Pediatric Dentistry—The Hidden Jewel of Our Profession
by Dr. Gregory Psaltis
When my fellow dentists discover that I am a pediatric specialist, it
is not unusual for them to express either amazement, pity, or at times, incredible
gratitude that I “do what I do.” I always marvel at the misconceptions
about my specialty and 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 feedback
I hear from my peers, it’s as if they view pediatric dentistry as a neverending
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 that come to observe my practice invariably comment on the calmness
of the office in spite of 50 or so patients being seen in a normal, non-hectic
way. Of course it helps to have a Team of talented professionals—both assistants
and a restorative hygienist. My Team consists of 15 women who make my job
remarkably easy. However, the cornerstone of the practice still evolved
from one simple tenet: we believe each child will have an ideal visit each
time he comes to see us. When the mindset is positive and the operators’
belief system is based on the conviction 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 fiscal rewards
that accompany the care.
To be certain, there are “tricks” of the trade, but if that first essential
piece is not firmly entrenched in the mindset of the providers, there is
no way for “cute” terminology, reasonable treatment planning, judicious
sedation or distraction techniques to overcome the negative assumption
that “children are a problem.” In my experience, I have found 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 myriad 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. This is
a function of the doctor’s attitude, plus appropriate use of skills that
will enable all parties to have a mutually fulfilling and successful visit.
It is beyond the scope of this article 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
1. 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.
2. 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.
3. 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 he is doing right. Be clear—“It is very helpful when you hold your
mouth open because 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.
4. 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.
5. Avoid pain. While some practitioners I have met often treat primary
teeth without local anesthetic, we routinely use it 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 visit
for a given procedure, so I prefer to anesthetize to insure comfort. We
use topical anesthetics and occasionally nitrous oxide to ease the injection
process, but do not routinely encounter responses to the actual procedure.
6. 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 nothing being dropped into patients’
mouths and potentially being aspirated. Having the appropriate clamps is
essential for successful dam placement and retention.
It goes without saying that one of the more controversial aspects of
pediatric dentistry 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 in your practice:
1. Explain your philosophy in specific terms, including the management
tools you will employ in treating their children, the child-friendly terminology
you will use and the role you expect them to play in the appointments
2. 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
3. Ask the parents for their support of the practice’s terminology—give
them a sheet with sample words so that they will not inadvertantly frighten
their child with words like shot, drill, yank a tooth or other negative images.
4. Advise the parents to NOT prepare the child for the restorative visit.
I manage this by explaining to the parent that I will prepare the child
literally on the spot. This I do 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.
5. 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 placing my focus on the behaviorial
side of dentistry has provided as much satisfaction for me as the purely
technical part. It must be 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 to which dentists strive. In this way, I view management
as a critical aspect of proper dental care for young patients.