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Behavior management considerations in the pediatric dental patient

Feb. 17, 2015
“I shook my head in protest as my mouth was shut tighter than a clam. I still remember the frustration on my dentist’s face ... I refused to open my mouth for my dentist. I was 5 years old. … He was holding a gigantic, dribbling needle two inches from my eyes and telling me to open, so he could ‘just look at my teeth.’ Yeah, I wasn’t falling for it.” Dr. Conway Jensen offers advice to help you work with young patients more easily. He suggests that a lot has to do with children’s capacities to deal with various situations.
I shook my head in protest as my mouth was shut tighter than a clam. I still remember the frustration on my dentist’s face and his tense body as I did that. I refused to open my mouth for my dentist. I was 5 years old. Why wouldn’t I open? He was holding a gigantic, dribbling needle two inches from my eyes and telling me to open, so he could “just look at my teeth.” Yeah, I wasn’t falling for it.NEVER STOP LEARNING ...Acute primary herpetic gingivostomatitis: a case report

So off I went to the “specialist” who can, according to my dentist, “deal with kids like your son,” they told my mom. Guess what? I refused again … well, until the dentist abruptly slapped his hand over my mouth and brought his face within millimeters of mine. His eyes pierced my soul with his scary stare as he spoke in a threatening tone, with such intensity as to jolt me out of my skin. Any sense of control I had fled as my body chemically bonded to the chair. My mouth opened so big that Cookie Monster’s mouth seemed miniscule in comparison. All I had done was refused to open. Did it work? Did I do as I was asked without hesitation? Absolutely! However, the essential question is: Was the method appropriate? Back then maybe so, but that was 37 years ago.

My experience happened just a couple of years after “Behavior Management in Dentistry for Children”(1) was published. At the time, it was the most comprehensive textbook in management and techniques for guiding children’s behavior while at the dental office. There has been no new edition to this book until 2014, (2) 40 years later. The American Academy of Pediatric Dentistry (AAPD) sets forth guidelines (3) on behavior management and updates them on a regular basis. This is a helpful resource for any dentist or parent and gives us a standard to follow.

Every child presents new and different challenges; e.g., the 4-year-old who won’t let go of Mom’s leg, or the 9-year-old boy with three earrings who can curse up a storm and acts all macho but screams in terror at the sight of the exam mirror. Not to mention the 3-year-old with 18 carious lesions and a severe heart condition. The scenarios are endless.

Why do some young patients walk in happy as a puppy and endure siting still for 20 minutes with their faces feeling like they fell off, while others scream, kick, hit, and hide under the bench?

My dear friend and mentor Dr. C. Post always used one word: capacity. Children have varying capacities to deal with situations. Some have zero capacity while others have a great deal of it. This is no different than some dental providers who have zero capacity to deal with a crying, misbehaving child while others do not notice it. Every dentist must understand the child’s capacity for stress and discomfort. Further, perception is another important component in managing children’s behavior. How individuals perceive the stimuli around them affects their interactions and behaviors. Watch kids and their parents on a playground. A skinned knee or bump can be brushed off as nothing, or the whole world can be brought to a halt as the child is hovered over and attended to as if their life is on the brink. Are children sometimes shown how to respond to stimuli instead of learning for themselves? Are children sheltered so much that they are denied learning to cope with life’s events?

The dental office experience is no different than the playground. To deal positively with that stimulus takes capacity. It is the provider’s responsibility to deal with the outward expression of that stimulus. Behavior management is a way to deal with that unique expression. Since each child’s capacity is different, different methods are needed to control the dental situations. The patient’s perception has huge effects on dental experience as well. By controlling capacity and perception, we as providers can redirect the behavior in order to accomplish the task needed. There are ways in which the experience of a dental visit can be controlled to be helpful for everyone.

Parents are a good start for a positive dental visit. Parents need to know you are qualified and that you have the best intentions. Children can sense their parent’s fear and anxiety. Parents can unintentionally transfer fear to the child before even walking in the office.

Instruct parents how to talk to their children about the office visit. Help them to help you introduce the dental visit in a nonthreatening way. Parents have good intentions and want to prepare their children for a visit. Educate parents before they inadvertently scare the pants off their kids. Despite best intentions, you do not need parents/guardians preparing their kids by telling them about the big needle that will be “stabbed in their mouth.”

To create positive stimuli, there needs to be a child friendly environment. Remember, perception is important. Kids need to know it’s OK for them to be at the office. An office full of items that cannot be touched or enjoyed may not be the best invitation for a child. How can a child relax if there is a feeling that the office is a no-child zone? Pediatric offices are set up just for them. It can be like a fun park. I am not suggesting you redo your office, but a friendly, inviting office is a good start in behavior management.

Friendly staff is also key. I visited an office where a large sign on the desk read, “Children’s butts belong in the chairs. Thank you.” The lady behind the desk reminded me of the grouchy, old witch I once saw in a scary movie. This scenario is probably not a good start. Removing the sign and placing a smiley person behind the desk changes the patient’s whole perception and experience.

Practitioners should learn and practice the techniques recognized by the AAPD. Dentists should learn to recognize and deal with different capacities. Professionals in the office have the ability to deal with capacity by controlling the stimulus. Don’t overload the child. The parent/guardian can pick up their little ones and force them in the dental chair and make them fold their arms with threats of punishment at home. On the other hand, the children can jump up in the big chair, watch a movie, and open big like a dinosaur to count their strong teeth. It is OK to change the delivery in order to cope with different children’s capacities. We as providers need to improve and control the perception as well. A dental drill can be a noisy, painful hole-maker or a simple water whistle that cleans and tickles teeth. Remember, your patient will observe you. Frustrations and anger from the provider are noticeable. Patient behavior can be affected by how the provider is perceived.

It is not easy to get a young patient through a dental appointment. It takes time and sometimes lots of failed attempts. What you see or hear other providers doing may not work for you. Learn the techniques and AAPD guidelines. Figure out what works for you and use it. Learn to perceive each patient’s capacity and perception and adjust your delivery to match. Do all this while providing a fun, safe, and controlled environment. This ideal environment is challenging to create, I know. Personally, I find parents the biggest challenge to manage. I cannot seem to find a textbook, clinical guideline, or advice on that one. But that is another article.

Conway Jensen, DDS, grew up in Calgary, Alberta. He obtained his bachelor’s degree in biology from Oregon State University. During dental school at Marquette University School of Dentistry in Milwaukee, Wisconsin, he received a couple of awards in the field of pediatric dentistry. After receiving his DDS degree, he went directly to his pediatric dental training at the Children’s Hospital of Wisconsin. He is a board-certified pediatric dentist in private practice in Washington State and is involved in the American Academy of Pediatric Dentistry and the American Academy of Behavioral Psychology. Outside the office, he spends time with his friends and family and enjoys the outdoors and travel. References 1. Write GZ. Behavior management in dentistry for children, W B Saunders CO; Oct. 1975. 2. Wright GZ, Kupietzky A. Behavior management in dentistry for children, 2nd Edition, Wiley Blackwell; 2014. 3. American Academy of Pediatric Dentistry. Guideline on behavior guidance for the pediatric dental patient. Pediatr Dent 2014; 36:179-191.