Terrifying, Troublesome, or Terrific? Secrets to Perfect Pediatric Patients

Dentistry Today


The crying started, then the wailing, then the screams. The patient was pediatric. I was in the office of a dentist who is often troubled when working on children. I, on the other hand, love treating kids because I know the secrets to perfect pediatric patients. There went the screams again. Little Jimmy could be difficult. More screams. Louder now. “No, I won’t do it. You can’t make me!” Feeling compelled to intercede, I peered around the corner asking, “Can I help you with little Jimmy?” Wide-eyed, the assistant proclaimed, “It’s not the kid screaming. It’s the doctor!”

While this scenario may be only slightly exaggerated, it is true that many dental healthcare professionals are intimidated by children. Indeed, sometimes I don’t know who’s more afraid, the kids or the healthcare provider. Treating children in the dental office can be challenging. However, it also can be rewarding, and when handled appropriately, have predictably positive results. This article will help you break through behavior barriers, outline clinical techniques, and teach you to train children to become model dental patients. 
Treating children in the dental office provides us with a unique opportunity to impact the lives of another human being in a huge way. Improperly managed, the child can become a fearful adult patient who avoids dentistry and becomes a nightmare to treat. Properly managed, the child patient will be cooperative, compliant, and healthy, one of your best dental missionaries, and most of all, fun.

I believe children are best served in the office of a pediatric dentist for the same reason you take a child to a pediatric physician. They are trained exclusively to deal with the clinical and behavioral challenges of growing, developing youngsters. On the other hand, many general practices treat children successfully. This article shares success strategies effective for both situations.

Table. Common pediatric expressions

Pediatric expression



(1) Mr. Thirsty saliva ejector
(2) squirt gun air and water syringe
(3) tooth counter explorer
(4) tooth tickler prophy angle/handpiece
(5) go for a ride moving chair position
(6) camera for teeth x-ray machine
(7) count your teeth exam
(8) tickle your teeth rubber cup polish
(9) vitamins for your teeth fluoride

The following are core beliefs of outstanding pediatric healthcare providers:
(1) Children are excellent patients when properly introduced to the dental office. This belief must permeate all you say and do to result in a self-confidence that the child will perceive as authoritative yet supportive and nurturing.
(2) The first-time child patient, under normal preventive circumstances, has no reference to fear dentistry. Any fear has been introduced by another person or situation. This is important to establish at the beginning of an appointment. If a child who has never been to the dentist is fearful, ask the parent why the child is afraid, then listen carefully. Typical reasons may be prior unhappy experiences in another medical office/hospital or taunting from an older sibling. It’s important to learn these reasons so you can act accordingly. Sometimes parents project their fear onto the child. This needs to be addressed from the beginning. It’s important to be clear with the parents and child that your absolute expectation is for their child to have a fun and positive experience with you that will establish the foundation for a lifetime of productive, enjoyable dentistry.
(3) Praise is powerful. Take advantage of every single opportunity to praise your patient, always ending on a positive note.
(4) Children have short attention spans that must be occupied. Giving children the opportunity to become bored creates cranky, tired, apprehensive children. Don’t give them (and their parents) the opportunity to “wonder and worry” in anticipation of their appointment.
(5) Patient education regarding expectations and procedures must be accomplished quickly, effectively, and in a manner that is fun. Preparation, explanation, and flexibility are keys to accomplishing this.

The purpose of the first preventive visit is to introduce the patient and parent to your office, equipment, and pending clinical procedures, and evaluate any necessary treatment. Plan your protocol ahead of time and prepare for these appointments. 
Devote a staff meeting to establish your pediatric philosophy and core beliefs. If you decide that mothers will not accompany their children to the treatment room, you will need to communicate this information to the mothers in a way that will make them feel confident entrusting you with their children. Send out welcome packets to all new patients explaining your office vision and pediatric philosophy. Support your policies with positive benefits for the patient. 
Schedule new child patients (3 to 5 years old) as well as difficult young operative patients early in the morning. Children are more cooperative when they are not tired. You too will be fresher. Be punctual. Do not keep your child patients waiting in the reception area. Their impatience and anticipation will quickly become behavior problems. Introduce yourself to the parent and to the child. I actually get down physically on the child’s level, eye to eye, as I introduce myself. Sit next to the parent as you review medical history and any parental concerns about the child. This is also the time to question parents clearly about their child’s comfort level at the dentist and discuss any potential behavioral management challenges frankly.

Pediatric radiographic protocol is as follows:
•New patients 3 to 5 years old—2 anterior occlusal periapicals and 2 pedo bitewings.
•Recare patients—bwx annually
•Six-year-olds—panorex, then every 3 years to monitor development of permanent dentition and third-molar eruption pattern
•Posterior periapicals—taken to monitor specific problems

Occlusal periapicals are a great way to introduce a child to the x-ray procedure. Practically any child can “bite on the paper and hold still like a statue.” This gives them a positive experience with this procedure even if bwx were not possible. I often bend the corners of the bwx films before insertion. This is more comfortable for the patient and does not interfere with the diagnostic interpretation. Peel-off bwx tabs work well for children and the Snap-A-Ray (Rinn) holder is indispensable. If a child is truly unable to accommodate bwx, you may sometimes skip these and wait until their next visit, when they’ll be older and more familiar with the dental experience. Do this only if the mouth looks clean and decay-free.

The maximum time for a child rubber cup polish for deciduous teeth should be no more than about 3 to 5 minutes. The majority of chair time will be spent building rapport with the child and introducing equipment and procedures. Ask the child, “Do you brush by yourself or does your mom help you?” Kids are reliably frank, and this information will help you deliver appropriate home care instructions to the parents.

Fluoride should be administered every 6 to 12 months, depending upon caries rate. Using a foam and tray system, always administer fluoride to the child in an upright position with the mandible parallel to the floor. This keeps fluoride and saliva from drooling down the front or seeping down the throat. Instead, it sits in the floor of the mouth where it can be evacuated with the saliva ejector. Upon removal, I have the child hold the saliva ejector. Then I say, “Give ‘Mr. Thirsty’ lots of kisses so the vitamins all go to Mr. Thirsty, none in your tummy.” (See table for examples of useful pediatric expressions.) Children are very cooperative with this system, which prevents accidental fluoride ingestion. Give the child a choice of 2 flavors. If a child is unable to accommodate the trays during the first visit, paint the foam on with a cotton swab. 
Invite parents to join you for the examination portion of the appointment. Praise the child to the parents, share the hygienist’s appropriate clinical and behavioral observations, and review oral hygiene instruction. Invite parents to sit or stand close to the child so they can be shown the doctor’s diagnostic findings at the exam. 
At this point, oral hygiene instructions should be given to the parents as well as the child. Young children need help with brushing and flossing. Explain to the parent that “in our office, we depend on all the parents to assist their children with this process. You must brush and floss your child’s teeth until they are able to do this effectively and safely.” Instruct parents to sit on a bed or sofa so the child can lay down with his or her head on the parent’s lap. This way the child’s head is supported and the parent can see as they floss their child’s teeth (“just like we do it here in the office”). This is much more effective than attempting to floss a child’s teeth while standing.
Trisha O’Hehir’s new book, The Toothpaste Secret, uses cartoons to deliver an important and unconventional message about tooth brushing. It’s a must for anyone who brushes, kids and adults alike (Dental Secrets, [800] 374-4290 or tooth-pastesecret.com). 
Appropriate nutritional counseling with the parent can also be done at this time. If rampant decay is a problem, parents need to be questioned about their child’s sugar intake. Avoiding processed sugar and carbohydrates is a huge challenge for our culture, especially for parents who must depend on others for child care. We often tell parents to treat their children as if they were “allergic” to sugar. This term seems to be more effective in driving home the urgency of sugar restriction to reduce decay rate.

(1) Explain each procedure. This is crucial for the first- time patient. The equipment and instruments can be very intimidating and frightening to a child. For example, tell the first-time patient, “My special chair is going to take you for a ride. Here we go, I’m going to count/tickle/take a picture of your teeth.”
(2) Establish clear expectations. Don’t beat around the bush pleading for cooperation. Tell children exactly what you want them to do. Some examples are the following: (1) “Bite on this (x-ray film) like a cracker.” (2) “Listen for the beep.” (3) “Give Mr. Thirsty a kiss.” (4) “Put your hands on your lap.” Children usually are eager to follow directions when expectations are clear.
(3) Solicit participation. Kids love to help. Utilize them as your assistant. Have them hold Mr. Thirsty in their left hand, provided you are approaching the chair from the right. Helping you keeps their attention occupied in a positive manner.
(4) Praise and encourage. It’s amazing how seldom people (young and old) get praised. It works wonders. Some examples: (1) “I’m so proud of you.” (2) “Your mommy will be so proud of you.” (3) “You took great x-rays!” (4) “Here’s a sticker for helping me so much.”
(5) Ask questions that require an acceptable response. Avoid yes and no questions. For example, never ask, “Do you want to get your teeth cleaned today?” Instead, ask, “Shall we count/tickle your top teeth first or your bottom teeth?” Questions like this give a child a feeling of choice while expediting their cooperation.

(1) Mom in the room. Don’t do it. It’s imperative for you to establish one-on-one communication with your child patient, creating an independent, trusting rapport. This seldom occurs with mom present. Moms think they mean well but are almost always a destructive distraction to communication. A typical 3-year-old new patient, present for a preventive appointment with no pain, should be able to have a prophy, x-rays, and fluoride treatment with no mom present, provided that the hygienist knows how to handle the pediatric patient and the office is committed to– and prepared for–this philosophy. This appointment should be a new adventure for the child and fun for the hygienist too. Do invite mom to join for the exam. By this time, the child should be compliant and proud of the completion of the first visit. Now is the time to brag to mom about what a good helper the child was.

Exceptions to this protocol are the following: emergency patients in pain; patients younger than 3 years of age; patients with physical and/or mental challenges requiring parental assistance; and foreign patients requiring a translator. (See “Kosovo Kids” by Janet Hagerman at rdhmag.com.) Sometimes when I’m faced with a clinging, crying child who could be a borderline behavior problem, I’ll make an exception only after making it very clear that mom can stay only if there is no crying. 

(2) Baby talk. Speak in plain English. We clean teeth, not toothies. You’ll need to relate to your child patient yet also establish and maintain your credibility as the authority.
(3) The H word (“hurt”): Don’t say it. I never say, “This won’t hurt.” It plants a seed I don’t want even remotely considered. Instead, preframe your child patients positively with phrases like the following: (1) “You won’t feel this picture, but you’ll hear it.” (2) “You’ll hear a click/beep. I want you to listen for the click.” (3) “This might tickle a bit. Does it tickle yet?”

Sometimes, circumstances dictate working with a totally uncooperative child. Examples may include babies with bottle mouth syndrome, traumatized children who have fallen or who have been in an accident, and behavior management challenges. In these instances, it is important to complete the necessary procedure quickly, efficiently, and safely, despite crying and sometimes screaming with flailing limbs. Always document the nature of noncompliant behavior and how it was handled in the patient chart. Here are 2 strategies to help you with the most common challenges.
(1) X-ray protocol with noncompliant child. Have the parent sit in the x-ray chair. Sit the child on the parent’s lap facing up, resting the child’s head on the parent’s chest. The parent crosses his or her arms over the child’s arms and crosses his or her legs over the child’s legs. Place the lead apron over child and parent. The parent’s embrace helps to soothe the child while securing him or her safely and unmoving for the x-ray. This sometimes requires the assistance of 2 dental healthcare professionals who should wear x-ray badges to monitor radiation exposure and lead aprons when applicable. If it becomes obvious that the child will need to be sedated for restorative work, x-rays can sometimes be postponed until that time.
(2) Exam protocol with noncompliant child. Have the parent sit on a chair opposite from and facing the doctor (or healthcare giver). Have the parent lay the child on his or her lap so the child is facing up with legs toward the parent and head resting on the parent’s knees. The parent can now hold the child’s arms while the clinician can look into the child’s mouth to diagnose dental problems.

In the event that you are not prepared to handle the clinical and behavioral challenges of an uncooperative child patient, refer them before attempting treatment. Don’t subject yourself and your staff to behavior that’s not congruent with the type of dentistry you want to practice. Don’t subject the child to traumatic and unproductive dentistry that sets the standard for a problem patient. Create your limits. Referring a difficult child to a pediatric office from the start will save you and your team unnecessary difficulties, and you will be doing the child a favor by putting him or her in an environment prepared to deal with his particular circumstances.

Although the caries detection device Diagnodent (KaVo) benefits all types of patients, it is especially useful for the child patient. This procedure is quick and easy and should always be used prior to sealants to be absolutely certain there is no incipient decay present beneath the grooves you intend to seal.

Ultradent offers some great products that will become your best friends. Any hygienist who has ever tried to place sealants without an assistant will love the following items: (1) PropEZ Plus, a mouth prop and tongue retractor combo that is simple to use and effective; and (2) the Ultra-Lume LED 2 curing light for sealant curing, which slips neatly into your bracket tray handpiece holder. No longer will you need to perform unergonomic, pretzel-like contortions reaching for a light that takes up precious counter space. Narrow, slim, and unintimidating for children, the light looks like a wand. (And you’ll swear it’s easy use is magic!)


Kid’s Day
Manage your pediatric patients in a select time and space by creating Kid’s Day. Select 4 days per year (one per quarter or more if needed) and schedule only kids that day. Plan to restore as well as provide preventative treatment so patients get all dental treatment completed in the same day. Coordinate this with a holiday or create a seasonal theme (Halloween, sports, spring, etc). Promote and advertise this day. Decorate the office. Wear costumes. Have fun! Your adult (especially cosmetic) patients will appreciate the absence of child distractions, and your child patients and parents will love you for the special attention. You will significantly reduce your level of stress.

Nursery Day
Once per year, contact a local nursery school to schedule a customized visit-the-dentist field trip. Promote and advertise. Also, use this as an opportunity to convert a previously noncompliant child patient by inviting the child and parents to join this day. Bring a group of no more than 35 children with their teacher for 2 hours in the morning. Do this when the office is closed, such as Friday from 9 to 11 am. Start in the reception room, where children can meet the dentist and hygienist. One staff member remains present and conducts story time about the dentist and oral health. Remaining children tour the office in groups of 5 to 6 with a staff escort, visiting such stations as the following: (1) operatory station–staff member provides show-and-tell with gloves, mask, glasses, and intraoral camera tour for 1 to 2 children; (2) photo station–staff member takes Polaroid of each child; and (3) toothbrush station–RDH or assistant demonstrates tooth brushing. Take-home bags can include toothbrushes and floss holder, stickers, coloring book, office business cards and/or brochures (children’s dentistry, sealants, etc), child’s Polaroid photo, certificate (“I visited Dr. Smith’s office”), and T-shirts with office logo.

Offer your patients a dental ID for safeguarding children. Toothprints (Kerr Corporation, kerrdental.com) are a wafer the child bites into under dental supervision. Like fingerprints, dental imprints are unique; they serve as accurate methods of identification. The parents keep the Toothprints record for quick access. Many offices are offering this quick-and-simple procedure for a minimal cost or as a complimentary service, while others use it as a marketing tool, practice builder, and community service.

Always take a Polaroid picture of the new child patient with the doctor for the patient to take home and put on the refrigerator or on a mirror. This can be easily done by the hygienist or assistant just prior to dismissing the child from the exam. Be sure to label the photo with the name of child and doctor.

Have T-shirts made up with office name and logo, with sayings like “We Love Kids,” “No-Sting Dentistry” (advertise air abrasion), or promoting your Kid’s Day theme.

Give away stickers and prizes for no cavities, best attendance, great home care, best improved behavior, and Kid’s or Nursery Day.

Handling children in the dental office doesn’t have to be intimidating for the child or for you. Use these success strategies to transform troublesome and terrifying children into children who are model dental patients who you love to see walk through your door.

Ms. Hagerman, a graduate of the Medical College of Georgia, has extensive clinical dental hygiene experience. She is the director of hygiene for Coast Dental, national speaker, and author of numerous articles including a monthly column for RDH magazine. She can be reached at hagermanjr@prodigy.net.