Clinician Offers Pearls for Pediatric Practices
NEW YORK – There are unique considerations that must be taken into account when treating children for dental complications.
“When you are treating a child, there is a triangle: the child, their parent, and the dentist,” Carla Cohn, DMD, told the packed audience of dentists at the Greater New York Dental Meeting. “It’s a much more complex relationship than when you have an adult patient in the chair and they can make their own decisions. The dentist is put into the position of treating and answering to both the child and the parent."
Dr. Cohn offered some pearls for clinicians who treat children. Typically, visits to her office start with a letter to the parents or guardians that explains the examination process, and offers the parent or caregiver advice for their child's visit.
“I say in the letter, please don’t use words like ‘needle’ and ‘drill,’ or ‘this is going to hurt,' because parents often bring their own biases to the visit. I ask them to let us explain in our child friendly terms what the visit will be like,” Dr. Cohn said.
Clinicians should use their best judgment when deciding whether a parent should remain in the room during the examination based on their comfort level. Dr. Cohn said she typically encourages the parent to remain in the room. One of the advantages is that it then becomes a bargaining chip with the child to encourage better behavior.
A prospective study of 440 children between the ages of 3 and 10 concluded that if a parent is removed temporarily from an examination room during a trip to the dentist, because of their child’s uncooperative behavior, 93% of the children behaved better in subsequent visits.
“Basically, if I don’t have the parents in the room in the first place, I lose that leverage,” Dr. Cohn said. On the other hand, she discourages siblings entirely from the examination room, because, she said, often the siblings, particularly older siblings, have a tendency to tease and make visits worse for the patient than needed.
Show and Tell
Once the child, and in some instances, parent, is comfortable in the office, Dr. Cohn said she or her assistant performs a “show and tell” routine, where they explain all of the instruments that are used during the examination and procedure. She uses terms children can relate to, such as calling a rubber dam “the raincoat,” or a clamp as the “button.”
Discussing the actual examination, Dr. Cohn said that she does not typically use oral sedation with nitrous oxide, because clinicians “have to get the child down to a deep level of sedation, which makes me uncomfortable because I am now watching the child’s heart rate, in addition to performing whatever procedure I am working on.”
Dr. Cohn said that for those patients that are very unruly, sometimes general anesthesia with intubation is required. She also has used papoose boards for very small children but only on an as needed emergency basis, and never for routine examination or restorative work. Distraction is also key, Dr. Cohn said, noting that she has placed a mobile in the line of site of her chair, so that she has a place to direct her patients’ eyes during examinations.
Discussing topical anesthesia, Dr. Cohn said she uses a unique compounded preparation of 10% lidocaine, 10% prilocaine, and4% tetracaine in an aqueous base. This preparation can be squeezed onto a gauze pad and applied to the site.
During the procedure, Dr. Cohn and her staff frequently engage the patient, reinforcing positive behavior with statements like: “you’re nice and still. That’s great.” She said the show-and-tell and the positive reinforcement all help the patient anticipate what is happening, so there are no surprises during the visit.
She also said it is important to assess numbness differently in adults and patients. “Children do not understand what the word ‘numb’ means,” Dr. Cohn said. “So it is important to ask ‘does this side of your tongue feel different than that side?’”
Discussing that infamous question: “will it hurt?” Dr. Cohn encouraged clinicians not to lie, because, she said, children will not forget being lied to. “Tell them you don’t know, because honestly, with every patient it is different and it may hurt or it may not. The important thing is not to lie because once you have lost that patient’s trust, it is very difficult to get it back.”
Tried and True Treatment Choices
When performing procedures, Dr. Cohn said it is important to consider the extent of decay, vitality of the pulp, age of the patient, and how close the tooth is to exfoliation, as well as whether or not the patient is cooperative for treatment. When performing procedures like crowns and placing glass ionomers, she has a few tried and true choices for certain procedures. She specifically cited SDI’s Riva Self Cure glass ionomer cement, GC’s Fuji IX glass ionomer, the dual-cured self-etching Futurabond DC products from Voco America, and the NuSmile pediatric crowns, which she said she uses for their durability, shade, and length varieties. Dr. Cohn stressed the importance of never underestimating the extent of decay and the strength of the remaining tooth structure after excavation of decay. Although glass ionomers and composite resins are more durable than ever, remaining tooth structure strength is critical for the success of a restoration, she said. Many times dentists will find themselves in a position in which the tooth needs full coverage due to extent of decay or pulpal involvement and the parent is demanding an esthetic alternative to the recommended stainless steel crown. These are the times when a preveneered stainless steel crown, like the NuSmile product is invaluable, Dr. Cohn said. With this as an alternative,clinicians do not have to be put in the position of choosing between esthetics and function and durability.
At the completion of a visit, Dr. Cohn also said she has instituted a rewards system, in which a child is given the opportunity to pick a sticker or toy from a box as a prize for a successful trip to the dentist.
