many children. However, it should still be our main goal to provide even our youngest patients with optimal, state-of-the-art treatment.

In addition, we must not forget that pediatric dentistry in particular is much more than just drill and fill. Our actual core task and daily challenge is prophylaxis and the prevention of caries. Unlike adult patients, children are not able to take responsibility for their own oral health. There is no reason for caries to develop in primary teeth, and yet, on a daily basis, we see that the reality is quite different. This is why we need to partner with parents and make them understand that they are the key to their children’s oral health. Sometimes this can be a considerable challenge.

The objective of the first dental examination is to fully inform parents about the relevant topics (fluoride, oral hygiene, diet, drinking), dispel any fears (eg, premature or delayed eruption of teeth, grinding teeth, teething troubles), and detect or prevent early childhood caries (ECC). This visit also serves to familiarize children with dental treatment in a positive way so that they are less anxious for future visits that may be required for trauma or caries. Most importantly, the purpose of these early visits is to establish a “dental home” for the child and their parents.

DENTAL HOME

The American Academy of Pediatric Dentistry (AAPD) defines a dental home as the “ongoing relationship between the dentist and the patient, inclusive of all aspects of oral health care delivered in a comprehensive, continuously accessible, coordinated, and family-centered way. The dental home should be established no later than 12 months of age to help children and their families institute a lifetime of good oral health. A dental home addresses anticipatory guidance and preventive, acute, and comprehensive oral health care and includes referral to dental specialists when appropriate” (AAPD, 2018). Our care should always be centered around the child, meaning that if we can’t offer proper treatment, we refer to someone who we think can; the referral of a patient does not mean we failed doing our job but rather that we care for our patients more than for our ego. For this we will not lose any patients but gain trust and thankfulness.

This introductory chapter briefly addresses the most important anatomical, physiologic, and morphologic basics of primary teeth that have practical relevance. This chapter may also be used as a source for mineralization and eruption times as well as the multifactorial etiology of caries. The teething charts can also be copied and handed out to parents.

STRUCTURE OF PRIMARY TEETH

The structure of primary teeth differs significantly from that of permanent teeth, and this factor has a direct influence on treatment. First, a few particular features must be kept in mind during adhesive cementation of fillings because of the morphologic characteristics of primary teeth (Box 1-1). Second, caries in primary teeth invades the dentin more quickly and endodontic treatments are required far earlier than with permanent teeth because of the macromorphology of primary teeth (Fig 1-1).

Box 1-1 Morphologic characteristics of primary teeth2

Macromorphology

• The enamel mantle is not thicker than 1 mm in any location.

• The pulp chamber of the primary teeth is relatively larger, and the pulp horns are relatively more exposed compared with permanent teeth.

• The occlusal surfaces of the primary teeth are narrower in comparison to permanent teeth, and their buccal and lingual facets diverge toward a strongly developed cervical or basal enamel bulge.

• Primary molars have a broader and flatter interproximal contact than permanent molars.

Micromorphology

• The enamel surface is characterized by a largely aprismatic enamel surface (layer thickness 30–100 μm).

• The enamel prisms in the cervical area increase from the dentinoenamel junction toward the occlusal surface.

• The mineral content of the primary tooth enamel is lower than in the permanent dentition.

• In primary teeth the enamel formed postnatally is far less densely mineralized than the prenatal enamel mantle.

• The structure of primary tooth dentin is different than permanent tooth dentin: The dentinal tubules are larger, the peritubular dentin is more highly developed, and the mineral content of the intertubular dentin is lower than in the permanent dentition.

Fig 1-1 Morphologic differences between primary and permanent teeth.

The micromorphology is characterized by an aprismatic and irregular enamel structure (Fig 1-2). The proportion of organic constituents is higher than in permanent teeth, which explains poorer conditioning by the acid etch technique. The dentin structure also differs from that of permanent teeth (Fig 1-3): The mineral content is reduced, the distribution of dentinal tubules is more irregular, and the tubules are larger. This explains the faster progression of caries and the lower dentin adhesive values.3

Fig 1-2 Cross section of a primary (a) versus a permanent (b) tooth revealing enamel layer thickness. In the primary tooth, the enamel layer is very thin compared with the permanent tooth. (Photographs courtesy of Peter Schaller.)

Fig 1-3 Longitudinal section of a primary (a) versus a permanent (b) tooth. The size of the pulp cavity is much larger in the primary tooth, whereas the dentin layer between the enamel and the pulp is much thicker in the permanent tooth. (Photographs courtesy of Peter Schaller.)

MINERALIZATION AND ERUPTION TIMES

To understand disorders such as hypomineralization or dental fluorosis, we need to know exactly when primary and permanent teeth are mineralized (Tables 1-1 and 1-2). Furthermore, when assessing radiographs in the mixed dentition, it can be helpful to know when the dental crowns of the permanent premolars or molars should be visible so that any agenesis can be diagnosed. Table 1-3 shows the eruption times of the primary and permanent teeth. It should be noted that relatively wide variations in these timings are possible; those listed in the table should only serve as a guide.

TABLE 1-1 Mineralization times of the primary teeth4

Tooth

Start of mineralization

End of mineralization

Root fully developed

Incisors

3–5 months in utero

4–5 months postnatal

1.5–2 years

Canines

5 months in utero

9 months postnatal

2.5–3 years

Primary first molar

5 months in utero

6 months postnatal

2–2.75 years

Primary second molar

6–7 months in utero

10−12 months postnatal

3 years

TABLE 1-2 Mineralization times of the permanent teeth4

Tooth

Start of mineralization

Crown fully developed

Root fully developed

Maxilla

Central incisor

3–4 months

4–5 years

10 years

Lateral incisor

Up to 1 year

4–5 years

11 years

Canine

4–5 months

6–7 years

13–15 years

First premolar

1.5–1.75 years

5–6 years

13–15 years

Second premolar

2–2.25 years

6–7 years

12–14 years

First molar

At birth

2.5–3 years

9–10 years

Second molar

2.5–3 years

7–8 years

14–16 years

Third molar

7–9 years

12–16 years

18–25 years

Mandible

Central incisor

3–4 months

4–5 years

9 years

Lateral incisor

3–4 months

4–5 years

10 years

Canine

4–5 months

6–7 years

12–14 years

First premolar

1.75–2 years

5–6 years

13 years

Second premolar

2.25–2.5 years

6–7 years

13–14 years

First molar

At birth

2.5–3 years

9–10 years

Second molar

2.5–3 years

7–8 years

14–15 years

Third molar

8–10 years

12–16 years

18–25 years

TABLE 1-3 Eruption times of the primary and permanent teeth*

Tooth

Eruption times

Primary

Central incisor

6–8 months

Lateral incisor

8–12 months

First molar

12–16 months

Canine

16–20 months

Second molar

20–30 months

Permanent

First molar (6-year molar)

5–7 years

Central incisor

6–8 years

Lateral incisor

7–9 years

Canines and premolars

9–12 years

Second molar (12-year molar)

11–14 years

Third molar (wisdom tooth)

16+ years

* Relatively wide variations in these timings are possible.

CARIES AS A MULTIFACTORIAL DISEASE

Because caries is a multifactorial disease, it is up to the clinician to identify each patient’s individual risk factors and intervene preventively and therapeutically in a targeted way. Especially in children who have no influence on their own diet and oral hygiene, it is important to identify all the etiologic factors contributing to the caries so that adjustments can be made, provided the parents are compliant and reliable, to achieve a lasting reduction of the risk of caries. Figure 1-4 represents the caries etiology model5 according to Fejerskov and Kidd, illustrating the various key components and their interactions for the purpose of successful caries assessment.

Fig 1-4 Multifactorial etiology model of the development of caries.

REFERENCES

1. Müller EM, Hasslinger Y. Sprechen Sie schon Kind?: Prophylaxe auf Augenhöe. Berlin: Quintessenz, 2016.

2. Ermler R. Diagnostik von Approximalkaries bei Milchmolaren mit Hilfe des DIAGNOdent pen. Berlin: Charité, Universitätsmedizin Berlin, 2009.

3. van Waes H, Stöckli P (eds). Kinderzahnmedizin, Farbatlanten der Zahnmedizin. Stuttgart: Thieme, 2001.

4. Mittelsdorf A. Kariesprävention mit Fluoriden – Eine Fragebogenaktion zur Fluoridverordnung in Berliner Kinderarztpraxen unter besonderer Berücksichtigung der Empfehlungen der DGZMK. Berlin: Charité, Universitätsmedizin Berlin, 2010.

5. Kühnisch J, Hickel R, Heinrich-Weltzien R. Kariesrisiko und Kariesaktivität. Quintessenz 2010;61:271–280.

2SUCCESSFUL COMMUNICATION WITH KIDS AND PARENTS

“The use of humor in pediatric dentistry is highly recommended. It may be used to facilitate communications with patients and parents, alleviate patient anxiety, and assist the dentist in coping with stress associated with the practice of dentistry.”

MOSTOFSKY AND FORTUNE1

Communication with your pediatric patient begins not when the treatment starts but as soon as the child enters the dental practice. Communication is not merely about talking; it includes a plethora of nonverbal signals. American-Austrian psychologist Paul Watzlawick expressed this clearly when he said “You cannot not communicate.” Communication consists of 55% nonverbal cues (gestures and facial expressions), 38% tone of voice, and only 7% actual content of what is said.2 This chapter examines the different levels of communication and their importance in the dental practice. Suggestions are then given regarding how to use verbal and nonverbal language to gain, improve, or maintain compliance for different types of pediatric patients.

IMPORTANCE OF CHILD-APPROPRIATE ENVIRONMENT

Children need to be engaged to feel comfortable in any public space. General dentistry practices without a specialization in pediatric treatment can create a child-friendly environment with just a few resources. To do this, it is helpful and necessary to visualize the viewpoint of a child; they first see what is at their eye level or below it. Pictures, wall stickers, or even toys in the waiting room should be placed at a height where children can see and reach. A coloring table, some well-chosen books, and a set of building blocks are sufficient to create an engaging environment for children. If space is a concern, there are also some brilliant space-saving play alternatives, such as wall-mounted drawing boards, magnetic boards, jigsaw puzzles, or games. Wooden toys are often a more robust and durable choice. In the interests of other patients and the practice team, toys that emit sounds are inadvisable. When selecting toys for a common space, consider the cleansability; toys that are hard to sanitize may prove poor choices during flu season. In addition, wall decals are a useful and variable design feature for the waiting room or a treatment room because they are easy to remove without leaving a mark.

Not every dentist has the facility to mount a monitor above the treatment chair; as a more convenient alternative, a photo or painting on the ceiling will not only fascinate young children but will also help to distract older, anxious patients. Finally, the reception counter often seems enormous to children, so a small stool can make it a little more manageable for curious children to sneak a peek. Air freshener spray should be kept on hand as well to eliminate the typical smells of the dental practice, which can unsettle or frighten some children.

NONVERBAL COMMUNICATION, INDIVIDUAL PERSONAL SPACE, AND PROXIMITY

“You cannot not communicate.”

PAUL WATZLAWICK

Children are particularly sensitive to nonverbal signals communicated by body language, such as gestures and facial expressions.3 Because nonverbal communication is unconsciously controlled by our thoughts, it is important to always have a positive attitude that enables us to communicate authentically and empathetically—especially in the company of children with behavioral problems. Children have a very keen sense of how well physical and verbal signals match each other—if they do not, the intended message will be misunderstood. Thus, the treatment of a child with behavioral issues may fail from the outset if the dentist exhibits antipathy but tries to cover it up. Children are highly sensitive to discrepancies between what is said and what is felt.4

One of the greatest challenges in the practice of pediatric dentistry is controlling the often-unconscious nonverbal signals we send out so that the young patient gets a positive impression. Especially when beginning with pediatric treatment, self-reflection and analysis of these nonverbal (and verbal) signals is key. Important positive signals include an open smile, a calm manner, and nonjerky movements. Equally important is a respect for the individual child’s personal space—the personal space that they need to feel safe and secure. If people invade our personal space against our will, it can result in rejection, aggression, and anxiety, so we should not expect children to react any differently. While we generally think of any violation of this space in terms of physical proximity, personal space can also be breached nonverbally with a look or a gesture.3 Note that anxious children generally require a larger personal space than outgoing children do.

Therefore, it is important for dentists and dental assistants to read, interpret, and respect a child’s signals when interacting with them. At the same time, however, this personal space needs to be shrunk enough to make dental treatment possible. This is often where the real challenge lies. It calls for patience, a slow approach, acceptance, positive nonverbal signals, rituals (eg, similar sequence when greeting patients or going about the treatment), and sometimes even the patient’s stuffed animals or toys to act as neutral mediators. Once comfortable, children will allow the dentist to encroach on their personal space, and a neutral approach can often be adopted. Stuffed animals can also be a great advantage during treatment: They can be used to demonstrate to the child what the dentist is going to do, thereby allaying the child’s fears, or they can reflect the child’s behavior and thus be used to alter that behavior.3 For example, the dentist can use a hand puppet to mimic a child’s resistance (eg, refusing to open their mouth) and then convince the puppet to let itself be examined, rewarding it with praise and maybe even a small prize. This can influence the child’s behavior and often positively change their attitude. It is not uncommon to see young patients reflect the behavior of the stuffed animal (eg, by opening their mouth).

As mentioned initially, these aspects do not only have a bearing when the child sits down in the dentist’s chair but as soon as the child enters the practice. A friendly smile from the dental assistant at reception and greeting the young patient by name while respecting the patient’s personal space will pave the way for a successful start. When greeting or calling a child from the waiting room, it is important to get down to the child’s eye level. Anything else has an intimidating and threatening effect. On first contact in the waiting room, the ideal distance to maintain from the patient is about 1 m (3 ft). The child should be greeted before his or her parents. Personal information that can be obtained from the case history (eg, the name of the stuffed animal or the child’s favorite color) makes it easier to establish contact and create trust. In doing so, it is important to be authentic and empathetic. If it becomes clear that the child is very anxious or agitated, do not tell them that what they are feeling is not necessary. Telling a child that “there’s no reason to be nervous” is well intentioned but will not reassure a child. On the contrary, it creates additional insecurity because children learn that the feelings they are experiencing are wrong. It is better to show empathy by saying, “I can see you’re pretty nervous. I can understand that. I’ll explain everything to you exactly. That’ll help you feel comfortable.”

To maintain this first connection, once established, it is important for the young patient to be accompanied into the treatment room. This can be used as an opportunity to explain what things you might notice along the way (sounds, smells, or images), or the dentist can give an idea of what is going to happen in the treatment room.5 If the dental assistant brings the child into the treatment room, he or she should introduce the dentist and explain to the child what will happen next.

During the treatment, it is an important part of nonverbal communication for dentists or dental assistants to reassure the child with appropriate touch as soon as they have a hand free. An assistant’s hand on the shoulder, tummy, or head (especially the temples), for instance, conveys a feeling of care and protection and may set the child more at ease.6 At the same time, various acupressure points can be massaged during the treatment (see chapter 7). By contrast, stroking is often counterproductive because it may increase a child’s awareness of being touched. Be aware of this nonverbal communication, and if it is clear that the child is uncomfortable with any of this touching, stop it at once.

VERBAL COMMUNICATION: THE RIGHT CHOICE OF WORDS

Even though children are often preconditioned by their family (“If you don’t clean your teeth properly, you’ll have to go to the dentist and he’ll drill them”), we as dentists are responsible for shaping children’s positive experiences with our profession. Generally speaking, voice control is needed when dealing with young patients: different phases of treatment can be accompanied by different tones of voice and/or levels of loudness. For example, while the treatment is going on, the dentist should talk in a monotone voice that is not too loud. If a child tries to touch the syringe, for instance, he or she can be stopped in a friendly way but with a louder voice. If the child is constantly crying or whimpering, a quiet whispering voice can be used, and the child’s curiosity about what is being said may silence the crying.7

Child-appropriate language is another foundation of successful pediatric treatment. This means using simple, short sentences without any complicated or foreign words. Before the age of 5 years, children cannot grasp abstract expressions of time (afterward, then, later, etc), which can easily be a cause of frustration. In addition, it can be very helpful for the dentist to be reasonably familiar with the latest children’s movies or TV series. This can be a way of gaining the young patient’s trust. The dental practitioner must be sensitive and reflect on his or her choice of words, especially when explaining equipment or treatment steps. If a toddler has only ever heard of a drill from daddy’s tool box, it is understandably frightening if the word is used in connection with their own mouth. (Table 2-1 offers suggestions for child-appropriate terms for dental instruments.) Children have a fertile imagination, which the dentist can readily tap into. In the beginning it may involve some effort to open yourself up to this world of imagination and create a story to explain the treatment and put the child’s mind at ease. Stories can help to distract young patients and make them far more relaxed during a dental treatment.

TABLE 2-1 Suggestions for correct choice of words

Instrument

Child-appropriate term(s)

Lamp

Sun

Probe

Tooth feeler; tooth counter

Suction

Magic wand that carries away spit; snorkel; drinking straw; vacuum

Red contra-angle or turbine (water)

Shower; water sprayer

Blue contra-angle

Tickle bee

Excavator

Little spoon

Syringe

Sleeping water; sleeping medicine

Etching gel

Smurf cream; tooth shampoo

Curing lamp

Magic lantern; light saber

Composite or other filling materials

Magic cream

Cotton wool rolls

Pillows for your tooth

Rubber dam

Raincoat for your tooth

Matrix

Gold or silver medals for your tooth (depending on the color of the matrix)

Wooden wedge

Garden fence

Forceps

Mini-crane

Caries, tooth decay

Sugar bugs

Steel crown

Knight’s or princess’s tooth

Treatment chair

Kiddie throne; lounger; up-and-down chair; magic chair

Air blower

Hairdryer or air pistol

Water spout

Waterfall

Inappropriate use of “okay” can pose another problem. We are often accustomed to ending a sentence with this word, but children frequently understand it as a question. It can become a bit of a challenge if a sentence such as “I’m now going to rinse your tooth clean, okay,” is answered by the child with a definite “no.”5 Generally questions by the dentist should be used very specifically. Before children reach preschool age, it is helpful to ask questions like, “What games do you like playing?” in order to build up a conversation. Communication can be established because children are then obliged to answer with a sentence and not just “yes” or “no.”3 Once children have reached preschool age, alternative questions can be employed that invite the child to make pseudodecisions, like “Do you want to climb up onto the chair by yourself, or do you want mom or dad to get up first and you can sit on their lap?” However, the dentist should make sure only to offer alternatives that are equally conducive to the ongoing treatment process.

Praise and reward are important elements when working with children. Young patients should be praised for a particular reason. There is no point in rewarding a child with something if the child has been thoroughly uncooperative; this tells these patients that their behavior was acceptable. It is more helpful to say exactly what you were pleased about and praise the patient for that. For example: “Today you came with us into the treatment room really nicely and you let me have a look at your front teeth. That was very good, so I’m going to give you a little prize. Next time I’d like you to open your mouth really wide so I can count all your teeth.” This can give the child an idea and an expectation about the next treatment.5 Praise during treatment is also an important motivating tool. Phrases like “You’re opening your mouth so well” and “You’re sitting so nicely” can really go a long way to making the child feel more comfortable and good about themselves.

At the end of treatment, the wrong behavior by parents or accompanying persons can also be problematic. Empathy is important, but exaggerated expressions of sympathy reinforce the child’s impression that the dental treatment was something traumatic, which in future will cause the child to be afraid.5 To avoid such situations, it can be helpful before dental treatments to issue parents with a brief guide on what to do (Fig 2-1). In general it is important to end a treatment session with positive feedback and a little reward for the child, for example, a sticker or other prize.

Fig 2-1 Example letter giving parents advice on what to do to improve their child’s experience at the dentist.

TELL-SHOW-DO METHOD

It is important to make sure you only explain or demonstrate the different treatment steps immediately before carrying them out (Fig 2-2). Because children have a short attention span, there is no point in explaining all the steps just at the beginning.

Fig 2-2 Tell-show-do method on a 4-year-old patient. A round bur is being demonstrated on the little girl’s fingernail. You can use the bur to “paint” a sun on the child’s nail, for example, then repeat the same thing on the tooth.

BASIC RULES FOR COMMUNICATION WITH CHILDREN IN THE DENTAL PRACTICE

Nonverbal: Be authentic, focus on the child, ensure there is a congruence between what the dentist feels and says, smile genuinely, use smooth movements, respect personal space, be patient, take the child seriously, let the child finish speaking, establish contact by appropriate touch during treatment (ie, touching the shoulder or the temples), communicate at eye level, and perform ritualized actions.

Verbal: Control your voice, show (not exaggerated) empathy, avoid denials or negative sentences, do not use unfamiliar foreign words, avoid irony/sarcasm, use descriptive language, talk in a low and calm tone of voice, keep sentences short and simple, be careful about questions ending with “okay,” allow for patient involvement in noncritical decisions (ie, getting in chair alone or with parent), choose positive words, and offer praise during and after treatment.

Other: Hypnosis, behavior management, and acupressure are auxiliary methods that can be used.6

DIFFERENT TYPES OF PEDIATRIC PATIENTS AND PARENTS

Constant criers

This type of young patient will cry constantly even without any discernible reason. It can help to talk extra quietly to these children. This often arouses their curiosity and they quiet down so that they can actually understand what is being said. Dentists who are comfortable singing can utilize the element of surprise and start singing a children’s song a little louder than the child’s crying. Many children will then stop in surprise. Then you can continue singing quietly and start/continue the examination.

Extremely shy patients