Pediatric Management: How To Become The Person in Charge!

Tell, show, do. It’s a widely used pediatric behavior management tool.

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Above: Children at the office of pediatric dentist Jay Reznik are taught to keep their hands at their sides or on their stomachs at all times. A recare appointment is an important opportunity to reinforce positive behavior. Here, Rachel Law has her teeth cleaned by hygienist Andrea Adkins.
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Tell, show, do. It’s a widely used pediatric behavior management tool. But if you’ve never seen the concept in action, it might seem ridiculously simple. How could that possibly work, you wonder, thinking of your own three-year-old at her most obstinate.

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Above: Brennaa Sullivan is calmly drifting under oral sedation as she has restorative work done by Jay Reznik, DMD, MS. She’s listening to Scooby Doo music on a CD player.
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“If I tell her to pick up her toys, and then show her how, does it follow that she’ll do it? Uh ... no.”

So why should it work in dentistry? If we tell a three-year-old that she’s going to lie down in the chair so we can count her teeth, then show her how easy it will be, does it follow that she will do it?

You’d be surprised. Pediatric dentist Jay Reznik, DMD, MDS, of Monaca, Pa., has a favorite speech for fussy little patients: “This is not your house. I’m not your mother. Maybe you can do whatever you want to at home, but here there are different rules, and I’m the boss. Here, you do what I say.”

You see, he really isn’t the child’s mother. He’s an unknown quantity, and the child doesn’t know how he’ll react, so she tends to be careful. It’s easy to ignore your own mother, but it’s a little harder to ignore a new authority figure that even Mommy treats with caution.

It can be surprisingly easy for a hygienist to adopt that same persona - that aura of being The Person in Charge. I used to get really frustrated with pop-up kids. You know the ones I mean. Every time you let go of them they pop up like Jack in the Boxes: “Are we done yet? What’s that thing for? Can I go tell my mom something? What are you gonna do next?”

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A comfortable atmosphere where children feel at home is important in pediatric dentistry. Here, Cassidy and Cameron Knallay enjoy the game room before their appointments with Dr. Jay Reznik.
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I used to try to placate them: “We’ll be finished soon, Emmy. Lie back down now, OK?” It never worked. Next time I let go, Emmy would pop right back up with the same four questions.

Now I handle things differently. The first time it happens I stop, swing around to face Emmy, look her right in the eye, and tap the headrest sternly. “Emmy. Don’t sit up again. I want you to keep your head on the pillow.” I tell Emmy what to do, show her where, and nearly every time, she’ll do it. It works so well because, with direct eye contact and unequivocal orders, I’ve become The Person in Charge.

Once you’ve become That Person, you have amazing power. I was shocked the first time it worked to get a child to stop crying. Kaden, a five-year-old, was deep into that monotone wailing that never stops, although his mouth was open and he was sitting still. Mommy was standing nearby, looking more and more distressed. If I could just get him to shut up, I thought, maybe I could tell him what was coming next and relieve some of his anxiety.

“Kaden!” I cried (a little desperately). I held an index finger up in front of his face. “Wait a minute. Listen! I have to tell you something. Listen a minute!”

He stopped in mid-wail. I almost fell off the stool. Mommy’s eyebrows went up, and she started to look more cynical than distressed. Kaden got interested in the sweet cotton-candy smell of the fluoride gel, and he forgot all about wailing.

With today’s permissiveness, it’s more critical than ever for dental professionals to become experts in child management. A 2004 article in Pediatric Dentistry addresses the impact of societal changes on pediatric behavior in dental offices. Children have fewer boundaries, the article states, and less discipline and self-control. Both parents and contemporary culture expect less from children in terms of behavior than we used to expect.

More and more frequently, we see children who have turned the tables on authority. They control their parents to an astonishing degree, and expect to do the same with us. If we want to provide them with quality dentistry, we can’t let that happen. So what techniques can we use to become The Person in Charge?

Dentists in Australia were asked in one study to rate their favorite techniques with children. They were these: permitting the child to exercise some form of control over terminating the treatment; furnishing waiting areas with play materials; using a tell-show-do approach to the provision of dental care; spending more time with the child before entering the operatory; setting shorter appointment sessions; and permitting the child to hold a toy or a mirror during dental treatment.

In another study, parents watched videotapes of eight behavior management techniques, and then rated them for acceptability. Their favorite technique was tell-show-do, followed by nitrous oxide sedation, general anesthesia, active restraint, oral premedication (sedation), voice control, passive restraint, and hand-over-mouth.

In many offices, we don’t have the option of sedation, but the other techniques can work equally well. But how do we start?

Dr. Reznik has spent 25 years treating children, and has learned that the best way to begin is with a determination - what he thinks of as the “fear” or “bad” determination.

“During my first interaction with a child, whether it’s verbal or just observation, there’s something in me that makes an evaluation. Is he going to be OK, or not? Is he afraid, or is he just bad?”

He makes the decision by watching for clues. How attached or unattached is the child to his mother? Is he hiding behind something, or playing with the toys? Is he willing to make eye contact? How does he respond to a greeting?

Jane Soxman, DDS, who has practiced pediatric dentistry for 22 years and speaks nationally on the topic, says her most important strategy is to enlist the parent first.

“It’s important for the child to see rapport between you and her mother. That way you’re not a stranger. It gives the child a chance to size you up, and meanwhile the parent can offer you insight into the child’s behavior. How many other dentists has she seen? What happened before she got here today? Is she potty training? That produces a lot of stress in children.”

Dealing with a frightened child usually takes no more than calmness, empathy, and lots of patient explanation. (See sidebar.) Dealing with a problem child is something else entirely.

“No one,” Dr. Reznik says, “wants to hear that their child is spoiled or stubborn or ill-mannered, but sometimes it’s true. If a child doesn’t have limits at home, she has no reason to expect them in a dental office.

“If two-year-old Kylie runs around the dining room table, and her father says, ‘Stop that,’ and she continues to run around the table, what happens? Lots of times, all that happens is that Kylie learns she doesn’t have to do what she’s told. There are no consequences, because Daddy doesn’t follow through.”

Dr. Reznik doesn’t hesitate to restrain a child himself. With the parent or an assistant holding the child’s legs and hands, he holds a child’s head firmly between his elbow and his side to keep it steady.

“If the child won’t open, press your thumb hard against the lower frenum, cupping the jaw with your palm, or worm your index finger back far enough to press on the ramus. That will make the child open his mouth, and then you can use a small adjustable mouth prop to keep it open.”

Dr. Soxman says that in management cases it’s important to get the parent on your side.

“You have to have the mother on the same page first. If she’s a smothering mother, if she can’t make a decision to have the child cooperate, then the child won’t, because she’s too used to manipulating her mother.

“In that case, I look at the mother and say, ‘Your appointment is for an exam and cleaning. What would you like us to do?’ If the mother says, ‘I don’t think she can do it,’ then I reply, ‘Yes, she can, but you have to make the decision.’”

If restraint is necessary, Dr. Soxman believes that’s the mother’s responsibility.

“I have the child sit on the mother’s lap. She wraps her legs around the child’s legs, and holds the child’s hands with hers. This way you enlist the active support and cooperation of the mother. This not only helps us, it tells the child, ‘You’re getting this done.’ We always praise the parent for her help and trust and cooperation. That goes a long way toward making the next visit easier.”

Neither dentist thinks it’s a problem if the child is crying.

“I always tell parents that we don’t mind at all,” says Dr. Reznik. “At least their mouth is wide open.”

“It’s called compensatory crying,” Dr. Soxman says. “And it’s very different from crying because they’re afraid or in pain. Sometimes they cry because that’s just the way they deal with things.”

After treatment, try to get the child to think about what happened. “I brushed your teeth with my electric toothbrush, Hayley, and the dentist counted them. We didn’t hurt you, but you were kind of scared. Now you’ve seen all our stuff, and you know how the toothbrush feels. Kind of tickles, doesn’t it? We’d like to invite you to come back next summer, Hayley, so we can brush your teeth again. Next time, you won’t have to be scared, will you?”

Providing dental care to children can be maddeningly frustrating and powerfully rewarding at the same time. With every child you see, and every trick you try, you learn a little more. Dr. Reznik’s best advice is, “Pay attention to what’s not working. Then do something else.”


Home-care Tips for Parents

At least once a day, some hygienist somewhere hears this excuse: “Timmy won’t let us brush his teeth.”

Don’t accept it. Toothbrushing is just as important as diaper changing and bathing. If a child fusses and squirms while Daddy is washing his face, does Daddy give up and say, “Timmy won’t let me”? Of course not, he does it anyway. Toothbrushing is just as important - maybe more important - and it’s your job to help parents understand that.

The reason why parents fade so fast on toothbrushing is that they literally don’t know how to approach it. They stand in front of Timmy, bend over him, block the light, and try to poke in a brush loaded with too much toothpaste. They can’t see, Timmy backs away, and that’s that.

First, make sure both children and parents understand that skimping on toothbrushing is unacceptable. The child’s health is at stake, and parents must find a way to make it work.

Second, remind parents they only need a small amount of toothpaste for a child - pea-size or match-head size. There are dozens of flavors and consistencies on the market if a child is picky. Suggest shopping at a health-food store for even more variety. Brushing with just a damp toothbrush can be an option, as long as the child has fluoride supplements.

Third, suggest that another person be there to help. Daddy or Big Sis can hold Timmy’s hands if necessary, or get behind him and hold a palm on either side of his face.

Here are Dr. Reznik’s suggestions for home care:

Place Timmy with his back against the wall. Get on one knee in front of him, and use one thumb to hold the lower lip down, bracing his head securely against the wall. Put the toothbrush in, and use it to push the cheeks away as you brush.

With you standing, position Timmy with his back against your thigh, bending your knee for support. Tilt his head up, supporting it between your body and forearm. Hold the lower lip down with one thumb, and use a forefinger along the outside surfaces of the teeth, holding the cheek out against your palm to make room for the toothbrush.

Sit in a chair with Timmy facing away from you between your thighs. Put one ankle on the opposite knee to corral him and keep his hands down. Put his head in the crook of your elbow, tight against your side. Use your thumb to hold the lower lip down, and brush.

Put Timmy in a high chair or booster seat, and stand behind him for brushing.

Wrap Timmy in a blanket, papoose-style, and sit on a bed or couch with his head in your lap for brushing. As a child gets older, you can offer him a choice. “We can use the blanket, Timmy, or you can hold still by yourself. Which do you want to do?”


Management Tips

1)Don’t be a stranger - If time permits, go to the waiting room to meet new children in advance. Don’t frighten them before you even get them in the chair. I once saw a speech therapist come into a waiting room for a young girl. She stood a bit too close and bent down over the child.

“TIFFANY!” she boomed. “I’M SO HAPPY TO SEE YOU TODAY!”

The little girl cringed back against her mother and hid her face. You can bet she wasn’t looking forward to that appointment.

Instead, kneel, stoop, sit, or sprawl on the floor - whatever you have to do to make eye contact - and introduce yourself calmly.

“Hi, Cody, my name is Cathy. In a few minutes, I’m going to look at your teeth. I’ll use a light and a tiny little mirror so I can see everything, and I’ll use my electric toothbrush to polish your teeth.”

If the child is receptive, make a little conversation. “Wow, cool shoes, Cody. Is that Spiderman?”

If the child cries or turns away or says no, ask his mother to repeat the information and walk away.

I believe it’s wise to let parents decide whether they’ll come to the operatory the first time. If they want to, they can. But set ground rules. Parents shouldn’t repeat everything you say, and they should not answer for the child.

Dr. Soxman explains this to the parent as “being a silent partner.” A child, she says, can only listen to one person at a time, and a parent should be made aware that, in this case, it’s you.

2) Get Mommy on your side - Some hygienists don’t care about this, but I usually ask Mommy to stay on my side of the chair. It’s natural for her to take up a station opposite you, but that just makes the child turn to her (and away from you). You want as much of Connor’s attention as you can get, and if he keeps turning his head away to check that Mommy’s still there, it does you no good at all. Ask Mommy to stand on your side, and Connor will automatically keep his head (and his eyes) pointed in the right direction.

3) Don’t startle the child ­- Make fun of your mask, glasses, loupes, or shield. Kids know that PPE can signal shots and other scary stuff. Say: “I have to dress up before we start, Zak. Here are my glasses, so I can see, and my mask, so I don’t breathe any germs on you. How do I look? Pretty funny, huh? Here, touch my gloves. They’re all soft and mushy, aren’t they?”

Raise and recline the chair before the child arrives. Then you won’t frighten him by moving the chair with him in it.

Let the child sit upright and look around. Show off all your cool stuff, and explain everything exhaustively. Use the child’s name at every opportunity.

“This is my straw, Taylor. It makes a big noise. Hear it? The straw works like a vacuum cleaner. See, it can suck up all the water in my cup. Here, Taylor, you try it.”

When the time is right, use a very matter-of-fact voice to say, “Taylor, put your head on the headrest so we can get started.”

Then hold your breath, because she might or might not want to do it.

You can try firmness.

“We’ll play later, Taylor, it’s time to get your teeth cleaned now. Put your head here.”

You can try logic.

“Your dad brought you to have your teeth cleaned, Taylor. And I can’t see inside your mouth unless you put your head on the headrest like a big girl.”

You can try bribery.

“If you put your head back like a big girl, Taylor, you can pick a prize from the treasure chest as soon as we’re finished. You want to take home a prize, I’ll bet.”

You can try the truth.

“I’ve shown you everything we have here. We’ve talked about how it will feel and how it will sound. Nothing I’m going to do is going to hurt you, Taylor. Let’s get started.”

4) Don’t ask for approval - All you really need is cooperation. Don’t say, “Campbell, I’m ready to get started now, OK?” That gives her a chance to refuse. Instead, say, “Campbell, I’m going to clean your teeth now.”

Don’t say, “Campbell, can I show you my fluoride tray?” Say, “Campbell, this is the tray we use to hold the fluoride vitamins.”

5) Go overboard with praise - “Close on the straw again, Jake. Wow, you’re really good at that.”

“My goodness, Jake, you’re the best brusher I’ve seen all day.”

“You were great with those X-rays, Jake. You did everything exactly right.”

But don’t say, “Good boy!” if Jake was the worst little boy you’ve had in months. Instead, say, “Jake, I know you were scared today, but next time you’ll be older and it’ll be easier. When I clean your teeth next summer you won’t have to be scared, because you already know everything we do.”

6) Don’t be too sympathetic - You have to be sensitive and careful with a three-year-old, and make allowances for age, but you don’t have to take whining and fussing from a six-year-old. Appeal to the child’s dignity.

“Chelsea, you’re too old for this. Sit up straight and act like a six-year-old, not like a three-year-old.”

“I can’t understand you, Chelsea. Talk like a six-year-old, and then I’ll know what you want to say.”

“Chelsea, why are you making such a fuss? You’re almost seven years old, and you’ve been here four times. Sit still, and keep your hands on your belly. The more you fuss, the longer it takes.”

7) Be nice to their friends - It makes a cute picture when a child comes to a dental appointment armed with a favorite teddy bear or doll. Use that to your advantage.

“Josh, what’s your bear’s name? We’ll look at Mr. Grizzly’s teeth first. See? He’s sitting up in the big chair. Let’s turn on the light. Here’s my mirror. Does Mr. Grizzly have cavities? No? Well, Josh, he’s a very good patient. I think he likes me.”

8) Hands, hands, hands - Keeping kids’ hands away from your sharp instruments is a continuing problem, and there are three strategies that can work well. First, tell Brighton to keep his hands on his belly, and tell him why. “My instruments are sharp, Brighton. I don’t want you to poke yourself.”

If he can’t remember that, tell him to put his hands under his bottom. And if even that isn’t enough, give him two small stuffed animals, one for each hand.


Nutritional Counseling

Both Drs. Reznik and Soxman spend a significant part of their time talking to parents about diet.

“We’re seeing the decay rate actually increase,” Dr. Reznik says, “because parents don’t parent. They’ll say, ‘Oh, Braden didn’t like what we were having for supper, so he ate some Ding Dongs.’ It’s our job to get them to take responsibility for their child’s diet.”

Dr. Soxman has learned that just forbidding candy doesn’t work.

“You have to discuss specifics. Instead of saying, ‘Don’t eat this, don’t drink that,’ we give them alternatives.

“I tell parents that the best snack is a Hershey’s Kiss. It clears the mouth within one minute with good salivary clearance, and the tannin in the chocolate keeps bacteria from aggregating on the enamel surface.

“Instead of milk or juice at bedtime, I recommend bottled water with fluoride.

“We tell our moms, look in their children’s mouths 20 minutes after they eat their favorite snack. ‘If you see food in the pits of that first baby molar, you need to start avoiding that snack.’ We point out that some kids have good salivary clearance, and some kids don’t. I always recommend chewing gum with xylitol for kids with deep occlusal pits or poor brushing habits.”

Dr. Soxman keeps a pack of sour candies in her office, and uses it to give parents a lesson in reading ingredients lists. “When they see acid, acid, sugar, and sucrose, their mouths drop open. Parents just don’t realize what they’re feeding their children.”


Germy Toothbrushes

If Bethany’s favorite thing in the whole wide world is her purple glow-in-the-dark Barney toothbrush, it can be hard to make her give it up, but parents need to be tough on this one. A study on Head Start children discovered high concentrations of Strep. mutans on toothbrushes and acrylic orthodontic appliances. Dr. Soxman recommends a strict protocol for children with strep infections.

“As soon as they get an antibiotic prescription, I have the children throw away their toothbrush and start using a cheap or disposable one. When the antibiotic is finished, they throw that one away and get a new, good toothbrush.”

She also provides a handful of disposable toothbrushes to any child who comes to her office with a cold, a runny nose, or a cold sore.

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