Dentists who treat children must have empathy and insight. The child who arrives at our practice is a complete human being, filled with awe, fear and, we hope, a desire to learn about dental care. The best way to manage any child is to understand his or her specific needs. This understanding enables the dental team to help the child accept dental procedures. The process is active and ongoing, and promotes the emotional growth and development of the child.

Since fears are learned, they can be unlearned. It is important for dental students and dentists to understand the needs of the individual child. We must also understand the subject of fear so that we can find ways to allay the child’s apprehensiveness. Finally, both pharmacologic and non-pharmacologic techniques can be used to teach children to accept dental procedures.

Making First Visits Successful

New Patient Research Form

The new patient research form is used for pediatric and special care dentistry for the purpose of obtaining pertinent information about the new patient prior to the first visit. At each morning huddle, we review these forms and discuss our patients prior to the start of the day. This gives the team a ‘heads up’ if we know that a certain new patient has a behavior problem and we can discuss what methods we can try to alleviate this problem.

Most children have a fear of the unknown so, in addition to the letter sent to the parents in the welcome package, we send a My First Visit book to all of the children under six years of age. This book is customized with the child’s name and the dentist’s name throughout the book. The letter requests that they read the book to the child several times prior to the first visit. Also, the child is encouraged to bring the book to the appointment to receive a sticker from the dentist and his/her autograph.

Use Your Practice Website to Your Advantage

We created a video called ‘first visit’ on our website. This five-minute video was created for our autistic and first-visit patients. It shows my partner and I each performing a brief oral exam, the dental hygienist performing an oral prophylaxis, taking radiographs, and giving a fluoride treatment. The welcome package includes a letter explaining how this procedure is executed. Patients can go onto the practice’s website at www.kidsmyl.com and click on the ‘first visit’ section to view the video.

Call Each New Patient Prior to the First Visit

‘Hello Mrs. Smith, this is Dr Soandso. I am calling to confirm your son’s appointment with us next Tuesday at 9am. Do you have any questions or concerns prior to this appointment?’

When you call your patients prior to the first visit, the response that you will typically receive is, ‘Wow!’ Not only does this start you off on the right foot, but it also allows you to discuss what you (and the parent and child) can expect at the upcoming first visit. You will have the opportunity to set the ‘ground rules’ in a non-threatening environment. This also gives our dental team an idea of what we have to look forward to when this patient comes into our practice.

For example: Mrs. Smith tells me that Johnny is six years old and still sucks his thumb. I then have the opportunity to explain to Mrs. Smith that I will be glad to work with her and Johnny to try breaking this thumb-sucking habit. I explain my philosophy and now Mrs. Smith and I are on the same page when Johnny comes in for his visit. This technique is also very helpful for the disabled patient so that I can better prepare the dental team for any special needs this patient may have.

 Innovations

During the first and subsequent visits, the following innovations may be used to make the child’s visit more comfortable and therefore more successful:

1. Sunglasses to prevent the glaring operatory light to allow more comfort for the child.
2. Music, DVDs, and/or television can be an aid as a distraction for some children. For our special needs patients, we enquire about these distraction devices with the parent or guardian.
3. Aromatherapy is especially useful for the autistic patient. Vanilla and lavender sprays are available and have been shown to have a calming effect on autistic patients. I had a nine-year-old autistic boy that would not sit in the dental chair. However, when I sprayed lavender in the surgery not only did he sit in the dental chair but we were able to perform an oral examination, oral prophylaxis, fluoride treatment, and full-mouth radiographic series.
4. Behavior modification charts are used for tooth brushing and oral habit elimination. These are given to the child with an explanation to the child and parent and have been very successful. The child returns in one month with his/her completed chart and then receives a ‘special’ prize.
5. Puppets and dolls are used to provide comfort to the child. Most patients’ fears are the fear of the unknown. By using a familiar toy or doll, the patient is more comfortable. Puppets can also be used to calm a nervous patient.

Anticipatory guidance: According to the American Academy of Pediatric Dentistry’s perinatal guidelines (http://www.aapd.org/media/Policies_Guidelines/G_PerinatalOralHealthCare.pdf), the child’s first visit should be by 12 months of age. This will enable the dentist and/or dental hygienist to discuss with the parent/guardian the prevention of early childhood caries, oral hygiene, fluoride uptake, and diet. Follow-up visits are scheduled per the dentists discretion based on the individual needs of the patient.

Assessing Patients’ Potential Behavior

When your assistant or hygienist goes to the waiting room to bring your new patient into the surgery, it only takes a matter of seconds to assess that child’s potential behavior in the dental operatory. In that brief moment, you can quickly decide if you would like to invite the parent to accompany his/her child. If the child is clutching the parent’s hand and sitting next to the parent or on the parent’s lap, you can assume that the child is anxious about the dental appointment. If, on the other hand, you see the child sitting by himself/herself and reading a book or playing a game, then that child is more likely to be a more co-operative patient.

If the parent is invited to accompany the child into the surgery, it is important to set the ground rules immediately. I look the parent(s) in the eyes and tell them that they need to be silent observers. For example, I’ll say, ‘Your child can only listen to one person at a time, and I need your help in allowing me to be that person.’ Or I’ll say, ‘I appreciate your willingness to help, but right now I need to speak to your child to establish a relationship with him/her.’

If you would rather not have the parents come into the surgery there are several ways of politely communicating this to them. One way is via the parent's letter in the welcome package. If you choose to employ this tactic, you might want to add the following, ‘We need to establish a friendly relationship with your child and we find what works best for most of our patients is for mom/dad to stay in the reception room. If we need your help in making your child’s visit a successful one, we will invite you into the dental operatory’.

When Do I Invite Parents into the Operatory?

1. When I have assessed that a particular child needs the support (even if it’s just visual) of the parent sitting nearby, in view of the child.

2. My special needs patients often feel more comfortable when the parent can hold their hands during the dental visit. Many of my special needs patients need someone to stabilize their hands, head, and/or feet during the dental visit.

3. Many of my younger special needs patients sit on the parent’s lap during the dental visit. This has several positive effects, including the child feeling more secure by having physical contact with the parent. Also, the parent can hold the child’s arms and wrap his/her legs around the child’s legs. This is the best stabilization system for many young children.

4. If a child needs a physical restraint, such as a pedi-wrap, I have the parent help place the child into the restraint and have the parent stay in the surgery. From a liability standpoint, this has the benefit of showing the parent that we are not hurting the child and that we use the least amount of restraint necessary to prevent injury to the child and the dental team.

TELL, SHOW, DO Technique

In our practice, we use the ‘tell-show-do’ method. We begin by explaining to the patient, in simple terms, what we will do. We then demonstrate what we will do using a model or the patient’s fingernail. For example, before we use an explorer, we use it to count the patient’s fingers by gently touching the finger with the explorer. Then, we use it to gently count the patient’s teeth. Instruments such as the scaler and prophylaxis rotary cup are introduced in the same way.

The child receives positive reinforcement during the entire process. We compliment him or her and thank the child for being a good helper. We use a brief explanation of each instrument to help build the child’s confidence. Finally, we perform the procedure we have explained and demonstrated.

In my experience, allowing the child to observe the procedure either with a handheld mirror or, preferably, an operatory light mounted mirror, allays the patient’s apprehension. Seeing what is happening is always better than imagining. However, we never allow a child to view an injection or extraction.

When taking radiographs of an infant, toddler, or special needs child, we place the child in the parent’s lap, facing the operator. The parent helps by placing his or her legs around the patient’s legs and by holding the patient’s hands. After a lead apron and collar are placed on the child, the parent holds the plastic encased film in the child’s mouth, the patient is instructed to keep his or her eyes open and then the radiograph is taken. A dental auxiliary may substitute for a pregnant parent. For patients who gag, the film holder allows them to breathe through their mouth. A small amount of salt rubbed on the sides of the patient’s tongue decreases the gagging response.

Behavior Modification

Behavior is learned, therefore, the principles of learning may be successfully applied to change behavior. Before attempting any change, you will need to decide the child’s limitations. For example, ask yourself, ‘Will this patient’s behavior prevent me from meeting my treatment goals for this appointment?’ Modifications must be made so that the child can comfortably sit still long enough for the treatment to be administered.

I treated a 13-year-old female who is mentally disabled and has cerebral palsy with concomitant spasms. Her previous dentist recommended three carious teeth be restored in a hospital operating room with the patient under a general anesthetic. I suggested the patient be treated in my practice. Using nitrous oxide as an analgesic for muscle relaxation, a local anesthetic, a rubber dam and a mouth prop, we restored the teeth. The patient’s medical-dental history form can be used to assess the need for behavior modification techniques. This written history, together with discussion with the parent or career, should provide the following information:

• The patient’s disability;

• The names and dosages of the patient’s medication;

• Physician’s recommendations for prophylactic antibiotics;

• Whether the child has previously been treated by a dentist;

• The identification and causes of untoward consequences of previous dental visits;

• Parent’s specific concerns;

• History of heart problems, allergies, seizures, childhood diseases, excessive bleeding and other systemic conditions that might complicate dental treatment;

• History of oral habits; and

• History of hospitalizations or surgeries.

A necessary part of the medical-dental history is the signing of a formal consent from the parent or guardian.

Restraints

Todd is an 11-year-old patient who has cerebral palsy and is also quadriplegic. He is severely mentally disabled and cannot talk or understand simple commands such as ‘open your mouth’. Todd was referred to our practice as a possible candidate for dental treatment administered in a hospital operating room with the aid of a general anesthetic. My oral examination and radiographs showed that Todd required nothing more than an oral prophylaxis and the extraction of three primary teeth. We accomplished this in our dental practice by having Todd’s parents hold his arms and legs while we cleaned his teeth (using a mouth prop). After placing a topical anesthetic and then administering a local anesthetic, I extracted three over-retained primary molars. This simple treatment saved the expense of hospitalization. It also saved Todd the risk of general anesthesia and the frightening experience of spending his first night away from home.

There are various types of restraints that may be used to effectively and efficiently provide dental treatment. Parents or guardians, dental assistants, mouth props, and body wraps can be used in one or more forms. The least amount of restraint may simply be a mother holding her son’s hands on his lap during the injection of a local anesthetic. The child would be given a rubber-coated mouth prop to bite on to make sure that his mouth remains open.

Frequently, infants and toddlers will sit on the parent’s lap during treatment. In this way, the parent helps restrain the child by holding the child’s legs still. The mother might hold the child’s legs while the father holds the hands. Often, I will have a dental assistant sit behind the patient and support the child’s head. Another aid that is available is the elbow and knee ‘stabilizers’. These prevent the child from injuring himself/herself and/or the dental team members.

Nitrous oxide analgesia is beneficial for some children with disabilities. We use nitrous oxide as a muscle relaxant for patients who have cerebral palsy, patients who have moderate to severe mentally disabling conditions, for patients who fear injections, and for patients unable to cope with the idea of dental treatment. The patient is weaned off of the nitrous oxide as quickly as possible by reducing the nitrous oxide/oxygen ratio at each subsequent visit until only pure oxygen is used.

A variety of pre-medicating drugs exist that may be used for modifying a patient’s behavior. An explanation of these does not fall within the scope of this article. There are several continuing education courses that will help the dentist in choosing proper conscious sedation techniques.

The following types of patients are candidates for general anesthesia with an anesthesiologist present:

• The child with whom communication is not possible because of physical or mental health, or chronological age;
• Children younger than age two and one-half years who have severe bottle caries;
• Children with systemic conditions such as diseases or disorders of the heart, those who are severely epileptic, and patients with hemophilia. These patients should be treated after a consultation with the child’s physician; and
• Patients with severe behavioral problems who have not responded to mild or moderate restraint.

Conclusion

The techniques discussed within this article are those I use in my practice. This does not mean that other practitioners lack the latitude to include or exclude certain devices and techniques when treating children who have disabling conditions. In 1931, the orthodontist Wuerpel wrote: ‘The mind of a child is as tender and as lovely as the petals of a full-blown rose. Beware how you touch it! Meet it with all the reverence of your being. Use it with gentle respect and fill it with the honey of love, the perfume of faith and tenderness of tolerance. Thus, shall you fulfill the mission of your life.’

Related Reading:

1. Margolis, FS.  Beautiful Smiles for Special People.  Self-published.  Available at www.dentaled.org
2. Behavior Management of the Child and Adolescent.  University of Illinois at Chicago College of Dentistry, Chicago, IL.
3. Bond, A.W., Modarski, S.W. Dental Hygiene Care of the Special Needs Patient. Chicago: American Dental Hygienist's Association, 1983.
4. Brandes, D.A., et al. Special Care in Dentistry 15, 119-123, 1995.
5. Dental/Oral Health Services for People with Special Health Care Needs.  DDD Dental Services. POB 45310, Olympia, WA 98504.
6. Developing Dental Education Programs For Persons With Special Needs: A Daily Oral Health Care Guide For Parents and Staff.  Massachusetts Dept. of Public Health, 150 Tremont Street, Boston, MA 02111.
7. Developing Dental Education Programs For Persons With Special Needs: A Training and Reference Guide. Massachusetts Dept. of Public Health,150 Tremont Street, Boston, MA 02111.
8. Grundy, M.C., et al. An Illustrated Guide to Dental Care for the Medically Compromised Patient. Aylesbury: Mosby,1993.
9. Guide to Etiquette and Program Accessibility when Working with People with Disabilities.  Office of Equal Opportunity, Professional Arts Building, 11th and Washington, P.O.Box 45839, Olympia, WA 98504.
10. Hunter, B., Dental Care for Handicapped Patients. Bristol: Wright,1987.
11. Kroeger,R.F., How to Overcome Fear of Dentistry. Cincinnati:Heritage Communications, 1988.
12. Kroeger, R.F., Managing the Apprehensive Dental Patient. Cincinnati: Heritage Communications, 1987.
13. Lange,B.M., et al. Dental Management of the Handicapped:Approaches for Dental Auxiliaries. Philadelphia:Lea and Febiger,1983.
14. A Manual for Families and Case Managers of Persons with a Disability.  University of Missouri-Kansas City School of Dentistry, Kansas City, MO
15. Module III Dental Prevention for the Patient with a Disability.  School of Dentistry, University of Washington, Seattle, WA.
16. Module V Anxiety and Pain Control for the Patient with a Disability.  School of Dentistry, University of Washington, Seattle, WA.
17. Oral Care Training Program Workbook.  Specialized Care Company, 15 Renee Court, Edison, NJ 08820.

18. Patients with Physical and Mental Disabilities.  American Dental Association, 211 E. Chicago Ave., Chicago, IL 60611.
19. The President's Conference on the Dentist-Patient Relationship and the Management of Fear, Anxiety and Pain.  American Dental Association, 211 E. Chicago Avenue, Chicago, IL. 60611
20. Prevention and Treatment Considerations For the Dental Patient With Special Needs.  Johnson and Johnson Consumer Products, Inc., Grandview Road, Skillman, NJ 08858.
21. Recommendations for the Use of Restraint in the Delivery of Dental Care for the Handicapped.  Academy of Dentistry for the Handicapped, 211 E. Chicago Avenue, Chicago, IL. 60611
22. Weinstein, P., et al. Oral Self Care. Seattle: University of Washington,1991