We are all aware that treating children in our dental practice can be extremely challenging. Whether it be their inability to sit long enough to complete their dental treatment or their anticipation or generalized anxiety, these factors and many more add to the difficulty in treating our pediatric patients. Not only is the experience difficult for the patient but many dentists avoid treating children because of their own anxiety and inexperience. Many dentists are more fearful of the child than the child is of the dentist. Many practitioners are confronted with the dilemma of what role the parent plays in the dental treatment of their child. The dentist must decide whether the parent should play an active role in their child’s dental treatment or a passive role, which in many cases involves complete absence from the dental operatory. Traditionally, pediatric dental treatment was provided with the parent waiting in the waiting room while the dentist completed the treatment. The parents were not seen as being part of the treatment and in many cases thought to be interfering with the dentist-patient relationship. Presently, the parents are more commonly invited and in attendance in the operatory while their child is having dental work completed. The parent can play a crucial role in the successful treatment of the pediatric patient but what is the role of the parent in the dental operatory?
All dental treatment for the pediatric patient begins with an in depth and thorough discussion and explanation of the treatment required with the parent and child. Whether it’s the material that will be used or the level of sedation required to treat the child, the parents must understand all the information required to give consent. This step must be ensured by the dentist before embarking on any dental treatment. Secondly, this should be documented in the patient’s chart. The parent is a partner in the dental treatment of their child. For younger patients where the child does not explicitly understand the treatment being provided the consent is provided by the parent or legal guardian. It is important to note that consent is a continual act, and the parent can change their mind at any time. Having the parent in the operatory while the dentist treats the patient ensures they are consenting to the continuation of treatment. Keeping the parent informed and communicating with the child and parent assists in ensuring a successful treatment.
As a child gets older, they may be deemed by the dentist to have a full understanding of the treatment being provided. This brings up the concept of the age of consent. For example, there is no minimal age of consent with regards to dental treatment in Ontario, so long as during the informed consent discussion the patient shows that they thoroughly understand the risks and benefits and the potential consequences of not doing the treatment.1 The current RCDSO guidelines state that while there is no set age limitation for informed consent, for children under the age of 12, informed consent should be obtained from the parent or legal guardian.2 For an adolescent aged 16 and above, the dentist can presume that the patient has the capacity and maturity to make his or her own decisions regarding treatment, so long as the dentist finds no evidence to the contrary 2 This is an understandable concept in principle however can be challenging for the clinician to determine if a child can give consent to or decline treatment. When possible, involving the parents in the treatment of their older child makes sense and should be encouraged. A typical situation where this may arise is when an older teenage (16-year-old) patient comes to an appointment without the parent. Following a thorough discussion with the older teenager I will routinely ask the patient if it is alright to call their parent to let them know we are taking a set of radiographs. Should the teenager not want the radiographs taken then the dentist is unable to take them. In many cases the parent is still able play a role as a partner in the treatment of their older child. Where possible, the parent, patient and dentist should function as a team. The dentist is responsible to be aware of the laws regarding the age of consent in their jurisdiction.
Once the parent has agreed to the treatment being provided, it is important to educate the parent on their role in the dental operatory. The primary role of the parent is to support and comfort their child through the dental treatment. Having said that, this role will be very different for the parent of an infant, toddler, preschooler, school aged child, or an adolescent. The parent will likely play a more involved role when the child is younger with a decrease in involvement as the child gets older. Prior to the start of dental treatment it is important to explain to the parent what you require from them and to clarify their expectations during the treatment. The dental operatory can be a setting of great anxiety with unknown expectations for the child and the parent. If the treatment ahead of them is explained in everyday language and delivered with empathy the clinician will set the stage for a successful appointment.
The Infant (0-1 years of age)
For the general dentist, the infant is one of the most stressful patients to treat. Most dentists graduate from dental school with no experience at all with infants in a dental chair. This could explain why to this day most dentist still recommend that the child see a dentist at the age of three and not the recommended age of one or when their first tooth erupts. The parent is very much a participant in the dental operatory with an infant patient. The parent in most cases is sitting in the chair with the child on their lap. Figure 1 illustrates a very effective technique used by many pediatric dentists to examine an infant patient. The position of the child laying on their parent’s lap while the dentist is in a knee-to-knee orientation with the parent helps comfort the child while stabilizing them. Stabilization of the infant is extremely important. When using this technique, it is important to stabilize the child’s head with the palms of your hands to minimize movement of the patient’s head while you are examining. (Fig. 2) In this manner the dentist can stabilize the head between their two palms while the parent holds the infant’s hands. This method will ensure that the dentist can examine the mouth thoroughly while keeping the child comfortable and safe.
The Toddler (1-3 year of age)
The toddler can be an equally challenging patient and requires the support of their parent as well. The quintessential moving patient is the toddler, and the role of the parent is to support their child both from an emotional and physical standpoint. The parent is most supportive with these children when they are sitting in the chair sideways with the toddler’s legs over their lap while holding hands. This is clearly illustrated in Fig. 3. This is a safe and effective way to treat the patient while involving the parent in a supportive role.
The Young Child (Preschool and School Aged Children)
Once the pediatric patient gets to be a preschooler, the role of the parent in the operatory changes greatly. With the child’s developing independence they often want to sit in the dental chair by themselves with their parent being in the room for comfort. It is important to note that children develop and meet their developmental milestones at different times. Therefore, these age groups can be grouped together. For instance, a seven-year-old may require the emotional and physical support of their parent, while a four-year-old can be treated with little or no parental involvement. A specific finding on a medical history such as attention deficit disorder (ADD) may require the parent to be more involved in the dental procedure. Secondly, an underlying anxiety disorder or a previous negative dental experience can be an indication for more parental involvement. Typically, in a child older than four the parent’s supportive role can be best performed by holding the child’s hand or ankle for comfort. (Fig. 4) The dentist must establish a relationship with the child so in their supportive role the parent is best in adding words of encouragement while not interfering with the dentist-patient relationship. By having the discussion with the parents prior to treatment, the parents understand and appreciate the care you are providing for their child.
Adolescent patients can present a different set of challenges than their younger counterparts. Although in many cases they don’t require the support of their parents, they often require the guidance of their parents. Patients in this age group often come to their appointments alone and are commonly tardy for their appointment. As mentioned, it is relevant to contact the parent for scheduling and guidance purposes to make sure they arrive to their appointment. Following a quick discussion with the teenager it is beneficial in many cases to contact the parent to keep them informed. It is important to respect and assess the patient’s ability to give their own consent regarding aspects of their medical history and the treatment being provided. I feel that establishing a team like approach in the care of the adolescent whereby the parent and child are both part of the treatment leads to a successful appointment. A follow up discussion can be helpful to make sure that the results of the visit are communicated to the parents. As with their younger counterparts the parents can also play a more involved role whereby, they are present in the operatory supporting their child emotionally.
In pediatric dentistry the care of the patient involves the parent. In the past, the parent’s role was minimized or even non-existent. The parent can play an integral role in the successful treatment of a child in the dental operatory. With a thorough discussion and understanding of their role in the treatment of their child, the parent can be a useful and critical factor in the success of their child’s dental appointment. Knowing your patients and their parents as individuals and optimizing parental involvement in the child’s treatment will result in a successful dental experience. Communication with your patients and parents is the key to consensual and successful treatment of the pediatric dental patient.
Oral Health welcomes this original article.
- Goertzen, E. Current Guidelines, Considerations, and Challenges of Informed Consent in Paediatric Dentistry. Oral Health Journal. January 2019, 109:24-29
- Royal College of Dental Surgeons of Ontario-Practice Advisory: Informed Consent Issues Including Communication with Minors and Other Patients Who May be Incapable of Providing Consent. 2007
About the Author
David R. Farkouh is a pediatric dentist in private practice in Toronto, Ontario. He is on staff at the Hospital for Sick Children in the Department of Dentistry in Toronto, Ontario. He is the Pediatric Dentistry Editor for Oral Health.