Tricks or Treatments: Techniques for Managing Adolescent Patients
Fred Margolis, DDS
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.
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
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.
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
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
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
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
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.
(Continued from page 1 )
During the first and
subsequent visits, the following innovations may be used to make the child’s
visit more comfortable and therefore more successful:
- Sunglasses to prevent
the glaring operatory light to allow more comfort for the child.
- 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.
- 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.
- 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.
- 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.
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.
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.
(Continued from page 2 )
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
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
• The names and dosages
of the patient’s medication;
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
• 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
A necessary part of the
medical-dental history is the signing of a formal consent from the parent or
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.
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
- 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.
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.’
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