Chapter 16
Practical Considerations and the Dental Team
The foundation for practicing pediatric dentistry is the ability to guide infants, children, and adolescents through their dental experiences. Today, practicing pediatric dentistry is a team effort, with dentists leading and delegating responsibilities to team members: trained dental auxiliaries and administrative office staff. A pediatric dental team has to work together so that the patient develops a positive attitude toward the dental experience.
The pediatric dental team is an extension of the dentist in that it uses communicative behavior guidance techniques, leading the child patient stepwise through the dental experience. All personnel have a stake in guiding the child through the experience. Dental auxiliaries and reception staff are invaluable when dealing with the pediatric patient (Wright 1983). Therefore, all dental team members are encouraged to expand their skills and knowledge in behavior management techniques. When assembling a team, technical skills are important, but the authors have found that it is more important to hire for positive attitude and passion first. Happy individuals are much more likely to participate in activities that are adaptive, both for them and the people around them (Fredrickson 2004).
Team Rules for Behavior Management
There are six fundamental rules of behavior management for establishing positive relationships for both the team and the pediatric patient (Wright and Stiger, 2011).
While nearly everyone would agree with these rules, following them is another matter. They are often overlooked. To illuminate the points, Wright applied these rules in context with case scenarios (1983). These updated cases remain applicable today.
Case 16.1, Discussion: Both the receptionist and the dental assistant greeted Johnny, and the dental assistant tried to relax him to encourage a smooth patient transfer from the reception area to the dental clinic. Without realizing it, however, the dental assistant’s final comment violated a fundamental precept of pediatric patient management: the entire dental team’s approach must be positive.
A more positive effect could have been created if the receptionist had simply said something concrete and truthful, such as “Hi Johnny, I like your outfit, it is so colorful and bright. I am glad you came today. We are excited to see you.” Then the dental assistant could have taken the lead and said “Come on Johnny. You were such a good boy last time when you were able to help count your teeth. Dr. J. really wants to see if you can still count to twenty. Let’s go quickly.”
To achieve success with children, it is important to anticipate success (Wright 1975). Positive statements are far more effective than thoughtless questions or remarks directed mostly to parent figures. When dealing with difficult pediatric patients, the dental team has to mask emotional reactions and remain positive. The dental team member’s attitudes or expectation can affect the outcome of an appointment because children are likely to respond with the type of behavior expected of them. In essence, the child fulfills the dentist’s prophecy. This theory was advanced by Rosenthal and Jacobson in their book Pygmalion in the Classroom, which discusses children and the educational process.
In addition to taking a positive approach, the dental team has to be direct, specific, and confident. Questions that imply choice should be avoided unless the choice will definitely be granted. For example, the dental assistant summoning a child from the reception area will undoubtedly get a better response by saying “Johnny it’s your turn to see Dr. J., please come with me,” rather than asking, “Johnny, would you come with me?” The same is true when the dental team member says, “Now I am going to brush and clean your teeth. Please help me by opening nice and big,” rather than “I think it is time to clean your teeth now, OK?” Positive and direct communication is easy to learn, and after a short period of time it becomes automatic. All members of the dental team should be aware of its importance and help one another to use it with children. Another approach is indeed to give the child a choice, but structure the question and possible choices so that both options will be acceptable and lead to the same outcome. For example, do not ask “Would you like me to clean your teeth?” Instead, ask “Would you like me to clean your top teeth first, or start with your lower ones?” The child is given a choice. Both options will lead to the start of the cleaning. There is actually a benefit to this approach: the child subconsciously realizes that he made the choice to start the cleaning.
Case 16.2, Discussion: The proper team attitude for dealing with children includes personality factors, such as warmth or patient interest that can be conveyed without a spoken word. A pleasant smile is body language that engages multisensory communication, and it may indicate to a child that the adult cares. In this case, the greeting to the child and his mother was businesslike, matter of fact, and formal. While this may be suitable for some adult patients, a nicer welcoming for the child might be, “Hi Billy, good to see you. How is school these days?” Children are informal. Consequently, they respond best to an attitude that is natural and friendly. Acknowledging Billy’s presence first also makes him the center of attention. It places the child at the apex of the Pediatric Dentistry Treatment Triangle. At that point, the receptionist can hand out the medical update, which includes a section on insurance, and ask the parent if she needs help filling it out.
An attitude of friendliness can be conveyed to the child patient almost immediately. A casual greeting, such as, “Hi buddy, how are you today?” usually evokes a smile, whereas “Hello William” does not tend to put a child at ease. A mechanical tone certainly should be avoided, and modulation of voice control should be encouraged. As they famously say in Hawaii, “Hang loose.”
Children can be made to feel at home in the dental office in many ways. If youngsters have nicknames they prefer, these should be noted on their patient records and used during future appointments to promote a natural and friendly atmosphere. For example, if William prefers to be called “Billy,” it should be noted and used at all times.
The world that we live in today is one that embraces multi-culturalism and diversity. Just look at the authors and contributors in this book. “It is a Small World After All” (Thomas Friedman). Today it is very common to welcome children in our practices with unique names. For those names that are unfamiliar and difficult to pronounce, it often helps to have the phonetic spelling noted in their charts.
Additionally, patients’ school accomplishments or extracurricular activities should be noted in the dental record. Most children are delighted to share their interests and hobbies. Keeping this in mind, and keeping a record of those interests, helps the team initiate future conversations and demonstrate a caring attitude toward child patients. However, care must be taken to prevent matters from getting out of hand. For example, after telling the dental team stories, a child may become excited and difficult to settle down for the dental procedure. While friendliness is fundamental to behavior management, over-permissiveness or an overly affectionate approach should be avoided. Thus, the dental team must project a degree of firm confidence when necessary. Children have to respect the team approach and realize who the leader is. They must be aware of what is expected of them. Sometimes the behavior guidelines can be re-established by simply saying, “Billy, there is a time for play and a time for work. Now it is time to work.” The whole team must embody this attitude and culture.
Case 16.3, Discussion: This case illustrates another fundamental aspect of behavior management. In pediatric dentistry, an organized plan or protocol is a necessity. A proper, prioritized treatment plan should have been discussed with the parent prior to the appointment, ideally at the examination and treatment planning appointment. In this case, detailing the procedure at the beginning of the appointment delayed the start of the treatment and was unfair to both the child and the parent. Technical discussions in the presence of a child may build apprehension, and hurrying the conversation does not allow a parent sufficient time to ask questions and make an informed decision.
Organized plans and protocols in the dental office have many dimensions. For example, begin with the reception area. Who summons the new patient—the dentist, the dental assistant, the dental hygienist, or the receptionist? If a child creates a disturbance in the reception area, who deals with the situation? A plan might stipulate that the dentist be summoned at once, but this may differ from office to office. Each dental office must design its own contingency plans, and the entire office team must know in advance what is expected of them. Such plans can be placed in the office and employment manuals, and are a key feature of many pediatric dental offices. Good plans increase efficiency and contribute to successful work environments as well as positive relationships between dental teams and child patients.
Case 16.4, Discussion: Many dental assistants have been placed in a position similar to this one. The child asks the question with an apparent concern. If the dental assistant replies affirmatively, the young child might become very apprehensive, and a behavior problem could ensue. If the dental assistant states that the child is not going to have an injection and, in fact, the child needs one, then credibility is lost. Therefore, the assistant adopted an appropriate, “middle-of-the-road” course of action. She deferred to the dentist to inform the child and intercept any adverse behavior if it occurs.
Unlike adults, most children see things as either “black or white.” Examples must be concrete. There are no “shades of grey.” To them, shades between are abstract and difficult to understand. To youngsters, the dental team is either truthful or not. Therefore, truthfulness is extremely important in building trust, and is a fundamental rule for dealing with children.
As the above case exemplifies, the dental team should be careful not to be trapped into being untruthful by circumstances. For example, when a child is told that an appointment is for a checkup, it is wrong to proceed with a restoration without the child’s permission. Since children often do not understand the reason for a change in plan, the dentists must take the time to explain. Sometimes parents coax the dentist to complete the work at the checkup appointment. If this occurs, it seems reasonable to ask the child, “Would you mind having a filling today so that you do not have to come back tomorrow? If I do it today, then Daddy won’t have to take more time off work.” If the child is agreeable, then the dentist may proceed. If the reply is negative, the child patient’s choice should be respected because the youngster was told at the beginning that the appointment was for a “checkup.” Parents will accept the explanation that it is wrong to establish one set of expectancies for their child and then suddenly revise them. Remember, parents and caregivers are part of the Pediatric Dentistry Treatment Triangle, and most are interested in their children having good working relationships with their dentists. They do not want to see confidence and trust destroyed.
Case 16.5, Discussion: This could happen. Children sometimes whine, fidget, and aggravate, despite the best dental team efforts to minimize disruptive behavior. The important point is that the dentist recognized a potential loss of personal control. This story demonstrates that all people have limitations in dealing with negative behaviors. Recognizing individual tolerance levels and empathizing with the patient and situation is important when dealing with children.
Tolerance level and empathy are seldom-discussed concepts in dentistry, and they vary from person to person. As an illustration, consider the possible effect of Paul’s behavior, which might be described as borderline cooperative-uncooperative, on two different dentists. Dr. A. copes with Paul’s whining with the attitude that the child will gain confidence and eventually change. She ignores the whining and continues treatment. Dr. B., on the other hand, finds the whining highly irritating. Because it is bothersome and upsetting to the entire dental team, as well as the parent, Dr. B. manages the child by using a firm, reassuring, positive voice control technique. The dentists tolerated and reacted to the child’s behavior quite differently. Yet both provided the treatment successfully, even though their approaches to the problem were dissimilar. Their management of the situation was governed by their individual tolerance levels.
As well as varying from person to person, tolerance levels fluctuate for the individual. For example, an upsetting experience at home can affect the clinician’s mood in the dental office. Some people are in a better frame of mind early in the morning, whereas the abilities of others to cope and empathize improve as the day progresses. The important thing is for clinicians to know their tolerance levels. Morning people should instruct receptionists to book behavior problems first thing in the morning. Learning to recognize factors that overtax tolerance levels is one way to avoid loss of self-control.
Case 16.6, Discussion: Daniel may have had an urgent need, or he may have been delaying treatment. The dentist tried to determine the necessity and, failing to do so, allowed Daniel to go to the bathroom. To avoid this situation, patients should be asked to use the restroom before entering the treatment room and be told that during treatment it will be difficult to stop and go to the bathroom. However, Daniel was not prompted before treatment to use the bathroom. In cases such as this, the child has to be given the benefit of the doubt. Sometimes, however, children use this ploy as a means of delaying treatment. The bathroom incident is of secondary importance in this case. It is included here to point out another important principle when dealing with children: the dental team has to be flexible. Since it was not Daniel’s fault that the office was operating behind schedule, there was no reason to be impatient with him.
Children are children. They lack the maturity of adults, and the dental team must be prepared to change its plans at times. A child may begin fretting and squirming in the dental chair after half an hour, and the proposed treatment may have to be shortened. Conversely, a dentist may plan an indirect temporary pulp treatment with final restoration at a second appointment, but because the child is difficult, the plan may have to be altered to complete the treatment in one session. Sometimes a child may appear for a dental appointment out of sorts, with a low grade fever and stuffy nose that was unrecognized previously by a parent, and the dental appointment has to be terminated.
The size of children may also demand a change in operating procedure. Many dentists, following accepted four-handed dentistry practices, work at the eleven or twelve o’clock position. This is not always possible with the young child patient. Thus, the dental team has to change with each situation, and flexibility becomes a necessary ingredient in the behavior management of children.
Keys to Effective Communication in a Pediatric Office
Communications are used universally in pediatric dentistry. Establishing communication with the pediatric patient helps alleviate fear and anxiety, builds a trusting relationship between the dental team, the pediatric patient, and the parent, and aids in promoting the child’s positive attitude toward oral health. The dental team must consider the cognitive development of the pediatric patient as well as the presence of other communication deficits, such as hearing disorders, when communicating with them (AAPD 2012). There are keys that help open and guide effective communication with children. These are:
- The first rule is to establish communication. Engage the child in conversation. This enables the dentist and the team to learn about the patient, and may relax the child.
- Be sure that everyone acknowledges the lead communicator. Members of the dental team must be aware of their roles when communicating with a child, and at which point one person takes the lead over the other. For example, the dental assistant starts engaging the child in conversation before the dentist arrives. Then, when the dentist arrives, the dentist takes over the lead and the assistant becomes an active listener. It is important that communication comes from one single source. If the parent is in the operatory, this must be explained in advance. When the dentist is conversing with the child, the parent must be a silent observer and active listener. If multiple people try to engage the child in conversation or give directions at the same time, it can be confusing for the child.
- It is important that the message is simple and age-appropriate. When talking with children, use real-life descriptive examples to explain procedures.
- Use the voice appropriately. A controlled alteration of voice volume, tone, or pace to influence and direct the patient’s behavior is known as voice control. The objectives of voice control are to gain the patient’s attention and compliance, avert negative or avoidance behavior, and establish appropriate adult/child roles.
- Use multisensory communication. In addition to spoken messages, nonverbal messages can be used with patients. Body contact such as a simple tap on the shoulder or a smile conveys a friendly feeling of warmth and reassurance. Eye contact is important. Children that avoid eye contact may not be fully prepared to cooperate. When talking with children, every effort should be made to speak at the child’s eye level, rather than towering over them. Eye level communication allows for a friendlier and less authoritative or intimidating experience.
- Be sure that everyone acknowledges the lead communicator. Members of the dental team must be aware of their roles when communicating with a child, and at which point one person takes the lead over the other. For example, the dental assistant starts engaging the child in conversation before the dentist arrives. Then, when the dentist arrives, the dentist takes over the lead and the assistant becomes an active listener. It is important that communication comes from one single source. If the parent is in the operatory, this must be explained in advance. When the dentist is conversing with the child, the parent must be a silent observer and active listener. If multiple people try to engage the child in conversation or give directions at the same time, it can be confusing for the child.
The foregoing are keys to communicating with children. There are others as well. All are described in greater detail in the communication section of Chapter Six.
Training the Dental Team
The practice of pediatric dentistry is a team effort, with the dentist leading and delegating responsibility to the pediatric dental staff (including trained dental auxiliaries and office personnel). Each pediatric dental auxiliary and office staff member has to be trained and should actively participate in the management of child behavior in the dental office (Wright 1975). The dental auxiliaries and office staff members must support the dentist’s efforts to welcome the patient and parent into a child-friendly environment and facilitate behavior guidance and a positive dental visit (AAPD 2012). The responsibility, or role, of individuals varies according to the philosophies and competency of those concerned.
In the Pediatric Dental Team Approach, everyone contributes. The pediatric dentist is the leader, but it is important to note that this means giving the team members autonomy and empowerment. As Bill Gates said, “As we look ahead to the next century, leaders will be those who empower others” (Aeker and Smith 2010). There are instances where the dental assistant or hygienist may be the “key” person in the control of the child’s behavior—instances in which they engage the pediatric patient better than the pediatric dentist. In such instances, it is important to give the dental auxiliary considerable freedom in developing rapport with the child. Research has shown/>
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