Treating children, not teeth
The assessment of the child-parent interaction is important in determining how to deal with the dental situation. First of all, I recommend the doctor does an initial exam and have the preventive aspect at a follow-up appointment. For young children, timing is important—a morning appointment is highly recommended. Children are more tired and cranky in the afternoon, making compliance and useful work and communication more difficult. Of course, parental time availability is a factor, but you should prioritize a morning appointment.
The reason I suggest a separate appointment for the preventive and educational aspect and doing an initial exam only at the first meeting is because it gives you the time and place to interact with the child and parent, in a non-invasive activity. You can judge how the child and parent interact, and that will give you clues on how to proceed. How do they enter the operatory? Is the child coming in reluctantly or coming in ahead of the parent? Does the child need to be carried or dragged in? Is the parent unable to persuade the child or even get them into the operatory? All these are clues as to how to deal with the dental situation. I never help the parent bring a child into the operatory, unless asked by the parent.
Secondly, if you do the exam and follow-up preventive aspect, the child may be tired, making the situation difficult to even verbally communicate with the parent. As an aside, the cost factor can come into play. The combined visit may cost from $200-$500 and the parent may consider this expensive because “you did not even do anything.” They may be reluctant to come back. If you break it up to two appointments, it becomes more palatable. In addition, you can use the second appointment to go over options in the treatment plan, with pros and cons of each treatment. In addition, the non-attending spouse is given the information before starting any dental work. At a second appointment, the child is often more compliant.
You need to assess parenting styles to give you guidance on how to approach the situation. If a parent is progressive and permissive, you need to approach them with this in mind, and it will give you guidance on how to handle a non-compliant child. If the parent is also non-compliant, you need to go over your goals and aims for that child, and options to achieve them. The overprotective parent is reluctant to let the child experience a new and strange situation and may move in and reprimand you if they think you are too aggressive. There is also the abusive parent who threatens the child if they misbehave. Lastly there is the nurturing parent who is looking for you to help to do what is best for the child.
Parenting is tough, and the attending parent may have to deal with a non-attending spouse or in-laws who have a different point of view. You should be there for the attending parent and give them the information they need about the treatment, so that they can explain the treatment to their partner, and let them know that the partner can call or come at the next appointment. There are many different cultures. However, in my experience, most parents from all cultures I encountered want what is best for their kids. A little communication goes a long way. Inform before you preform is always a good strategy. Parents need support for dealing with new situations because they can be over whelming with interaction with family, siblings, and others with good intentions. They are not dealing with the issues at hand but have opinions that may not be relevant to the child’s needs.
Before starting any treatment, you need to go over the health and treatment history, both medical and dental. Sick children with multiple hospitalizations and numerous medical treatments, or negative dental experience, should be noted and details taken. In addition, a medical history and list of medications the child is taking. This may help explain child’s actions in new situations, and their behaviour in the operatory. Do not confuse a child with multiple medical visits with a shy child who may just react to a new and strange situation. They need to be handled very differently.
Ask the parent, what is the goal of this visit? Did the child already have any dental experience, and if they did, have the parent elaborate. Is the child in good dental health, or are restorations and extractions planned? How the child deals with the dental prophylaxis is an indication of the child’s compliance to more difficult procedures. Sedation may be indicated for more difficult treatment, and it is better to address this issue ahead of time. Do not be critical and show the parent you are here to help them address their goals.
Abusive parents are very rare, but you must be on the lookout for signs, from parental threats to any unusual injuries. Some parents ignore the child’s dental problems until they become acute. They now demand immediate care. Much more common is the overprotective parent. The overprotective parent is very damaging to the child, as it is not about the child but the parent. They do not want the child to suffer, cry, or deal with any difficulties without interfering. Examples of this is that they claim the 2-year-old child will not let them brush their teeth. Or the child is too young for dental treatment that is necessary.
Remember you must have consent when dealing with these parents, and you may need to stop treatment and go over pros and cons of necessary treatment that you want to provide. Under no circumstances should you threaten a child. But you must be firm, as with brushing teeth with a non-compliant infant, all with parental approval. You should not let the child dictate the treatment but do adjust the situation to address the child’s needs. For example, if a child is caries free or has rampant decay, brushing will be more important in the second situation. Be firm, but gentle. Encourage and celebrate good behaviour. Praise the child for good performance and praise the parent as well. If extensive dental treatment is to be done in the future, do not speak to the parent in front of the child, but speak to them in private. Although the child may not comprehend the spoken words, they read body language very well. Lastly, parents must take responsibility for the outcome of dental treatment, good and bad. Since they are the ones who will maintain dental health.
The initial preventive appointment sets the tone for future dental interactions. Make it a good one, even if you do not accomplish all that you want. I always do “Tell Show Do,” on all kids, even infants, before starting any procedure. If the child is very reluctant to co-operate during a dental prophylaxis, you may need to consult with the dentist, and he/she may need to reevaluate the treatment plan to include sedation or other procedures to carry out more invasive treatment. This is a good time to discuss it rather than after a bruising battle attempting to do any extensive work. This is precisely why I always prefer to do the preventive non-invasive appointment first, rather than at the end of the dental treatment. This also gives me a chance to measure brushing success at succeeding appointments and see if parent is able to keep the child’s mouth clean. At the end of the preventive appointment, I always give the child a small gift as well as praise the parent.
Following the end of treatment, a recall appointment should be scheduled and explain why it is necessary. You job is to educate and coach, not just clean teeth. If the parent is not on side, you will not succeed. Thus, you need to use the appropriate approach to each individual’s needs. Only they can do it; you can help them and win the ultimate reward—a healthy, happy caries-free child. If they want it, only they can do the work.
About the author
Originally from Montreal, having taken his dental education at University of Montreal (in French), Dr. Maltz moved to Toronto in 1973. He practiced for 5 years and obtained his diploma in Paediatric Dentistry from U of T in 1979. He lectured for hygiene at Niagara College for two years and also served as head of the dental department at Peel Memorial hospital, and started the paediatric division at Etobicoke General Hospital. As a two-term president of Ontario Society of Paediatric dentistry, he did a presentation at Queens Park on dental care. In addition to being a clinical instructor and lecturer at U of T, Dr. Maltz wrote numerous articles for the professional and lay press, including a book for the public, “We Treat Children Not Teeth”. He is happily married for 35 years with three kids and three grandkids. Hobbies and pastimes include traveling, swimming, hiking, fishing, reading good books, and enjoying fine food and fine wines.
