Michael R. Young presents an overview of caring for children in a general practice setting, discussing when children should first attend and how best to advise and communicate with parents.
Children's dentistry is a specialty in its own right. However, every GDP and every DCP should know how to treat children in a knowledgeable and compassionate manner so that their very young patients end up with a disease-free mouth and a very positive attitude towards dental health and dentists in general.
This article will help you answer some of the questions parents (and guardians) might ask you about their child's dental care. It will also hopefully help you see that treating children is different to treating adults.
The first visit
Let's begin at the beginning and ask, ‘When should a child first see the dentist?’ Opinions vary between from birth to when they have teeth to not until they are two-years-old. There is no hard-and-fast rule or even guidance it seems. However, experience has shown that children who regularly visit a dental practice from an early age develop a very positive attitude towards their own dental care and to dentistry in general. Early-age dental visits for a child helps them become accustomed to the sights, sounds and smells of a dental practice, and helps eradicate any fear they may possibly have.
Parents may be sceptical about their newborn needing to see the dentist before they have any teeth. This is perhaps understandable as most people associate dentists with teeth, ignorant of the fact that dentists do other things besides look at teeth! New parents are probably too busy to make a dental visit a priority for the baby, so why not encourage them to make a note in their diary to bring baby when they get their first tooth? This provides a tangible reminder. You can reassure Mum and/or Dad that even though there is a lack of teeth, the dentist will examine the baby's mouth and check that it is developing normally. In the long term, all children should, I hope, have had their first dental visit by their first birthday.
Baby teeth are important
To start off with, some parents don't see their child's baby (deciduous) teeth as being important. Getting the message across that baby teeth are important is a good place to start. What do you say to the parent who places so little value on dental care that they ask you, ‘Why should I take my child to the dentist; aren't their baby teeth going to fall out anyway?’ Baby teeth are important because they help the child to:
Chew their food easily
Learn to speak clearly
Have a pleasant smile.
You could point out that the early loss of baby teeth because of decay can lead to crowding problems, which may later require lengthy and expensive treatment. There is also the risk that the child's general health can suffer if diseased or broken teeth are not treated early.
Sowing positive seeds
Some parents might ask for advice about what they should say to their child about seeing the dentist for the first time. Here you can help sow some very positive seeds. A child's knowledge is based on what they have experienced for themselves and what they have been told by others. Tell them to always talk to the child about their visit in a positive way, using words that they are able to understand. Ask them not to allude to unpleasant memories of their own (possibly childhood) dental experiences, and to try very hard not to put the child off by displaying their own dental fears. One of the major problems with treating children is that they often come to the dentist having already been told or having heard negative things about the dentist that fill them with dread. It is part of your role to counter this negative message.
Gently remind the parent that if they don't know what the dentist plans to do at their child's appointment, then do not make things up. Misleading the child will undermine their trust in them and the dentist. Stress to them that it is the policy of the practice that emotive words such as ‘hurt’, ‘needle’, ‘injection’, and ‘drill’ are not used within earshot of children. They should be urged not to use these words within the practice, or when they talk to the child about the dentist. Older siblings can be a problem or a blessing. Ask parents to look out for and discourage older siblings from trying to scare a younger brother or sister with made-up stories about the dentist. However, if the young child has an older sibling who is a model patient then use the latter to encourage positive behaviour in the younger child.
Mutual trust and understanding
Perhaps the biggest problem GDPs have treating children is managing their behaviour. Difficult adult patients are difficult enough, but at least this is a one-to-one encounter. Difficult children come with a parent in tow and this three-way relationship needs to be worked on if the goals of the child's dental care are to be achieved. Co-operation between the parent, the GDP and DCP, and the child is very important because there must be a relationship of mutual trust and understanding between all parties. An initially difficult child will gain confidence and develop the trust needed to become calm, unafraid and co-operative when the parent and dentist work together. By working together, the GDP, DCP and parent can help develop a positive attitude in a child, which leads to a lifetime of good dental experiences. This communication triangle (child, parent and dentist) is a very important part of a child's long-term dental care. Never underestimate parental influences, good and bad.
You should reassure parents that the dentist and staff at the practice are experienced at managing children's behaviour and know how to handle children of all ages in a gentle, compassionate manner.
If you can train the parents, you are half way there to being able to manage the kids. Setting out a very clear list of dos and don'ts, which the parents will hopefully take heed of, helps enormously (see below).
What to expect
You could be asked, ‘What will happen during my child's first visit?’ Obviously this depends on the age of the child – not all children are first seen as early as you would like! However, and assuming the child doesn't require emergency treatment, then you should tell the parent the following:
Their teeth will be counted to see that their development is normal for their age
Each tooth will be examined for signs of decay
Their cheeks, tongue and gums will be examined for evidence of disease
The way in which the teeth meet when your child bites together will be checked
X-rays of the teeth may be taken to look for hidden decay
X-rays may be taken to check for the presence and position of unerupted teeth.
As well as the above, you could add that both the parent and child will be given advice on how to maintain the child's teeth and help their mouth stay healthy.
If treatment is required
So far I have covered what could be termed the preparatory phase of managing a young child, but unfortunately not all children get away with never having to have treatment, even if it is something as straightforward as having their teeth polished. What do you say to parents to reassure them if and when their child does need treatment?
The practice should have guidelines whereby all children are introduced to dentistry gently, usually by having a simple procedure carried out at the first visit. Polishing a child's fingernail with a rubber polishing cup (no polish to begin with, and maybe not using a hand piece) then progressing through to them eventually allowing the dentist or hygienist to polish their teeth, is a simple, step-by-step method of gaining a child's and their parent's confidence. Children's dental treatment requires the same, high level of treatment planning that adults generally receive as a matter of routine. You should therefore tell the parent that once the child has been examined and any proposed treatment discussed with them and your child, then a treatment plan will be drawn up. It is important that if parents are to have confidence and trust in the practice, the practice must demonstrate that it takes the care of its child patients seriously; treatment plans and discussion help do this.
Pain control, and more specifically injections, are a major concern for parents, so you must reassure them that it will be used whenever it is clinically necessary. In the background, the GDP must know how to give pain free injections, and DCPs must know how to prepare injections and pass them to the dentist (if this is how you work) without the child being aware of what is going on. The routine use of a topical analgesic gel is to be recommended.
Parents in the surgery
A major, contentious, and often divisive, issue in children's dentistry is whether parents should be in or out of the surgery. What do you think? Your practice might not have hard-and-fast rules about whether parents are allowed into, or are excluded from, the surgery. As a rough guide the following factors should be considered:
The child's age
The child's previous dental experiences
The child's behaviour
The parent's attitudes and behaviour.
Some children react well when a parent is present in the treatment room and others behave better when their parent remains in reception.
Parents often believe that if they are excluded from the surgery they are abandoning their child. It is important that you reassure them by saying that sometimes their presence can undermine communication and rapport between the GDP and the child, and the only way to regain the child's attention is by the parent being elsewhere. The GDP should decide, based on their experience and knowledge, whether it is in the child's best interest to have their parent in the treatment room. In my experience, an uncooperative child will almost always calm down and co-operate if the parent is out of sight.
This article is no more than a very brief overview of caring for children in a general dental practice setting. If you would like to learn more about managing child patients you can read Guideline on Behavior Guidance for the Pediatric Dental Patient from the American Academy of Pediatric Dentistry, which can be found online at http://www.aapd.org/media/policies_guidelines/g_behavguide.pdf.