1. Managing slightly uncooperative pediatric
patients
SHARON NICHOLSON HARRELL
J Am Dent Assoc 2003;134;1613-1614
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2. C L I N I C A L D I R E C T I O N S
Managing slightly place floss through the rubber
mouth prop so that I can
retrieve it easily. Mouth props
uncooperative pediatric come in three sizes—small,
medium and large. The advan-
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patients tage to the mouth prop is that
the patient cannot close down
during injection or treatment.
The dentist’s fingers are at most
SHARON NICHOLSON HARRELL, D.D.S., M.P.H.
risk during the injection, and
use of this simple device greatly
ccasionally, a general the way in which they often reduces the chance of injury to
O dentist is faced with
the challenge of
accomplishing treat-
ment on slightly
uncooperative pediatric
patients. I define a “slightly
uncooperative” patient as one
respond when they are scared,
irritable or in an unfamiliar
place. To make a child feel more
comfortable, always greet him or
her in an upbeat manner (even
though your own knees may be
shaking). Ask the child about
dentist or patient.
Use a firm tone of voice.
Use voice control by means of a
firm tone (not by yelling). This is
especially important during the
injection. I instruct the patient
by saying, “Do not move.” I
who is apprehensive and teary- his or her new shoes or favorite repeat this several times during
eyed or crying but is not cartoon character. Use the “tell, the injection. Remember, of
screaming, kicking or moving show, do” method you learned in course, that these instructions
excessively. dental school. will not be effective without the
While I do not expect this Use the parent as a model. use of topical anesthetic. I call it
article to transform general den- The most successful way I have “sleepy jelly” and explain that it
tists into pediatric dentists auto- found to introduce the first will put the gum and tooth “to
matically, my hope is that it will instrument during the patient’s sleep.” Since children often are
serve to give practitioners some initial visit is by holding it up to familiar with a syringe from
confidence to continue treatment the parent’s or guardian’s teeth their visits to the pediatrician’s
despite what is called “the first. Children always will try to office, I prefer to keep the
whimper factor”—a tool that model what their parents do. syringe out of the patient’s eye-
children can use effectively to (By the way, I allow parents in sight. I tell the child to close his
scare away practitioners 10 the operatory only for a child’s or her eyes so that I do not spray
times their size. first visit if he or she is younger the “sleepy juice” into them.
than 5 years of age. I will Count to 10. During the
TIPS FOR DEALING WITH address the topic of parental injection, let the child know that
SLIGHTLY UNCOOPERATIVE involvement in more depth you are going to count to 10, and
PATIENTS later.) that then you will be finished
Use a mouth prop. Use a with this part. By counting to
Know that children do cry. mouth prop for injections and 10, which most children can do,
First, realize that crying is a treatment. I prefer a rubber the patient knows that there is a
normal reaction in children. It is mouth prop (Figure). I usually definite endpoint to the injec-
JADA, Vol. 134, December 2003 1613
Copyright ©2003 American Dental Association. All rights reserved.

3. C L I N I C A L D I R E C T I O N S
dam cumbersome. However,
with children, it isolates the
teeth, helps them keep their
mouths open and minimizes the
risk of injury if they should start
to move. The mouth prop also
can be used in conjunction with
the rubber dam.
Use child-level language.
Use children’s words, not adult
words, to describe clinical situa-
tions. Use terms such as “sugar
bugs” to describe the presence of
caries, “tickle your tooth” when
removing decay, “Mr. Whistle”
to describe the handpiece, “Mr.
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Thirsty” to describe the saliva
ejector and “raincoat” to
describe the rubber dam.
Figure. A rubber mouth prop prevents the patient from closing down during
treatment. Keep the parent in the
waiting room. Bring the child to
tion. I tell the child that his or during the procedure. Kids love the operatory without the parent
her face will “feel sleepy” from the story of “Goldilocks and the except, as I stated previously, for
the ear to the lip or around the Three Bears” or “The Three the child’s first visit if he or she is
cheek, so that he or she will not Little Pigs.” Many times they younger than 5 years of age.
be alarmed by the sensation of will stop crying and start to Assure the parent that you will
numbness. Counting also can be listen. Sometimes I insert the come to get him or her if neces-
used during the procedure (“I’ll child’s name into the story. This sary. Sometimes, the child will
count to 10 and then you can can be done only if you can do cooperate if you promise that
rest for a moment”). two things at one time, of Mom can come back after the
Use the assistant’s sup- course; you must continue to sugar bugs are chased away.
port. Ask the dental assistant prepare and fill as you tell the
to restrain the patient during story. CONCLUSION
injection by gently placing his or Keep it short. Minimize
her hands across the patient’s appointment time by having all Interactions between dentists
shoulder closest to the dentist. If instruments and materials and children often fail because
the patient should begin to ready. Many children have a set the dentist is as nervous about
move, the assistant is in a posi- amount of time for which they treating the child as the child is
tion to keep the child from will remain cooperative before about seeing the dentist. By
harm. In general, the assistant’s they have had enough. That using techniques geared toward
role is one of support. Many time can be as short as 10 or 20 reducing the pediatric patient’s
times the assistant will try to minutes. If the procedure needs anxiety and increasing the den-
console the patient with gentle to be halted while the assistant tist’s confidence, dentists will
words as the dentist is giving gets a needed item that was not have the armamentarium neces-
instructions. However, only one placed on the tray before the sary to combat both the patient’s
person should speak to the appointment, it wastes valuable fear and their own fear. s
patient at a time because the time.
patient simply cannot listen to Use a rubber dam. Always
Dr. Harrell is a general dentist and the
two people at once. Encourage use a rubber dam. I put this director, FirstHealth Dental Care Center, 105
the patient to focus on you. near the end of this list because Perry Drive, Southern Pines, N.C. 28387,
e-mail “sharrell@firsthealth.org”. Address
Tell tales. Tell a fairy tale some dentists find the rubber reprint requests to Dr. Harrell.
1614 JADA, Vol. 134, December 2003
Copyright ©2003 American Dental Association. All rights reserved.