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Оглавление2SUCCESSFUL COMMUNICATION WITH KIDS AND PARENTS
“The use of humor in pediatric dentistry is highly recommended. It may be used to facilitate communications with patients and parents, alleviate patient anxiety, and assist the dentist in coping with stress associated with the practice of dentistry.”
MOSTOFSKY AND FORTUNE1
Communication with your pediatric patient begins not when the treatment starts but as soon as the child enters the dental practice. Communication is not merely about talking; it includes a plethora of nonverbal signals. American-Austrian psychologist Paul Watzlawick expressed this clearly when he said “You cannot not communicate.” Communication consists of 55% nonverbal cues (gestures and facial expressions), 38% tone of voice, and only 7% actual content of what is said.2 This chapter examines the different levels of communication and their importance in the dental practice. Suggestions are then given regarding how to use verbal and nonverbal language to gain, improve, or maintain compliance for different types of pediatric patients.
IMPORTANCE OF CHILD-APPROPRIATE ENVIRONMENT
Children need to be engaged to feel comfortable in any public space. General dentistry practices without a specialization in pediatric treatment can create a child-friendly environment with just a few resources. To do this, it is helpful and necessary to visualize the viewpoint of a child; they first see what is at their eye level or below it. Pictures, wall stickers, or even toys in the waiting room should be placed at a height where children can see and reach. A coloring table, some well-chosen books, and a set of building blocks are sufficient to create an engaging environment for children. If space is a concern, there are also some brilliant space-saving play alternatives, such as wall-mounted drawing boards, magnetic boards, jigsaw puzzles, or games. Wooden toys are often a more robust and durable choice. In the interests of other patients and the practice team, toys that emit sounds are inadvisable. When selecting toys for a common space, consider the cleansability; toys that are hard to sanitize may prove poor choices during flu season. In addition, wall decals are a useful and variable design feature for the waiting room or a treatment room because they are easy to remove without leaving a mark.
Not every dentist has the facility to mount a monitor above the treatment chair; as a more convenient alternative, a photo or painting on the ceiling will not only fascinate young children but will also help to distract older, anxious patients. Finally, the reception counter often seems enormous to children, so a small stool can make it a little more manageable for curious children to sneak a peek. Air freshener spray should be kept on hand as well to eliminate the typical smells of the dental practice, which can unsettle or frighten some children.
NONVERBAL COMMUNICATION, INDIVIDUAL PERSONAL SPACE, AND PROXIMITY
“You cannot not communicate.”
PAUL WATZLAWICK
Children are particularly sensitive to nonverbal signals communicated by body language, such as gestures and facial expressions.3 Because nonverbal communication is unconsciously controlled by our thoughts, it is important to always have a positive attitude that enables us to communicate authentically and empathetically—especially in the company of children with behavioral problems. Children have a very keen sense of how well physical and verbal signals match each other—if they do not, the intended message will be misunderstood. Thus, the treatment of a child with behavioral issues may fail from the outset if the dentist exhibits antipathy but tries to cover it up. Children are highly sensitive to discrepancies between what is said and what is felt.4
One of the greatest challenges in the practice of pediatric dentistry is controlling the often-unconscious nonverbal signals we send out so that the young patient gets a positive impression. Especially when beginning with pediatric treatment, self-reflection and analysis of these nonverbal (and verbal) signals is key. Important positive signals include an open smile, a calm manner, and nonjerky movements. Equally important is a respect for the individual child’s personal space—the personal space that they need to feel safe and secure. If people invade our personal space against our will, it can result in rejection, aggression, and anxiety, so we should not expect children to react any differently. While we generally think of any violation of this space in terms of physical proximity, personal space can also be breached nonverbally with a look or a gesture.3 Note that anxious children generally require a larger personal space than outgoing children do.
Therefore, it is important for dentists and dental assistants to read, interpret, and respect a child’s signals when interacting with them. At the same time, however, this personal space needs to be shrunk enough to make dental treatment possible. This is often where the real challenge lies. It calls for patience, a slow approach, acceptance, positive nonverbal signals, rituals (eg, similar sequence when greeting patients or going about the treatment), and sometimes even the patient’s stuffed animals or toys to act as neutral mediators. Once comfortable, children will allow the dentist to encroach on their personal space, and a neutral approach can often be adopted. Stuffed animals can also be a great advantage during treatment: They can be used to demonstrate to the child what the dentist is going to do, thereby allaying the child’s fears, or they can reflect the child’s behavior and thus be used to alter that behavior.3 For example, the dentist can use a hand puppet to mimic a child’s resistance (eg, refusing to open their mouth) and then convince the puppet to let itself be examined, rewarding it with praise and maybe even a small prize. This can influence the child’s behavior and often positively change their attitude. It is not uncommon to see young patients reflect the behavior of the stuffed animal (eg, by opening their mouth).
As mentioned initially, these aspects do not only have a bearing when the child sits down in the dentist’s chair but as soon as the child enters the practice. A friendly smile from the dental assistant at reception and greeting the young patient by name while respecting the patient’s personal space will pave the way for a successful start. When greeting or calling a child from the waiting room, it is important to get down to the child’s eye level. Anything else has an intimidating and threatening effect. On first contact in the waiting room, the ideal distance to maintain from the patient is about 1 m (3 ft). The child should be greeted before his or her parents. Personal information that can be obtained from the case history (eg, the name of the stuffed animal or the child’s favorite color) makes it easier to establish contact and create trust. In doing so, it is important to be authentic and empathetic. If it becomes clear that the child is very anxious or agitated, do not tell them that what they are feeling is not necessary. Telling a child that “there’s no reason to be nervous” is well intentioned but will not reassure a child. On the contrary, it creates additional insecurity because children learn that the feelings they are experiencing are wrong. It is better to show empathy by saying, “I can see you’re pretty nervous. I can understand that. I’ll explain everything to you exactly. That’ll help you feel comfortable.”
To maintain this first connection, once established, it is important for the young patient to be accompanied into the treatment room. This can be used as an opportunity to explain what things you might notice along the way (sounds, smells, or images), or the dentist can give an idea of what is going to happen in the treatment room.5 If the dental assistant brings the child into the treatment room, he or she should introduce the dentist and explain to the child what will happen next.
During the treatment, it is an important part of nonverbal communication for dentists or dental assistants to reassure the child with appropriate touch as soon as they have a hand free. An assistant’s hand on the shoulder, tummy, or head (especially the temples), for instance, conveys a feeling of care and protection and may set the child more at ease.6 At the same time, various acupressure points can be massaged during the treatment (see chapter 7). By contrast, stroking is often counterproductive because it may increase a child’s awareness of being touched. Be aware of this nonverbal communication, and if it is clear that the child is uncomfortable with any of this touching, stop it at once.
VERBAL COMMUNICATION: THE RIGHT CHOICE OF WORDS
Even though children are often preconditioned by their family (“If you don’t clean your teeth properly, you’ll have to go to the dentist and he’ll drill them”), we as dentists are responsible for shaping children’s positive experiences with our profession. Generally speaking, voice control is needed when dealing with young patients: different phases of treatment can be accompanied by different tones of voice and/or levels of loudness. For example, while the treatment is going on, the dentist should talk in a monotone voice that is not too loud. If a child tries to touch the syringe, for instance, he or she can be stopped in a friendly way but with a louder voice. If the child is constantly crying or whimpering, a quiet whispering voice can be used, and the child’s curiosity about what is being said may silence the crying.7
Child-appropriate language is another foundation of successful pediatric treatment. This means using simple, short sentences without any complicated or foreign words. Before the age of 5 years, children cannot grasp abstract expressions of time (afterward, then, later, etc), which can easily be a cause of frustration. In addition, it can be very helpful for the dentist to be reasonably familiar with the latest children’s movies or TV series. This can be a way of gaining the young patient’s trust. The dental practitioner must be sensitive and reflect on his or her choice of words, especially when explaining equipment or treatment steps. If a toddler has only ever heard of a drill from daddy’s tool box, it is understandably frightening if the word is used in connection with their own mouth. (Table 2-1 offers suggestions for child-appropriate terms for dental instruments.) Children have a fertile imagination, which the dentist can readily tap into. In the beginning it may involve some effort to open yourself up to this world of imagination and create a story to explain the treatment and put the child’s mind at ease. Stories can help to distract young patients and make them far more relaxed during a dental treatment.
TABLE 2-1 Suggestions for correct choice of words
| Instrument | Child-appropriate term(s) |
| Lamp | Sun |
| Probe | Tooth feeler; tooth counter |
| Suction | Magic wand that carries away spit; snorkel; drinking straw; vacuum |
| Red contra-angle or turbine (water) | Shower; water sprayer |
| Blue contra-angle | Tickle bee |
| Excavator | Little spoon |
| Syringe | Sleeping water; sleeping medicine |
| Etching gel | Smurf cream; tooth shampoo |
| Curing lamp | Magic lantern; light saber |
| Composite or other filling materials | Magic cream |
| Cotton wool rolls | Pillows for your tooth |
| Rubber dam | Raincoat for your tooth |
| Matrix | Gold or silver medals for your tooth (depending on the color of the matrix) |
| Wooden wedge | Garden fence |
| Forceps | Mini-crane |
| Caries, tooth decay | Sugar bugs |
| Steel crown | Knight’s or princess’s tooth |
| Treatment chair | Kiddie throne; lounger; up-and-down chair; magic chair |
| Air blower | Hairdryer or air pistol |
| Water spout | Waterfall |
Inappropriate use of “okay” can pose another problem. We are often accustomed to ending a sentence with this word, but children frequently understand it as a question. It can become a bit of a challenge if a sentence such as “I’m now going to rinse your tooth clean, okay,” is answered by the child with a definite “no.”5 Generally questions by the dentist should be used very specifically. Before children reach preschool age, it is helpful to ask questions like, “What games do you like playing?” in order to build up a conversation. Communication can be established because children are then obliged to answer with a sentence and not just “yes” or “no.”3 Once children have reached preschool age, alternative questions can be employed that invite the child to make pseudodecisions, like “Do you want to climb up onto the chair by yourself, or do you want mom or dad to get up first and you can sit on their lap?” However, the dentist should make sure only to offer alternatives that are equally conducive to the ongoing treatment process.
Praise and reward are important elements when working with children. Young patients should be praised for a particular reason. There is no point in rewarding a child with something if the child has been thoroughly uncooperative; this tells these patients that their behavior was acceptable. It is more helpful to say exactly what you were pleased about and praise the patient for that. For example: “Today you came with us into the treatment room really nicely and you let me have a look at your front teeth. That was very good, so I’m going to give you a little prize. Next time I’d like you to open your mouth really wide so I can count all your teeth.” This can give the child an idea and an expectation about the next treatment.5 Praise during treatment is also an important motivating tool. Phrases like “You’re opening your mouth so well” and “You’re sitting so nicely” can really go a long way to making the child feel more comfortable and good about themselves.
At the end of treatment, the wrong behavior by parents or accompanying persons can also be problematic. Empathy is important, but exaggerated expressions of sympathy reinforce the child’s impression that the dental treatment was something traumatic, which in future will cause the child to be afraid.5 To avoid such situations, it can be helpful before dental treatments to issue parents with a brief guide on what to do (Fig 2-1). In general it is important to end a treatment session with positive feedback and a little reward for the child, for example, a sticker or other prize.
Fig 2-1 Example letter giving parents advice on what to do to improve their child’s experience at the dentist.
TELL-SHOW-DO METHOD
The “tell-show-do” method combines the most important levels of communication (tell = verbal, show = nonverbal) and also addresses another sensory level: feeling. This technique is therefore ideal for explaining treatment steps to children. During the execution part of the method (do), the sensations that are to be expected should therefore be mimicked. For instance, the pressure from the rubber dam clamp or the extracting forceps can be imitated by pressing the hand on the child’s shoulder. With very nervous children, it may be advisable to demonstrate all the actions first on yourself or on a hand puppet. In an expansion of the method (tell-show-ask-do), the dental practitioner obtains the child’s consent before performing the actions and only continues once the child has signaled his or her agreement.3
It is important to make sure you only explain or demonstrate the different treatment steps immediately before carrying them out (Fig 2-2). Because children have a short attention span, there is no point in explaining all the steps just at the beginning.
Fig 2-2 Tell-show-do method on a 4-year-old patient. A round bur is being demonstrated on the little girl’s fingernail. You can use the bur to “paint” a sun on the child’s nail, for example, then repeat the same thing on the tooth.
BASIC RULES FOR COMMUNICATION WITH CHILDREN IN THE DENTAL PRACTICE
Nonverbal: Be authentic, focus on the child, ensure there is a congruence between what the dentist feels and says, smile genuinely, use smooth movements, respect personal space, be patient, take the child seriously, let the child finish speaking, establish contact by appropriate touch during treatment (ie, touching the shoulder or the temples), communicate at eye level, and perform ritualized actions.
Verbal: Control your voice, show (not exaggerated) empathy, avoid denials or negative sentences, do not use unfamiliar foreign words, avoid irony/sarcasm, use descriptive language, talk in a low and calm tone of voice, keep sentences short and simple, be careful about questions ending with “okay,” allow for patient involvement in noncritical decisions (ie, getting in chair alone or with parent), choose positive words, and offer praise during and after treatment.
Other: Hypnosis, behavior management, and acupressure are auxiliary methods that can be used.6
DIFFERENT TYPES OF PEDIATRIC PATIENTS AND PARENTS
Constant criers
This type of young patient will cry constantly even without any discernible reason. It can help to talk extra quietly to these children. This often arouses their curiosity and they quiet down so that they can actually understand what is being said. Dentists who are comfortable singing can utilize the element of surprise and start singing a children’s song a little louder than the child’s crying. Many children will then stop in surprise. Then you can continue singing quietly and start/continue the examination.
Extremely shy patients
Extremely shy patients will hide under a chair or behind a person they trust (ie, a parent) while still in the waiting room. These children need a lot of time and space to settle into the new situation. It is important to accept the personal space that the individual child needs and not crowd the patient. It can help to ignore the child completely and solely address the parent, who is examined by the tell-show-do method. While the parent is being examined, all the findings are communicated to the dental assistant in a child- appropriate way (“I’ve counted eight of mommy’s teeth and they are lovely and sparkling”), and cooperative behavior is praised and rewarded in a way that is obvious to the child. These patients will often lose some of their shyness as their parents are being examined and take a curious look into their parent’s mouth or want to hold the mirror (Fig 2-3). Occasionally the prize at the end of examination will tempt them and will boost cooperation.
Fig 2-3 (a) Demonstrating a brush on daddy. (b) This young patient was able to use the suction and “examine” daddy’s teeth with a little mirror.
It is important not to put pressure on this type of patient and expect too much of them. Investing a little more time at the outset will pay off later. Sometimes two appointments may be necessary to examine these children.
CAUTION
If the parents are anxious patients themselves, it is not advisable to examine the parents by way of example. Overstressing anxious and nervous parents is not productive and tends to create mistrust in the child.
Know-it-alls
These young patients think they know everything about all the treatment steps and like to share their knowledge with the dentist. It can be difficult to sell a syringe to these children as “sleeping medicine.” Sentences such as “I know that’s a syringe and not ‘sleeping medicine’” can easily put the dentist and dental assistant off their stride. It is helpful to reflect the children’s behavior and show off with a foreign word, for instance, saying, “You’re absolutely right, it’s not ‘sleeping medicine’ but anesthesia.” This rebuttal can elicit a suitable reaction from the young patient. The child learns something he or she did not know before, and the dentist remains master of the situation.
Overly spoiled children
The particularly spoiled child is one of the most difficult patients in daily practice. They often confront the dentist petulantly and are defended in their behavior by their parents. Without actually being afraid of the upcoming treatment, they refuse to cooperate. In these cases, dentists can use voice control to their advantage, speaking calmly and more quietly if it is working well. If the child does not cooperate, the dentist speaks more loudly in a more assertive tone of voice. Furthermore, a timed ultimatum can be set during which the child has to go back and sit in the waiting room. If the child entirely refuses to cooperate, a new appointment is made in 2 to 3 weeks.8 Sometimes it may be more advisable to separate the child from the parents for the examination or the treatment.
These children are often raised in anti-authoritarian households with few boundaries and are simply transferring this behavior to the dental practice. The result is a constant testing and challenging, for instance, pressing the buttons on the treatment unit without asking or being disrespectful toward the dentist or practice personnel (“You’re dumb and no way am I going to let you look in my mouth!”). It is important to communicate the rules clearly to these children: “Please listen to me. This is my practice and in here we work by my rules. I’d like you to be nice to me and everyone working here—just as nice as you expect me to be. I cannot keep your teeth healthy if you disrespect me and my helpers and mess with all of my instruments.” These children generally accept these boundaries and usually can be treated without any more difficulty.
Helicopter parents
“Helicopter parents” can make life difficult for you as the dentist, especially if you are fairly young. They are excessively protective of their children, constantly interfering verbally in the treatment, and questioning everything first. This can prevent the dentist from establishing a connection with the child because he or she is continually being distracted by the parent. In this situation, it can be helpful to audibly explain the different chairs in the treatment room to the child and for the parents: “Here we have two special chairs in the room. You can sit on the neat up-and-down chair and your mom can sit on the magic chair there in the corner. That chair magically quiets the voice of whoever’s sitting on it. This means we can talk to each other without being disturbed.” It can also help to give a “strict look” in the direction of the accompanying person who is interrupting. If possible, attempt to separate the parent from their child for the treatment. If the parent will not allow it, an explanatory chat between the dentist and the parent after the treatment may help. Once again, it is useful to guide parents on what to do, either in the form of a letter (see Fig 2-1) or as text on the practice website.
Little tricks from nonverbal behavior management can be useful with very forceful parents. For example, parents can be placed lower down than the dentist on a small seat or stool in the treatment room. This enables the dentist to stay in control of the situation. When greeting parents, the dentist can deliberately move closer within their personal space. This also demonstrates superiority and taking control.
FRONT-OFFICE COMMUNICATION
Communication extends beyond the waiting room and the treatment itself. How the staff approaches scheduling also reflects the positive communication of the practice. Scheduling appointments with patients can occasionally be very difficult. If a practice has newly accepted pediatric patients, this new group of patients can pose entirely new challenges for the practice team. For mothers of babies, arranging and arriving punctually for appointments is undoubtedly a challenge. Flexibility in scheduling and accommodating the realities of life with an infant or toddler will go a long way toward keeping your patients calm and relaxed. Furthermore, morning or early afternoon appointments are generally best for children, but of course they are not always possible because of parents’ working hours. Keeping in mind children’s compliance, however, it is entirely reasonable to give priority to these appointments and communicate that to the parents.
It is also helpful for the front office staff to ask patients to arrive 10 minutes early for appointments. This gives the child some time to get used to the environment, to play a little, and thus to relax. In the meantime, parents can fill out the medical history form or any other necessary documentation. Furthermore, if the staff member garners any personal information when scheduling the appointment with the parents, this can be used for an individual welcome. This creates trust in the child and the parents.
REFERENCES
1. Mostofsky DI, Fortune F. Behavioral Dentistry, ed 2. Ames, IA: John Wiley & Sons, 2014.
2. Müller EM, Hasslinger Y. Sprechen Sie schon Kind?: Prophylaxe auf Augenhöhe. Berlin: Quintessenz, 2016.
3. Kossak HC, Zehner G. Hypnose beim Kinder-Zahnarzt. Verhaltensführung und Kommunikation. Heidelberg: Springer, 2011.
4. Atzlinger F. Kinderhypnose in der Zahnheilkunde. Diplomarbeit. Universität Budapest, Fakultät für Zahnmedizin, 2008. http://www.zahn1.at/service/downloads?file=files/assets/content/Download/DiplomarbeitKinderhypnoseinderZahnmedizinges.pdf. Accessed 26 August 2017.
5. Goho C. „Top 10“ der Fehler im Umgang mit kleinen Patienten. ZWP online, 28.02.2011. http://www.zwp-online.info/zwpnews/wirtschaft-und-recht/patienten/top-10-der-fehlerim-umgang-mit-kleinen-patienten. Accessed 26 October 2018.
6. Zehner G. (Hrsg.) Quick Time Trance und Hypnopunktur, 2004. http://www.kinderzahnarzt-praxis.info/app/download/5872895961/QuickTimeTrance+und+Hypnopunktur.pdf?t=1359880533. Accessed 2 December 2016.
7. Goho C. Die erfolgreiche Behandlung von Kindern. ZMK 2011;27(12):778-782. http://www.zmk-aktuell.de/fachgebiete/kinderzahnheilkunde/story/die-erfolgreiche-behandlung-von-kindern_595.html. Accessed 2 December 2016.
8. Goho C. Erfolge und Misserfolge in der Kinderzahnheilkunde; Fortbildungsveranstaltung der LZÄK Sachsen, Dresden, 2011.
