Managing Pediatric Patients

Today’s post is all about managing pediatric patients! Some of my colleagues love PEDS, while others admit that treating children is not their cup of tea. Personally, squirmy patients with high pulp horns aren’t my favorite! 😜 BUT, PEDS rotations are a dental school requirement, and treating pediatric patients can be a great practice builder. To learn how to best manage pediatric patients, I interviewed Dr. Katie Park, a Pediatric Resident at NYU Langone in Tampa, FL. Read her and her co-resident’s tips below!

What’s the biggest difference between adult and pediatric patients? How does your approach reflect this difference?

For me, treatment planning is very different. Adult patients’ treatment planning is focused on saving the tooth. However, for the pediatric patient, we have to consider behavior (cooperation) and dental development, such as exfoliation and spacing issues.  Pediatric patients have a very dynamic dental environment which is continuously changing.  We have to take all that into account when treatment planning. 

The most significant difference between adult and pediatric patients is the much greater need for behavior management. Rather than just going for the injection and prepping the tooth, you have more things to focus on, like keeping the patient calm and happy. There’s a lot of tell-show-do, telling distracting stories, and singing while doing procedures

What small-talk conversation starters do you use with kids? Do you have silly names for your instruments?

I introduce myself, and I like to do TSD from the beginning. Most of the time, the patient is very nervous, but when I explain to them that I will show everything before the procedure, I can see that they are more relaxed.  I call my explorer “tooth counter”, rubber dam “raincoat”, isodry “fishtail”, slow speed “bumpy brush” and my high speed “whistle brush”.

I like to ask seasonal questions, so things like “do you like your new teacher?”, “did you dress up for Halloween?”, “did you eat any yummy food for Thanksgiving?”, etc. I also ask about siblings and pets a lot. I call my handpiece my “fancy electric toothbrush that sprays a lot of water”. I also call the explorer the “tooth counter” and call the suction “Mr. Thirsty”, the standard terms! If I use a mouth prop I call it “my chicken nugget” and they usually love that.

In your experience, what behavior modification techniques are the most useful?

TSD, TSD, TSD!  And distraction such as movie playing while you are working is excellent as well. 

As I mentioned above, tell-show-do is definitely the go-to behavior management technique that is truly proven to work. Just exposing the kids to the instruments and explaining what I’m going to do can really put them at ease because the instruments honestly do look scary. I also love distraction. When I am giving an injection, I play the question game and try to guess their favorite food, animal, color etc. I have the kids hold up a thumbs up or thumbs down until I get it right.

Any tips for quickly calculating how much anesthesia to use on a child?

I made a spreadsheet so I can quickly lookup.  After awhile, it becomes second nature to you.  But, here are some essential facts. 

  • Articaine do not use under the age of 4 
  • Lido : Weight (lb) * (1 lb / 2.2 kg) * (4.4 mg/1kg) * (1 carp / 34 mg) 
  • Articaine: Weight (lb) * (1 lb / 2.2 kg) *( 7 mg/1kg) * (1 carp / 68 mg)

Honestly, I just pull out the calculator app on my phone to calculate if I think I will need more than two carpules for a patient. But definitely memorize those maximums!

In your opinion, what procedures should a general dentist be comfortable doing on a pediatric patient?

I think a general dentist is capable of doing all of the procedures.  I think the most important skill is knowing when to refer the patient. If the patient has multiple quadrants of work that needs to get done, it would be best to refer the patient instead of treating the patient and referring them halfway through the treatment. 

Extractions and composites, at the very least! But if you do not have stainless steel crowns in office, I would not recommend restoring more than two surfaces on primary teeth or doing any pulpotomies/pulpectomies. 

How do you handle crying?

If the procedure is quick, I don’t mind them crying a little bit.  However, if the procedure is more involved and requires patient cooperation, I give patient a break and comfort them.  Calming the patient down, so they can breathe through their nose and follow directions will lead to a better appointment experience for both provider and the patient. However, there will be a patient that you cannot console, and sometimes you just have to finish the treatment if you are in the middle of the procedure.  Most of the time, children stop crying when the procedure is done and recovers quickly. 

Depending on the patient, I may let them have a short break, let them explain why they’re crying and try to solve the situation, or continue working while trying my best to distract them and make them laugh. If I know I am almost done with the procedure then I know I can give them a sticker soon too which helps.

Any tips for dealing with parents?

Always go over treatment options and possible outcomes with the parents BEFORE the treatment.  Parents are also nervous too.  Spend time with the parents and explain why such treatment is recommended and what to expect during and after the appointment. 

Make the parents feel heard without judgment. Even if you know it is the parent’s fault for the child’s cavities, at least they brought them in to get them fixed. I try not to judge and to give short, understandable tips to help improve the situation for the child.

When should a general dentist refer a child to a pedo?

Behavior! Evaluate their behavior, and if you see an anxious and nervous child, it is probably better to refer them to a pediatric dentist from the beginning.  Once they have a tough appointment, it only creates more fear for them. 

A general dentist should refer whenever they feel something is out of their scope of practice. Like I said before, I would refer large lesions if you do not have stainless steel crowns in office. Another good time to refer is if the child needs more than nitrous oxide and your office does not do sedation dentistry. 

Any tips for dental students completing their peds rotation at school?

Practice behavior management. Even if you are not going into pediatric dentistry, behavior management works on adult patients too! 

Keep an open mind! Though you may think pediatrics is not for you, it can be very rewarding and fun! Don’t get too frustrated if an appointment doesn’t go well because it happens to us pediatric dental residents every day

Any advice for new dentists who don’t particularly care for peds? 

If treating the pediatric patient is not your cup of tea, you should refer the patient.  Their parents will be happy if their children have a positive dental experience and will thank you for the referral. 

If you want to keep children in your practice, I would try to take your time with those appointments with your behavior management. Let the nitrous sit for a few minutes, let the local anesthesia sit for a few minutes, and really explain what you are going to do for the patient in fun terms they will understand.

Additional thoughts/tips?

If you are considering doing a pediatric residency, be ready to work hard.  Residency is an amazing opportunity to learn and grow as a pediatric dentist!

What tips do you have for managing pediatric dental patients? Comment below!


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