*Dental Exam Went Well, Thank Flouride:
http://query.nytimes.com/gst/fullpage.html?res=9B07E3D91039F937A15752C0A9649D8B63&ref=janeebrody
*The Claim: Dental Cavities can be Contagious:
http://www.nytimes.com/2011/03/29/health/29really.html?_r=1Think you Dental
*A Closer Look At Teeth May Mean More Fillings:
http://www.nytimes.com/2011/11/29/health/a-closer-look-at-teeth-may-mean-more-fillings-by-dentists.html?pagewanted=all
National Children's Health Foundation......
*Pediatric dental disease is 5 times more common than asthma and 7 times more common than hay fever
*44% of American children will suffer from pediatric dental disease before they reach kindergarten
*73% of pre-schoolers and 48% of primary school age children who have experienced cavities currently have unfilled cavities
*While the American Academy of Pediatric Dentists (AAPD) recommends that every child establish a dental home by their first birthday, only 1.5% of 1 year olds have had a dental office visit compared with 89% who have had an office based physician visit
*4.5 million children develop pediatric dental disease every year
Related Articles:
*The Special Needs Child
*Parenting the Parents of our patients
*Wisdom Teeth
*The Special Needs Child
A growing percentage of our practice is comprised of patients who fall under the umbrella of “special needs children”. This may range from mild disruptive tendencies to far more severe aspects of autism, ADD, ADHD and so on.
Currently, our biggest challenge is the child diagnosed with autism. As with most disorders there is a wide spectrum of autism. Some children, while diagnosed as autistic, are minimally compromised while others are clearly and profoundly developmentally challenged. In New Jersey one out of 94 births results in a child that will be diagnosed with autism. What is most critical for the autistic child and their families is early detection. Of the hundreds of autistic children that we see in our practice, parents have indicated to us that they suspected a “problem” long before the pediatrician mentioned anything to them.
It is now clear from all research that early intervention is critical in allowing a youngster with autism to go on to lead a somewhat normal, if not fully normal, life.
So too, it is critical that an autistic child’s first visit to the dentist be no different than for any other child. We recommend age 2 ½ or earlier if any kind of problem is suspected.
Frequently, parents ask us how we are able to even look at their child’s teeth let alone clean, treat and care for their mouths. It should be remembered that while special needs children may be challenging, they are a routine occurrence in a pediatric dental office. Frequent crying and lack of cooperation is a common occurrence just as it is in a pediatrician’s office or any other child care facility. Crying is not a bad thing. It is simply a way for a non verbal child to relate his feelings whether that child is very young or falls within the guidelines of a special needs individual. All pediatric dentists are trained to work with uncooperative children and are able to visualize and examine the oral cavity. Depending on the circumstances, the pediatric dentist will do a clinical examination for the child and then sit down with the parent and explain findings and techniques to accomplish the appropriate treatment.
Parents are also concerned that they or several people may have to physically restrain their child in order to examine or accomplish dental treatment. This is not the case. If or when physical restraint is indicated it is done in an orderly manner with adequate explanation prior to any treatment.
It is helpful that two adults come with the child. This allows the dentist to sit down with one parent and explain the findings without the distraction of their child. It allows for adequate questions and answers so that the parent understands the findings and the perspective treatment if any.
Also, we see a large range of ADD and ADHD patients. These children, for the most part are cooperative but because of their disability their attention spans may be short or they are unable to sit quietly for longer periods of time. Treatment can often be adjusted so that long appointments are avoided and treatment be done efficiently to allow for appropriate treatment in the shortest amount of time. It should be remembered that for those children currently medicated for school, for example, they should take their usual medication in the appropriate doses making no special changes for their dental visits. If they take no medication normally, no medication should be given to the child prior to a dental visit unless discussed beforehand; certainly never for a child’s first visit.
A certain number of our patients that come to our practice are severely handicapped. Again, we make every effort to accommodate these children. We are wheelchair accessible and prepared to work with the individual child evaluating their oral and dental needs as necessary.
Recently, a mother brought a 4 year old child in for a routine 6 months visit after being referred to us by a general dentist. Although the child was uncooperative we went about our treatment with no particular problem. The mother, on the other hand, was clearly uncomfortable and visibly upset with the child. After completing the child’s treatment, we asked the mother why she was upset; after all, the child did quite well for a 4 year old. She told us that when she brought her child to the last dentist, the child was uncooperative and the dentist refused to see him and she was afraid that we would do the same. Not a chance! This is what pediatric dentistry is all about.
Cooperation or not we deliver uncompromising dentistry with the hope that as these children get older they all will become great patients with health mouths. As parents and professionals we must take the first steps toward that goal.
*Parenting the Parents of Pediatric Patients
This article appeared in a monthly periodical distributed to general dentists. It is worth reading. Obviously, not all aspects of this article are pertinent to the lay public as it is directed to the dentist but there are lots of “pearls” to be taken away.
Jane Soxman, DDS
Allison Park, Pennsylvania
Compendium – November 2006;27(11):630-634
Preparing the parent for his or her child’s dental visit begins with the first phone call to schedule an appointment. Practice polices, including scheduling, payment and broken appointments are explained. Parents usually prefer not to take their children out of school for dental appointment, but school calendars with in-service days and holidays may be found on the Internet. Check with parents regarding home-schooling or recommend scheduling the appointment during a nonacademic period. With so many working parents, late-afternoon appointment may be requested for toddler and preschoolers. If an examination reveals the need for multiple treatments, the parent may expect that these restorative appointment can also be scheduled late in the day.
Young children are more rested earlier in the day and cope better in the morning. This too should be understood before the first visit. Waiting for more that 15 minutes may be very disturbing for some parents and morning appointments generally have less wait time. Saturday morning appointments may be an appreciated option for working parents with young children. Parents often choose to schedule all of their children at the same time for convenience, but this can result in house of production loss because of the possibility of broken appointments. The amount of time reserved for the appointments should be stated on the phone along with any fee charged for a broken appointment. If a child’s parents are divorced or separated, the parent responsible for payment must be given the opportunity to agree to payment fore the initial examination and restorative treatment.
A brochure describing the first visit for a younger child, with the assurance that most behavior concerns can be carefully and appropriately handled by the dental staff, will help to calm the parent as well. Also, including advice in the brochure for the parents on how to approach the appointment of an apprehensive child is very helpful for both the parent and the child.
It is important to understand the family dynamic of the child, which is why “name of parenting adult” may be added to the health history questionnaire. It has been my experience that grandparents functioning as parents, same-sex partners, live-in boyfriends and girlfriends, and guardians are commonly referred to as the parent by the child. When addressing a child’s mother, keep in mind that women sometimes keep their maiden name after marrying. Refer to the ex-husband or ex-wife as Mr. Ms, or the child’s dad or mom. The actual relationship must be determined before any treatment may be performed to obtain legal consent.
Pretreatment Consultation
For a cooperative child, pretreatment consultation may require only a few minute, but for a child with multiple restorative needs or with behavior guidance needs, more time will be necessary. The parent who will accompany the child for each visit should be present, if both parents are not available. A separate appointment is not required, and a well-trained assistant can lead this discussion. Areas covered should be noted in the chart for documentation and future reference. The time spent with this communication will avoid confusion, mistrust and, in the worst case scenario, a law suit.
The need for morning appointments to perform longer procedures for the behavior management is explained. If the child had difficult during previous visit with another dentist, the parent may be asked what he or she believe went wrong. Questions may be as follows: Were you present while the treatment was being performed? How did that help or not help? Do you know exactly what the problem was?
The parent’s response may provide a better idea regarding who or what was actually responsible of the child’s reaction to treatment; determine whether the parent or child requires more behavior guidance. The final question may be, “How do you think your child will behave for treatment now?” This may be the optimal time to discuss the limitations that uncooperative behavior places on the quality of care that can be provided and to discuss your own management technique or style. Ask the parent about his or her expectations of the child’s ability to cooperate and discuss the reality of these expectations. The parent’s perception of the child’s temperament is a good indicator of how the parent will respond if the child is uncooperative during treatment. A check list format may be used with descriptive words (eg. Cooperative, strong-willed, defiant, becomes hysterical easily, fearful, and afraid or cautious with new experiences). The influence of in-born traits because of temperament may be noted by the dentist or assistant, which may result in a more honest response from the parent regarding the child’s personality. If the child’s behavior during the initial examination is stubborn and defiant but parent believes that he or she is “just afraid because all children are afraid of the dentist.” Treatment will be difficult and may require sedation. However, parents who have a realistic response may be a relief for the dentist and staff. This parent can be informed that he or she along with the dentist and the staff, will work together as a team to achieve the objective of treating the child. I have noted that a parent who is “sitting on the fence” regarding the desire to have the treatment completed, is a parent who can be easily influenced by the child’s well-rehearsed skill of manipulation.
The dialogue between the parent and the child before the appointment should be discussed. I have found that the less said to the child before the treatment usually results in a better outcome. Tell the parent that most procedures are performed with the Tell-Show-Do approach. The procedure is described with age-appropriate terms. The instruments and materials to be used for the procedure are shown to the child using a DVD, another child as a model, or a stuff animal. Finally, the procedure is performed.
Specific methods for managing the behavior of a more challenging child are discussed later when informed consent is obtained. Warn parent to be cautious with their choice of words: You get to come back to see the nice dentist,” instead of “You have to come back here.” Bribes should not be offered nor statements regarding the need to be brave. For apprehensive children, parents should sit closely beside the child, reading a story before the appointment. This seems to calm the children more effectively than free play.
Local anesthesia and its anticipated use should be included in the pretreatment consultation. The dentist or assistant should forewarn the parent that the sensation caused by the local anesthesia may be more upsetting to a young child than the actual injection. Our practice tells parents to refer to the numb feeling as “fat and fuzzy” rather than “frozen”.
Sometimes the need for local anesthesia is not initially planned, but if appointments are missed or the decay progresses rapidly, an injection may be necessary. Parents should not tell the child that he or she is not getting a shot because the plan could change. If a child is very apprehensive, senses are heightened and local anesthesia may be indicated to assure that pain not the reason for deteriorating behavior. Parents often think that lack of local anesthesia was the main reason for the child’s inability to previously cooperate. Whether or not this is an accurate assumption, the use of local anesthesia in an uncooperative child is probably a better plan for both the parent and the child. A tearful response to the injection is much more acceptable to a parent that a tearful response perceived to be caused by the procedure. Finally, fear of the injection may create a serious obstacle to begin treatment. The injection should be discussed by the parent before the restorative appointment.
Tell the parents that your objective is to restore the teeth, but the child’s behavior may limit your ability to complete the procedure or perform ideal dentistry. The block of time reserved on the schedule should be noted, along with the fee for this reserved time if the treatment cannot be accomplishing because of the child’s behavior. Inform the parent that the procedure could be at a point where immediate cessation would not be possible, but that every effort would be made to discontinue treatment as soon as possible if the child becomes hysterical or combative.
Parental anxiety may transfer to the child. Apprehensive parents should be informed of the effect of their body language and facial expressions. Preschool children are a few years past the nonverbal stage of their lives, and these silent cues are readily interpreted. Maternal anxiety is especially influential. Most parents know who would be the better parent regarding the comfort level with dentistry. Parents of children with low dental fear are more likely to consider themselves as more contributory and as having the ability to influence the child’s reaction. Whereas parents of children with high dental fear attributed the fear to factors beyond their control and felt powerless in helping their child to overcome the fear. It has been my experience that parents anxiety regarding treatment maybe alleviated by observing a similar procedure being performed on a younger child who is cooperative. Inform parents of children who require behavior guidance that generally behavior improves with each visit and that ultimately these fearful children are extremely relaxed patients.
In most cases, a child who requires behavior guidance should be brought to each appointment by the same parent. As the parent becomes more familiar and comfortable, so does the child. With each appointment, a rapport is developed among the dentist, parent, staff, and child. When a different parent accompanies the child for treatment, a new relationship must be established and the behavioral guidance initially tailored for the parent and child may require modification in accordance with the presiding parent’s philosophy.
Informed Consent
Informed consent may require repeated explanation. A study examining parents’ knowledge of proposed treatment 2 weeks after informed consent was obtained. On the day of the treatment, 40% of the parents could not accurately answer questions regarding some significant aspect of their child’s treatment.” Besides a verbal explanation, photographs, models, a prototype of the appliance to be used, and brochures may be helpful to provide supplemental information. CASEY Pediatric provides an entertaining and informative presentation on DVD for more procedures and other topics related to the child’s case.
Grandparents and caregivers cannot give consent for treatment. In the case of divorce, informing both parents of the treatment needs is recommended, particularly the parent who is responsible for payment. The laws regarding custody of young children vary, and advice from a local attorney may be necessary to determine the laws within the jurisdiction. An ethical dilemma regarding treatment could become a legal dilemma if treatment is provided without consent of the custodial parent. If a parent has visitation rights only, he or she may not be able to make treatment decisions. If the parent does not speak English, consent cannot be obtained using a minor as an interpreter. Document the conversation and all of the areas covered in the chart.
Behavior Management
In a survey of diplomats of the American Board of Pediatric Dentistry, almost 9 out of 10 concluded that they are observing negative changes in parent styles, and these changes have adversely influence their pediatric patients’ behavior. Respondents ranked the reasons for this change from highest to lower; parents are less willing to set limits, less willing to use physical discipline, unsure of their roles as parents, too busy to spend time with their children, and too self-absorbed or materialistic. The consequence is that behavior management techniques have becomes less assertive. The reasons for this shift in management technique may be the result of a defensive response to avoid the backlash of this more involved, protective parent or to use methods that may more effectively control behavior in order to accomplish treatment goals.
Parents may not be familiar with the methods used for behavior management. If the need for behavior management is deemed a possibility, the methods used by the practice should be discussed before the restorative appointment. The techniques may include voice control, hand-over-mouth, restraint, or pharmacological modalities. Sedation or general anesthesia may be preferred to physical restraint. Strong avoidance or combative behavior will create limitations for treatment that may be harmful or affect the quality of the dentistry. The dentist may assist the parent in making the appropriate decision depending on the child’s age, medical status, extent of treatment to be performed, and the child’s ability to cooperate.
By having this discussion before treatment, you also offer the parents the option to decide in an uncharged atmosphere whether these management techniques are agreeable with their own parenting philosophies. The parent who was present for the discussion and demonstration of the possible or planned behavior management should accompany the child for treatment. Parents, and often the parents of the same child, have very different opinion regarding the use of behavior management. Some parents find voice control to be too upsetting. If the parent appears to be reluctant to permit the dent’s methods for behavior management, the dentist may suggest that another practice’s treatment style may be more suitable.
Parents Presence for Treatment
Parents generally accompany their young children for pediatric medical examinations, so it follows that they would expect to do the same in dental practices. Some want first hand information, some believe that the child wants them present and some believe that the dentist cannot manage their child’s behavior without their assistance. Also, there are the parents to prefer not to be present for treatment. Ultimately, parental presence for treatment is determined by each practice’s philosophy and the circumstance that ensures optimal care for the child.
The first visit should be not only to meet the child but also to develop rapport with the parent. If both parents come for the first visit, inform them that only one parent should accompany the child for restorative appointments to avoid the child misinterpreting the seriousness of the next visit. If both parents prefer to accompany the child, only one may be present in the operatory for treatment. Parents may begin a conversation or argue during the procedure, creating a distraction.
Toddler and preschoolers see parents as having a protective power in a new or threatening environment. The child’s temperament and emotional health will determine the ability to separate from the parent. The separation is facilitated if the parent understands that by age 5 and for most 4 year olds, the ability to separate is a normal milestone in development. Parental trust enforces the child’s trust and empowers the child. The unspoken message to the child is that the parent trusts the dentist, there is nothing to worry about and that the child is capable. Children seem to fare better if the separation occurs in the reception area rather than after being seated for treatment.
Parents may become the “court of appeals” with the child’s avoidance behavior. Explain that both the procedure and the child deserve our undivided attention and that the parent can unintentionally distract both the dentist and the child. Reassure the parent that the door to the operatory will remain open and that once the procedure has begun, he or she may periodically check on the child. If a parent is in the reception room and the child begins to cry loudly or uncontrollably, it is best to bring the parent in the operatory. A parent who hears his or her child screaming during treatment may not only become distraught but very angry.
If the parent refuses to separate, the dentist should review the rules: the parent is the silent partner. His or her presence is support for the child. Warn the parent not to parrot the dentist’s request of the child, not to attempt to explain the procedure and not to comment on the time remaining to complete the procedure. The dentist cannot talk to the child through the parent. The dentist cannot compete with the parent for the child’s attention; the child’s attention must consistently be direct back to the dentist. The dentist must be perceived as the authority figure. Prepare the parent for a predetermined cue that indicates it is time him or her to leave should his or her presence interfere with the treatment objective.
For the disruptive and noncompliant parent who reuses to leave, treatment should cease with a reminder of the previously discussed guidelines. If the parent persists, compromising the treatment, the dentist may say, “I am not able to provide quality care at this time; perhaps we should reschedule. If yo prefer, I can help you to find another dentist who may better suit your needs.” This method has been quite effective in my practice in engaging the parent’s cooperation.
Post Treatment Consultation
Parents should comfort the child if necessary, but dentists should suggest not to dwell on the difficulties. If the child was emotionally upset during the appointment, tell the parent not to talk about the difficulties during the appointment because this may negatively influence future visits. Reassure the parent that most children eventually become very comfortable with treatment. Praise the parents for their good parenting when their children demonstrate good coping skills.
Conclusion
Each parent brings a new perspective of beliefs and behaviors depending on his or her cultural influences and personal history. Multiple issues will influence parental personality and expectation. Involving the parent through communication and engendering a cooperative spirit will assure reduced stress when treating our pediatric patients. Take the time to get to know the parents. By identifying their needs and appreciating their strengths, not only will the quality of the dental care be enhanced, but so will the quality of the emotional care for each child and his or her parent.
*Wisdom Teeth
As you may know, all our primary teeth are replaced with permanent teeth between the ages of 5 and a half and thirteen years of ago. The exception to this rule is the wisdom teeth which erupt at age 17 or later IF they have the room. The important word, of course, is “IF”.
Contrary to popular belief, wisdom teeth are not “extra teeth”. We are born with three sets of permanent molars. The 1st molars erupt at approximately age 6-7, the 2nd molars erupt at approximately age 12-13 and the 3rd set of molars erupt late in our teen years if they have the room.
Most of us have all four wisdom teeth, whether they have room to erupt or not. As the jaw grows some of us do, in fact, have the room for the eruption of these teeth. However, 95% of the population does not have the room for proper eruption, have subsequent discomfort, pain or infection and require that these teeth be extracted by an oral surgeon.
Because most of us have 28 normal, functioning teeth the loss of 4 wisdom teeth is not significant. The extraction of these teeth, however, may be quite significant depending on their position in the jaw bone. Some of these teeth will remain in proper position while some, mostly as a function of little room, may develop horizontally or even upside down. In order to evaluate the position of these wisdom teeth, a panoramic x-ray is taken of the jaw to see all teeth, their position and the size of the jaw bone.
Sometimes, the wisdom teeth appear to erupt into the mouth only to find that they have limited room and can only partially erupt. This may actually be worse since once the gum tissue has been perforated by the tooth, there is access for food, plaque and bacteria to enter the tissue and cause inflammation and possible infection. Furthermore, as the tissue swells, we tend to “bite” our gum as we eat thereby inflaming the tissue even more and resulting in significant discomfort.
Although we try to predict whether wisdom teeth will eventually erupt or require extraction before there is a problem sometimes it is a close call and despite our best efforts, some of our patients will become symptomatic.
In general, aside from contacting us or being referred to an oral surgeon for evaluation, the following palliative treatment is recommended:
- The use of an anti inflammatory analgesic such as Advil.
- Rinsing with warm salt water to reduce the inflammation of the tissue and make it less susceptible to trauma while eating.
- Soft diet.
- Good oral hygiene around the area to reduce the amount of bacteria causing the inflammation.
The use of antibiotic may be necessary if significant infection develops. That is evaluated on a one to one basis by the dentist or oral surgeon.
If we suspect that the wisdom teeth will not have the required room to erupt, we will recommend a consultation with an oral surgeon. It is best to go for the consultation even if extraction isn’t indicated right away. This way, if a problem does arise, x-rays and consultation have been completed and confusion can be eliminated when the patient requires treatment and is most uncomfortable.
What happens if you do nothing at all? Some of the possible consequences of not having wisdom teeth extracted are:
- Pain and infection particularly when teeth partially erupt but never fully erupt into the mouth.
- Future cyst formation. The body may encapsulate the tooth in a fluid filled sack (cyst) and over time the cyst will grow destroying jaw bone in the process. While not a malignant process, it can lead to eventual jaw fracture.
- Gum and bone problems behind the 12 yr molars as the wisdom tooth erupt against these molars and not allow normal bone and gum to develop.
- If wisdom teeth need to be extracted later in life, the roots of these teeth may have wrapped themselves around the large nerve that runs through the lower jaw resulting in damage to that nerve during extraction and possibly resulting in permanent numbness of part of the face.
Clearly, if wisdom teeth need to be extracted, the earlier it is done, the better and easier for the patient.
If necessary and as a general rule, extraction of wisdom teeth should be done the summer between the patients senior year of high school and college to eliminate any problems during the first year of college.
