#15 – Can do Preventive Care appointment with children

The PC (Preventive Care) Experience – See Everything, Overlook a Great Deal, Improve a Little

We have recorded a couple videos (you’re not seeing the kids, but you’re hearing the conversation) so you can hear how this visit goes. These are saved _________________.

We offer a unique experience in preventive dentistry for children. You will be asked to follow the general guidelines outlined in this section. If any of these ideas don’t agree with your experience, or what you where taught, get with your dentist and discuss them. Any procedure we do can be changed. If you have a better way, share it with us. We’ll all be better off. You make a difference in others’ lives in this experience more than anywhere else. Your preventive care appointment can actually change a child’s life (and through the child, the whole family). Understand this material thoroughly and apply it confidently. The results will be dramatic! Your professionalism and humanity can change what is often a miserable, humiliating, subservient appointment into a happy, growing, success. You make the difference!

Our pediatric dentist is responsible for all children younger than 10. You and the other hygienists are responsible for all children 10 and older. PC appointments are phased out for children between the ages of 12-14, when they demonstrate good home skills. When children turn 18, we treat them as adults.

First, let’s look at the goals. Everyone parent, child, doctor, and hygienist have a different view of PC. Your responsibility is to recognize and respond to these various needs by the different individuals.

Parent Goals

1. Be affordable
2. Provide good care for kid
3. Do what they should do
4. Learn
5. Have child accepted by office staff
6. Have their child accepted as the best, better than average
7. Give child positive attitude feel good about themselves
8. Be good model for kids!

Dr.’s Goals

1. Healthy kids growing
2. Economical profit
3. Vehicle for individual staff growth
4. Fun center of the practice
5. Establish and maintain relationship (long term)
6. Keep things running on schedule

Child’s Goals

1. Please the parent (younger kids)
2. Please self and parent by having no decay
3. Teens want attractiveness
4. Have a good time at the dentist office
5. Reward
6. Please us
7. Curiosity of dental office
8. Pretty smile
9. Chew food relate to here and now
10. Learn something new

RDH Goals

1. Fill the schedule
2. Enjoy affection and feeling of being needed
3. Being part of guiding child adult to a better dental health
4. Variety in the day
5. Have fun & enjoy the kids
6. Be on schedule

Preparation for the Child’s First Visit

Parents play a key role in the attitude a child brings in for their first visit. When a child comes in excited and ready to learn, you can almost guarantee no decay. When the child comes in frightened, most of the appointment will be spent on attitude and fear control with little help on preventing disease.
Here are ideas for parents
1. Allow the child to watch parents brush/floss (parent should make this look fun!)

2. Parent should tell the child they will visit dentist, but not say, “It won’t hurt.”

The goal of a preventive care appointment is to build the self esteem of the child and parent. The tools we use to accomplish this are brush and floss skill development. Be sure to read the book Your Child’s Self Esteem. It is summarized in the following pages. If you focus on manual skills and not the child, you missed the point. You became part of the problem, not the solution.

Remember the goal is not for you to teach brush and floss techniques. If the child has high self esteem he will want to learn how to be healthy and you won’t be able to stop him!

Child’s Self Esteem

The child’s self esteem is the major factor in their success in life. Our job is to build this self esteem.

How do we do this?

1. Establish a quality relationship with the child
a. Give them your total attention
b. Help them feel important
2. Help him feel competent to maintain his own health
3. Our attitudes toward child’s efforts are more important than the actual ability itself

Many parents set up the failure wheel for their kids. One positive appointment with you can have a major impact on breaking the chain!

How will you recognize a child with low self esteem?

1. Covers up feelings of inadequacy
a. Tattling
b. Bullying
c. Constant chatter
d. Attention devices
e. Very quiet, withdrawn

2. Child always good
a. Never does anything that could be criticized
b. Quiet, hard to give you eye contact

Traits of Genuine Encounter

1. Builds trust be honest, share your feelings
2. Use “I” words (tells how you feel) rather than “you” words that accuse, put down
3. Find the uniqueness of the child and appreciate it verbally to the child
4. Remember how we see the world or a particular situation isn’t the only way or even the best way!
5. Use empathy (listening with your heart, not your head) to help understand someone
6. Watch the child’s body language

How do we decide if our expectations are valid?

1. Why do we have this expectation?
2. Where did it come from?
3. What is in it for me?
4. Is it based on my needs or the child’s?
5. What purpose does it serve?
6. Does it realistically fit this child at this age with this temperament and background?

How do we handle a child’s negative feelings?

1. The fastest way to get rid of them is to acknowledge them and work them out. This takes precedence overall other agendas.
2. If you ignore them they will bottle up and be turned inward on the child (headaches, hyperactivity) or toward others (hostility)
3. Hear empathetically , accept feelings, provide acceptable outlets through negotiation.
4. Proof of understanding comes only through “active” listening (reflecting child’s thoughts).
5. Remember negative feelings come before negative acts. Don’t focus on the action, focus on the feelings. Embarrassment, frustration, jealous, fear, come before anger. Use active listening to get past the anger.
6. 6. Understanding never makes feelings worse, it only gives them permission to be revealed.

How do you strengthen the child’s self esteem?

1. Show the child you enjoy being with him that he is fun, intelligent, etc. Laugh, joke, tell stories, etc.
2. Don’t expect more than the child can do notice small successes and praise them
3. Don’t pressure the child
4. Negotiate your way through problems
5. Recognize and praise each sign for initiative
6. What you say matters less than what you do

Discipline: the goal is self-discipline your goal is to show the parent how to use discipline wisely

1. Limit the number of rules
a. Increase friendliness
b. Increase safety of child

2. Three approaches to limit setting
a. Power kept authoritarian nag, punish, reward, praise only works while you are there encourages dependence
b. Power given away
c. Power shared
1. Kid’s needs as important as ours
2. High level of trust
3. Can use other two occasionally

3. Constructive discipline
a. Increases self esteem, reliance, intellectual growth, creativity, and responsibility
b. We don’t own the kid they own themselves and their feelings
c. “I” reactions not “you” judgments
d. Realistic expectations, shared honest feelings
e. Decide what the problem is and who owns it
f. Stick to the facts, don’t make someone feel guilty
g. Empathetic listening
h. Try to create options, choices
i. Never demand conformity if not necessary
j. Avoid evaluation, fear
k. Give kid opportunity to make suggestions
l. Show process of problem solving and willingness to share power
m. Obedience not based on fear, based on admiration, inner conviction

Setting and achieving goals

At each performance review you, with the help of the administrator, will be expected to set several goals to improve the quality of care we provide and/or dollar production. Successful people set goals. We want you to be successful. This five step approach will be used for each goal.

Each three month performance review will give you and your doctor a chance to make sure you are “on schedule” with your projects.

Step #1 Describe the problem/opportunity
1. Just say it use as many words as needed
2. Refine it down to the fewest words possible

Step #2 What is your goal?
1. No negative phrases all positive ideas
2. Write down all possible solutions

Step #3 What actions would you take to achieve your goal?

Step #4 How will we know you have achieved your goal?

Results must be visible, achievable, specific and on a timetable

The Preventive Care Experience

I have titled this section the “PC experience” rather than an appointment. It is much more than a dental appointment. It is an opportunity to shape another human being’s life.

I hope you have the opportunity to visit Disney World. As you can see in the videotape “In Search of Excellence”, they know how to put on entertainment that involves and pleases everyone of all ages. They don’t have employees, they have actors. I want you to think of the PC experience as an exhibit in Disney World and you are our cast member!

I want you to memorize this entire script. You will be expected to act your part in providing a wonderful experience for each of these children.

I hear and I forget, I see and I remember, I do and I understand. (Old Chinese proverb)

• We remember 20% of what we read
• We remember 30% of what we hear
• We remember 40% of what we see
• We remember 50 % of what we say
• We remember 90% of what we see, hear, say, and do

Aim for service, not success, and success will follow.

Our primary purpose in life is to learn so we can grow, our secondary purpose is to help others grow.

I. Establish Atmosphere
A. Before child arrives
1. Send a note to new child patient welcoming them (see computer generated sample)
2. Read chart and learn about child
a. Favorite activities
b. History of problems
c. Level of success
3. Set up PC room brush, floss, red tablets, baggy, brochures
4. Be on time!
5. Set your personality: friendly, concerned, fun, knowledgeable, confident, gentle, honest, feelings, can do it attitude!
6. Remember always give choices, options that’s how people grow!

B. Greet the child and parent
1. Sit down with parent for a minute in the reception room. Introduce yourself using your first name. Mention something about the child. Get down to eye level with the child: “Hi, Jill, I’m Laura! Wow, those are cool shoes! or (boys) Do you like to play with balls?”
2. Bring them to the PC area and allow the child to choose a toothbrush.

Don’t use this as an opportunity to cram information into the parent. This isn’t the time for brochures, lengthy explanations, etc. This is the time to hear what the parent wants to tell you. SET YOUR CONTRACT WITH THE PARENT NOW. Once the parent understands the concepts, knows we care about the child and values the parents’ opinions, you can focus on the child. Don’t use big words (“gingivitis”) when a simple word will do (“gum disease”).

When your focus on giving information you may think your coming across as thorough and knowledgeable. In fact, you come across as foreign, superior, and untouchable. Many of these parents get through their adolescence with few or no dental appointments how can their children be so different?

If you don’t take the time to establish your contract (future focus), then you are left trying to justify your preventive appointment in terms of what exists in the child’s month today. These current problems (or lack of them) become the parents’ focus and that means cost and where could these problems be treated cheaper?

Here are some questions to help establish the parent contract:

“Mrs. Adams, while Julie is playing, let’s get to know each other. I want to provide Julie the kind of care that you want for her. Could I ask you some questions?

What kind of care were you and your spouse used to as you were growing up?

Have your or your husband had many dental problems?

Does ____________________ have any problems you’re aware of?
(If child has been to the dentist before)

Have you been taking ________________ to the dentist for treatment or to learn to become healthier?

Emphasize these points in your discussion

1. Controlling dental disease is easier, cheaper, and more fun than repairs.
2. Our goals for children in our PC program
a. Independently (of dentists) healthy
b. Graduate from high school with
1. All teeth
2. 3 or less fillings
3. No gum disease
4. Low dental bills
5. Teeth lined up well
3. If the child is going to be effective controlling dental disease, the parent must know how also.
4. We can arrest some small cavities rather than repair them.

When you’re ready to establish contract, try this

“Is there any reason you can think of that these ideas wouldn’t work for a child?”

Allow the parent to talk. Listen. Include entire family in discussion.

Don’t make long defensive explanations. Just concentrate on understanding why the parent feels the way s/he does.

You can’t quickly change people’s beliefs, but you can create a desire to try yours.

Usually your discussion with the parent will occur much quicker than it took to read this material. Parents appreciate your care and concern. There are only 2 reasons a parent will block you from beginning your PC appointment.

1. Deep seated preconceived ideas.
2. Irritation at the way you presented the ideas.

Now, say the contract to the parent, “Mrs. Jones, what I’m hearing is that your want Julie to be in our preventive care program so that she _______________________________________.”

This process will also give you your first indication of how successful you will be. What the parent believes the child will be in the future is the single biggest factor on how the child will learn.

2. Smile, touch, ask, listen, don’t judge, feedback
3. If the child is playing, show interest in what she/he is playing, after 1 2 minutes guide the child back to the PC room holding child’s hand or placing hand on child’s shoulder. “Come with me ___________. I’ve got lots of things to show you!”
4. Don’t allow interruptions
5. Show child which sink is “theirs” today

C. Spend 3 5 minutes getting to know the child and parent so you can confirm your “contract.” This “contract” is your primary job in this appointment. Most parents just bring their kids in because they believe they “should”. Your job is to clarify why Mom believes she and her child are better off. Remember the types of motivations. Talk with her. (If parent doesn’t give contract on first try) Ask parents if they have any concerns or goals for this appointment. If they say ‘no’ don’t give up. Find out what is valuable to her. Clarify it. Speak it. “Mrs. Jones, then from our talk, the main reason you bring Tom to us is _______.” The contract with the parent helps her to clarify the value of the appointment to her. Try again, “(Parent) What is the most important thing you’d like to see (child) and I accomplish today?”
Help Mom to understand the value of helping the child learn to become “independently healthy.”
I believe children are the lifeblood of a preventively oriented practice. Many dentists and hygienists prefer not to work with children since they can be uncooperative, slow to understand concepts, awkward, have a short attention span, be loud, unruly, messy and much more.

Even with all these negatives, the positives far outweigh them:
1. Children will do their best to please you. They are totally honest and will let you know exactly where you stand. They have a level of interest and excitement that can recharge you when you tap into it.

2. Your appointments with children will give you a real opportunity to alter someone’s life for the better. The greater the skills and interests are developed, the healthier they will be their whole life and you were a significant source of this development.

3. Through working with children, you have your best opportunity to improve the parents’ interest in preventive health care.

4. The flow and activity, our emphasis and obvious time commitment and interest will tell everyone here are people who want to help people!

Now please take a half hour and read our preventive care manuals on children and prevention.

Occasionally the parent will ask that the child’s teeth be cleaned but no PC. Honor the request. When finished, show the parent any decay or gum disease that might be able to be controlled by a PC appointment.

Next, bring the child to the preventive room, go through the same thing with the child. Again, you must help him clarify what s/he gains from working with you to develop his skills at becoming independently healthy: “Tom, what I’m hearing you say is that you want to develop good skills with the brush and floss so you won’t have to get shots and be drilled.” Who has shaped your child’s opinions? Ask if a teacher has talked about going to the dentist, a TV show like Sesame Street, have they been to a previous dentist, finally the experience they have in mind. Alter or reinforce their ideas as appropriate. You just developed your contract.
1. Write down some of the child and parent “contracts.” They will probably match some of the goals discussed on pg. #1 and #2.
a. Reduce sugar (be specific)
b. Brush
c. Floss
d. Fluoride
2. Make some statements to show that you know something about them as people.
“John, you had a filling 6 months ago. I bet your goal is to never have another one. Am I right?”
“Mrs. G., you work during the day. I bet it’s hard for you to find the time to supervise John’s flossing. Am I right?”

3. Ask some questions to get them on track: “John, tell me, when is the best time for you to clean your teeth? Show me how.

Build trust frankly tell him what you expect. Be honest share your feelings, good eye contact good body language

Look for these factors in gaining a commitment:
1. Choices always give choices shows respect
2. Show the rewards they can expect
3. What are obstacles to improved health?
4. No overload only one general commitment and three supporting behavior changes or less
5. You can give an opinion, but don’t judge or impose your standards

4. When you feel that you have the correct atmosphere let them show you how they take care of their teeth. First, let them pick the color toothbrush they want. What color is your toothbrush? Would you rather have a different color? If you plan to use disclosing solution, use a bib to protect the clothing of young children.
“This is a napkin. It’s like you use for meals at home. This will keep stuff off your nice shirt.”

a. If they are a new patient or under the age of 7 start by explaining what a red tablet is and how it works. For the young child, make it a game hide and seek. For the older child, offer them the ultraviolet approach so the red won’t show. The young child may be apprehensive that her parent is watching and judging how well she performs. Really work to keep the appointment light and fun. Hide and seek with the sugar bugs, etc. Only use disclosing solution if you need the “shock value” for the Mom or child. The red tablet forces you to judge the child. It’s good for the initial PC appointment, but has less and less value as you build your relationship.

b. For patients older than 7 who have been through a PC appointment at least twice, have them go through their brush and floss routine as they normally would at home, only more slowly, so you can see what’s going on. Remember, the goal is not to have the child perform to your standards. The goal is to maintain the child’s self esteem and have them develop skills that they can use easily at home. By waiting on the red tablet, you focus on them and give them a couple ideas on technique. When the red is in there it’s almost impossible not to focus on the red with comments such as “Let’s see if you got all the red off that time!” or “There’s still some red on the inside of your lower back teeth. Why don’t you brush there again.” The red tablet is an easy way to set up a judging pattern in the appointment. The later and less it’s used the better. Use the lighted magnifying mirror to help your child see in their month. When you have finished the skill development part of the appointment, got to the chair and examine them. Look for decay, gum infection areas, etc. Base your brush and floss suggestions on this rather than the red tablet. Ask them first if they know what the red tablet does.

5. Don’t ask someone to make a change unless there is some reason they have to change.

6. Don’t cram parents and children with informational “shoulds.” You rob them of personal growth. You make them dependent on you rather than on themselves.

7. Dr. Haim Ginot, a gifted psychologist, had several insights to help us from his book Teacher and Child as outlined in the 1975 issue of the Journal of Dentistry for Children.

a. Don’t argue or disown what a child thinks or feels. Good dental health is more important to you than the children. They are primarily afraid they’ll do something wrong or be hurt. This is why you will be in a room that has no dental equipment. Get a reading on the child’s feelings now. “You look happy (or unhappy) to be here today.” Your first effort at actually trying to understand how children feel can open the door for a closer relationship.

b. Don’t try to explain difficult scientific concepts. Allow fantasy to take the place of reality. Sugarbugs and the Tooth Fairy are on our side.

c. A child’s dignity is as important as an adult’s. Use “please” before requesting a behavior and “thank you” when it’s accomplished. Treat them like adults so they’ll act like adults. Children appreciate being respected. They will work hard to get more of it.

d. Praise carefully. Only praise behavior not the person. “You really brush you teeth well.” But not “You are a wonderful person.” Try “You’re a lot of fun. I really enjoyed our time together today, Jenny.”

e. We all grow by choosing among a variety of choices and living with the consequences. “Would you like me to count the top teeth first or the bottom teeth?” “Would you like to rest for a minute or shall we continue?”

f. Find the child doing something right and acknowledge it. Don’t focus on the mistakes. Ask questions. Why do you think we do this? What do you think this equipment does? Acknowledge even partial correct answers or behaviors. Help the children to feel successful.

g. Authentically love the children. Children read our feelings much more quickly and accurately than adults. A canned speech or false sentiments are an immediate turn off. If it comes from your heart, you can say “I like you. I’m glad I got to meet you today. Thank you for letting me help you today.”

D. As child is brushing

1. Keep it loose and fun Ask if they brushed before they came in. If not don’t worry! Make it fun. When you look in their mouth ask, “Are there any kitties or doggies in there? Did you bring your teeth with you?”

Children will try very hard to please people that they like. Always praise. Don’t criticize. Even if the child is holding the toothbrush by the wrong end, you can compliment him/her on having such a strong grip while you switch the brush around.
Points to emphasize while brushing:
a. Once a day thoroughly.
b. Race track pattern start on the outside upper in the back, work around, go to inside, then lower the same, the tops the same to avoid skipping around and missing teeth.
c. Angle the bristles toward the gums.
d. Use short back and forth strokes. “Big circles” don’t work. They bring the brush out of the sulcus, requiring continual repositioning. Tell the child to use a “race track” pattern; back right upper outside to left, then inside uppers, then repeat pattern on the lower teeth.
e. Floss using the same pattern with “pointing fingers” one in and one out of the mouth, breaking contact only.
f. Only try to get them to learn to hold the floss and break the contacts.

2. No paste on toothbrush explain that brush provides the cleaning and that toothpaste is just a flavored soap. We use toothpaste to:
a. Add flavor
b. Add fluoride
c. Add an abrasive to help the brush clean

3. If there’s no paste on the brush he can talk while they clean.

4. Now’s a good time to ask about hobbies, pets, friends, family, interests, etc. Use simple words: “Gums, spit, slobbers, etc.”

5. As you watch, make sure they have the basics down
a. How to hold the brush
b. Start on outside of upper right back molar
c. Race track pattern (outside of uppers, inside of uppers, drop down to outside of lowers start on back right molar and then insides, finally the tops of the teeth
d. Angle of bristles working edge at gum line

6. Don’t constantly correct them if you have to work hard on establishing the racetrack pattern then only mention brush angles and floss corrections briefly. If you need to correct the child, try putting your hand over his so he can get a feel for what you want him to do. Find out about him/her as a person. Enjoy yourself. One month from now they will probably have forgotten everything you’ve told them except that they either enjoyed being with you or not.

7. More than occasionally the child will be doing a good job. Use this as an opportunity to review so mom knows what the child is doing.(See notes on #1 in this section)

8. Now is the time to see what the child knows about the decay process. Don’t quiz him. Just ask if he knows how people get holes in their teeth (under 6). If over 6, assume they know the process unless you see an active decay problem. If the child is having a problem handling the toothbrush, introduce him/her to the Triumph and let them try it.

9. Next, have them floss. Again check the basics:
a. How they wrap the floss on their fingers
b. Same racetrack pattern
c. Saw through contact, bend and work up and down on both proximal surfaces

10. While they are doing this, ask how they are doing with sugar. If sugar or decay is a problem, find the worst offender (example sugar pop, lunch dessert) and offer a substitute the child likes (sugar free pop, juices, apples, bananas)

11. Next, check on fluorides both tablets and brush on. Ask child how often he uses the fluoride (check pink sheet first) and in which forms tablets and/or get. If it’s not being used, this is the time to try to reinforce it. Make sure they live at same address if still on fluoride tablets.

12. If the child; is not flossing, reassure him that you know he can do it, that it’s only a matter of finding the right time. When he finds a habit that he has that occurs daily, he’s relatively by himself, and doesn’t need his hands (ex. reading, TV), then tie flossing to it. Explain how hard it is to try to make flossing its own habit. It’s easier to tie it to a habit you already have. The worst place is in the bathroom before going to school or at night just before bed. It’s too easy to skip!

13. Be sure to find lots of positive things to mention. At least 3 positives for each negative correction and start out with at least 2 positives before the first negative. Never make more than three corrections.

14. Focus on mom now if the child still needs her help
a. Find a toothpaste the child likes probably one specifically designed for kids with sparkles, cartoons, etc. Cinnamon is a favorite flavor.
b. Have Mom arrange the bathroom for the child a stool so the child can reach the brush, floss, and see into the mirror. A personal cup to rinse with.
c. Look for results, not time. Don’t have mom set time limits. This only leads to authoritarian “have to” experiences. Have Mom work on skills and making it fun with lots of praise.
d. Encourage Mom to help as long as she believes her help is needed.
e. Encourage Mom to be a good role model. They can brush and floss together.
f. Never make brushing/flossing a punishment.

15. Your last step in the PC room is to have the child brush one more time with a toothpaste to clear any residual red off so you can evaluate the gingiva at the chair and help them look better.
E. Wrap up the session.
1. Bag up the supplies, pick out a sticker if appropriate

2. Have child wash down sink and clean up the area

3. Switch to an operatory. Take necessary “decay” x rays (Please don’t call them bite wings). Usually, we take our first decay x rays when the 6 year molars are in occlusion and then every 2 years after that. Allow the child to help. Place their own x ray shield. Raise the chair. Watch develop x rays. If a decay problem develops take them now and we may go to annual x rays. Try to take adult films if at all possible. This helps me see the position of the erupting permanent bicuspids. After you have placed the x rays in the processor, let me know that you are ready.

4. If this is the child’s first visit, show him the chair, light, etc., explain who doctor is and that doctor’s job is to help kids have big smiles and bright teeth!

5. Use your mirror and exploring point probe for decay. Remember, we don’t have to repair surface (enamel) decay particularly on primary teeth that have been in the mouth at least two years. Check for bite problems. Probe for periodontal disease. Here are the six possible distinct periodontal infections you may diagnose. Statistically, you can expect to see some bone loss and loss of periodontal attachment on 5 9% of 5 11 year olds and 5 46% of 12 15 year olds. The wide percentage ranges due to different results from different studies. The important point is that you can’t assume that the destructive forms of periodontal disease are confined to adults.

a. Chronic gingivitis stage I of soft tissue management program. By far the most common form.
b. Chronic periodontitis stage II of soft tissue management program. Usually associated with systemic diseases: diabetes, Downs syndrome, HIV, etc.
c. Localized juvenile periodontitis rapid bone loss at puberty (localized to molars and incisors in a client who is medically healthy Treatment same as stage II plus tetracycline if no primary teeth remain). Refer to periodontist.
d. Generalized juvenile periodontitis begins around puberty, generalized bone loss, inflamed gums stage III treatment with antibiotic.
e. Acute necrotizing ulcerative gingivitis/periodontitis interproximal ulceration, pain, sloughing tissue caused by stress and poor hygiene stage I treatment.
f. Prepubertal periodontitis Begins from time primary teeth erupt until age 5 rapid bone loss, inflamed gums, can be localized or generalized refer to specialist

7. Bring Mom back to the operatory or have the child bring her back. Ask Mom if she has any questions.

8. Polish off all stain and calculus

9. Review the changes (if any) that you and the child have decided on.

10. Evaluate occlusion
a. are jaws/teeth developing normally?
b. look for clinch/grind symptoms
1. 38% of preschoolers clench/grind
2. 33% of child bruxers will become adult bruxers

11. Reinforce positive, can-do attitude and confidence

12. Does Mom need any written info.? Sealants, PC/Kids, etc. If yes, be sure to write on it to personalize it for her.

13. Decide if child needs x-rays:
a. 0-2: no x-ray
b. Age 2-3: 2 BWX (size 0) as soon as primary molars contact each other size 2 occlusal
c. Age 3 on: 2 BWX (size 0) every 2 years – size 0
d. Age 6 Panoramic x-ray
e. 2 BWX annually after fillings placed (size 2)
f. 16+ if symptoms or to evaluate wisdom teeth, Pano
g. 18 – Panoramic for wisdom teeth

Now it is time to contact me. I may be a few minutes in getting to you, so stay with the child and enjoy talking about things that are important to him/her. The parent may try to dominate the conversation, but keep directing your conversation to the child. Here is an opportunity to learn the child’s interests be sure to record them in the remarks section for all of us in the future!

Next, give me your review ability with brush and floss, gums, decay, bite, and anything else that would help. Write down my comments. Decay charting goes in the remarks section. If the child is due for an ortho evaluation, note this in the chart and when I have left, give them Dr. Duchon’s information. From the age of 6 until their bite is developed I would like to see them every 6 months.

F. When the dentist comes in

1. Be sure to use the child’s and Mom’s first names so I can know them! Make sure the parents first names are written on the top portion of the pink sheet.

2. As I’m examining, tell me how the appointment has gone. You can read down the pink sheet if you want.

3. Write down all my comments

4. If child has gum problems, set up a time in 2 4 weeks to re evaluate (if Mom wants) plan on 15 minutes

G. When I leave

1. Discuss fluoride with mom (up to 65% reduction in tooth decay ) – 2 types
a. Fluoride tablets – optimum level .7-1.2 ppm. If child uses municipal water supply, look up the content in the State Fluo9ride list in PC room drawer above fluoride gel. Use the table to determine the correct fluoride supplementation.

Natural Concentration Age Dosage
0-6mo nothing
.3ppm or less 6mo-2yrs .25mg
2-3yrs .5mg
3-12yrs 1.0mg
3ppm-.5ppm 6mo-2yrs nothing
2-3yrs nothing
3-12yrs .5mg
.5ppm-.7ppm 3-12yrs .25mg
.7ppm-greater nothing

b. We recommend using topical fluoride if they are:
1. Having a problem with decay
2. Having trouble with manual dexterity
3. Eating sugar more than 2x a day
4. In orthodontic appliances
5. Preferred by parents
This can either be our fluoride gel or fluoride varnish. A study in 2010 showed that varnish on children’s teeth reduced decay 75% if used twice daily.

Commercial toothpastes are not strong enough. (*Most contain .1% fluoride 1,000ppm)

2. Fluoride mouth rinses are available two ways
a. School programs- these are either daily (usually a .05% NaFl solution or weekly (a .2% Nafl solution) Both programs are equally effective and reduce decay from 25-30%
b. Oralojel brush. This has been almost as effective as fluoridated water if used 1-2times a day.

3. Altering fluoride contents
a. Many people don’t cook or drink water from the tap any more. They use bottled water or filter it with home filtering systems.
b. Some home filters can actually remove almost all the fluoride from water.
1. Reverse osmosis units remove 90% of the fluoride.
2. Activated carbon filters remove varying amounts (depends on brand)
3. Ion exchange filters no effect
4. Water softeners no effect
c. Distilled water contains no fluoride
d. Bottled water fluoride content varies with the brand. Some have too much fluoride. The bottlers can’t treat the water or they would lose the “natural” label. The content of the water isn’t listed on the label, but they will provide the content when you send a written request.

4. A fluoride sample bottle kit should be given to the parent if they have their own well. Many of the area’s wells have either too much or too little fluoride occurring naturally. We keep water test kits in Pedo.

Department of Health for samples. Here is the procedure:
a. Explain the need to the parent
b. Show the parent the kit.
c. Fill out the mailer
d. Instruct the parent to fill the test tube at the kitchen sink. This is the source of most drinking and cooking water.
e. Pull out the fluoride list that includes all the areas around us. Find the general area road, development, etc. Discuss this with the parent. Even next-door neighbors can have a significantly different water fluoride content levels.
f. Be sure to remind the parent that there is a $12-14 fee from the state that we collect for the state for his service.

When we get the results of the exam from the state, we will contact the parent and provide them with a prescription to supplement the fluoride if needed.

The state recommends wells be tested every 5 years for changes in fluoride content.

5. Now is a good time to give Mom our booklets on PC and prevention. Be sure to underline several important points in each booklet to personalize them from Mom.

6. Focus now on the goals the Mom and her child discussed with you in the beginning of the appointment.
a. “Mrs. Jones, you were most concerned about Tom avoiding decay. Today we really worked hard on his racetrack pattern. If you will work with him on this skill until our next check up I’m sure he’ll have a better chance of avoiding decay. “Tom, you were really concerned about not getting decay. Your most at risk areas are between your teeth. Finding the right time to floss while you watch TV should be a big help in avoiding those shots and drilling!”

7. See if Mom has any other suggestions. Make sure they have their bag of brush, floss, fluoride, etc.

8. If the child is under 13 go to the NO DECAY bulletin board and let them sign their names. Teenagers would be embarrassed to be asked to add their name to the No Decay Club. They are entered on our Caviteen list. Tell them this is a contest where the winner receives a $ gift certificate.

A. While he is doing that you can drop the chart off at the desk, so Mom can complete the transaction with the secretary. Decide how long until the next recall and whether it should be a PC or a cleaning. Make sure the chart and pink sheet are filled out completely. Is there a referral sheet filled out for Dr. Farley? Fill in the remarks section of the yellow sheet with important info. about the child: favorite games, pets, names, etc.

B. Thank Mom for bringing her child and tell him how well you think he’s doing. Thank him for working so hard with you. Remind him to look in the next newsletter for his name if had no decay.

C. Write the child’s name on our newsletter no decay list (if decay free). Their name will appear in the next newsletter. Make sure they put their name in the no decay box. Only children with no decay can put their name on the bulletin board, share in their pride when they get to add a star to their name for a perfect check up. Another bulletin board displays our no decay club winner of the month. Each month all the kids who were in for their PC exam that month with no decay get their name in the box for a drawing.

D. Make a “dental missionary” out of the parent and child. Tell them how unique you believe our approach of helping children become “independently healthy” is. Tell them if they know any other parents or children who would like to develop this high level of health to call us. Have them mention your present clients names (give them one of our care to share cards for a new neighbor discount) for special consideration.

Write on the back of the business card:
Allow special new neighbor introductory fee.
Sign your name.
Stress for your clients to have their friends to ask for you.
This is a way to build your practice.

E. Use our Intraoral Camera for a fun experience for the child.
a. Take a fun smile photo of the child
b. Take a 4 picture series:
1. Picture of the child’s smile
2. Picture of you with word “floss”
3. Picture of child thinking
4. Picture of child flossing area

Special Situations

Mom doesn’t want to come back with you and child
Child older than 10 – preferred
Child less than 10 acknowledge Mom’s feelings, let her know you’ll give her a report
Work with child
Report results to Mom
All OK
Problems = report and encourage Mom to be with child next time

Child 4+ and Mom still cleans teeth
1. Let Mom show what she can do
2. Have child go through appointment – praise child show Mom how much he can do and encourage child to do their thing with Mom helping only once per day

Child has been in PC for several years and skills are good and no decay
1. Go through PC
2. Congratulations and time to go to regular cleaning

Child who won’t cooperate and Mom no help
1. Acknowledge the child’s feelings. “You’re really unhappy. I’ll bet you didn’t want to come. I’ll bet you want to go home right now!” Often the child will realize that crying is not necessary to show their feelings. This will give you an opportunity. “You must think I’m going to do something that you won’t like. I want you to show me how you brush your teeth, then I’m going to count your teeth and let you meet Dr. Smith and then you can go home. In this short speech, you did three things, you:
a. Understand his/her feelings
b. What his/her concerns are
c. How to overcome his/her fears – Usually, if you’ve done this while gently touching the child’s shoulder, using good eye contact, and a gentle, caring voice, they will cooperate.

2. If this fails, then focus on the child and tell him (eye to eye) that you would like him to be healthy, but you can’t do it for him. Does he want to work with you? If yes – go through appointment. If no – turn to Mom, acknowledge that skills cannot be learned by force and recommend discontinuing appointment and having me examine. Also recommend yearly x-rays, real care with sugar, and emphasize use of fluorides. Reassure Mom that child is OK. We’ll try again in 6 months. You like the little monster and will look forward to seeing it again. Don’t judge.

3. Use these guidelines

a. Direct your disapproval at the child’s actions not the child’s character.
b. Use “I” messages: John, when you won’t open your mouth, I can’t help you. Your mother expects me to help you. Neither of us wants you to (refer to contract you’ve established). I want to help you. Will you let me?
c. State your expectations
d. Give a choice. John, if you won’t allow me to help you, I’ll have to have your Mom come back with us so we can talk about why you won’t help me. Is that what you want?
e. Take some action
f. Find a way for the child to be helpful. John, would you pick out a toothbrush and floss while you’re thinking about what you want to do.
g. Show the child a way to show he’s sorry. John, if you want to show me how you brush your teeth, we won’t have to have your Mom come back with us.

Mom monopolizes you and won’t let you concentrate on the child
1. Listen to Mom, then as quickly as possible, tell her what she says is interesting and you enjoy talking with her, but now you need to work with her child
2. If she interrupts you later, try to answer with yes or no and don’t look at her.

Mom says this isn’t important – wants teeth cleaned
1. Find out why Mom doesn’t want a PC
a. Money
b. Fear
c. Socio economic background
d. Dental IQ
e. Remember 40-70% is nonverbal
2. Try to clarify why doesn’t want – 4 types of people
a. Money – save future dental bills
b. Self-preservation – be healthy, avoid body breakdown
c. Recognition – looks, self-improvement
d. Romance – social, business, dating, get parent to focus on the future of the child
3. If you can’t convince Mom of the value of the appointment, then clean their teeth instead.

Handicapped children – dental disease may be their only controllable health problem
1. Switch gears to match their behavior related age
2. Find out what they like to do to clean their teeth and work with these steps – parents don’t usually do a lot to help and don’t challenge the kids.
3. Make appointment fun.
4. Work hard with parent on sugar limits (not a treat for good behavior)
5. Basic considerations
a. Required diets may increase difficulty of maintaining good habits.
b. Nature of handicap may make cooperation difficult
c. Family members may be incapable of providing assistance – may need to use visiting nurse
d. Maintaining aesthetics may give emotional lift to child
e. Compromise with the ideal
f. Flexibility for different handicaps
6. Aids and techniques
a. Tongue blade prop to allow parents to see teeth
b. Disclosing tablets, electric toothbrushes, floss holders
c. Modify brush handles – sponge – fatter handle – bicycle grips
d. Pit and fissure sealants – prevent some decay
e. Fluoride rinses
f. Nutrition counseling

Abused Child
1. Bruises around face, frighten child
2. Parent (and often child) reluctant to talk about it
3. Your doctor is legally liable to detect child abuse.

Child has decay problem and Mom can’t seem to control sugar in child’s diet.
1. Praise Mom if she’s using more chicken (less red meat), switched to skim milk, and getting raw vegetables into the child’s diet.
2. Discuss reading labels. Is sugar one of the top three ingredients? Remember, they are listed in decreasing order of volume content.
3. Most people that eat too much sugar also eat too much fat. It is usually this craving for fat that leads to too much sugar.
4. Substitute nutrition for fat/sugar
a. After school – have carrots and celery cut up plus apples and bananas – how about a bowl of cereal
b. Artificial sweeteners substituted for sugar – in soft drinks, cereal sweeteners, etc.
c. When you need sugar and you can’t talk yourself into a non-sugar substitute, then have your sugar without the fat: Angel food cake – limit to two times per day

Mom has an infant aged two or less and doesn’t know anything about nutrition.
1. Don’t make her feel stupid. Reinforce how much you appreciate her honesty and concern for her child’s welfare.
2. Don’t blitz her with a broadside. Try these general recommendations.
a. Provide a variety of foods
1. For the first 6 months, breast milk is enough. Infant formula is the best substitute.
2. At 4-6 mos. Add a single grain cereal. Add another single ingredient new food every 3-7 days. This is long enough to see if the baby likes the food and can tolerate it.
b. Don’t overfeed or underfeed.
1. Babies know by instinct how much food is enough – don’t pressure them.
2. Feed the baby when s/he’s hungry.
3. Don’t force the baby to finish a whole jar.
c. Don’t worry about fat or cholesterol – babies have different needs than adults
d. Don’t overdue high fiber foods. Too much fiber can reduce calories and block absorption of many nutrients.
e. Some sugar is okay
1. Avoid foods that add sugar
2. Don’t use anything but plain water at nap times
f. Some salt is okay, but don’t add any salt if Mom is preparing her baby’s food
g. Make sure the baby is getting enough iron.
1. The baby has a 4-6 month supply “built-in” when born.
2. This is the nutrient that is the most likely to be in short supply in an infant’s diet.
h. Child is a thumb sucker
1. This is not a problem up to the age of 5.
2. Pacifiers are better than thumbs – easier to stop
a. Peers of child will force quitting
b. Easier to lose a pacifier than a thumb
3. In my experience, children who quit by the age of 6 are still okay.
4. Entering 4th grade is a good time to stop thumb sucking. The child is eager to be “grown-up” and “fit in.”
5. Reassure Mom that thumb sucking is okay up until the age of 6. Warn her that thumb sucking is a deep psychological need. She sets up a “no win” situation if she tries to come between the child and the thumb. She and the child will both get a big dose of guilt.
6. Encourage Mom to borrow a copy David Decides. Warn her not to be premature. Wait to read it when the child (not Mom) is ready.
7. If the child uses a blanket, this is a great signal when ready. When the child will freely give the blanket, its time for David Decides. Encourage Mom to read the parents section in the back of the book. Have Mom encourage her child to call you when s/he is going to stop. Call the child back in 1 week to see how they are doing. Warn Mom to wait until her child is ready. It’s only effective once.
8. Encourage Mom and child to make a three-week calendar. Put a sticker on each day the child is “thumb free.” Have Mom give the child a small gift when the child goes 10 days in a row with no thumb.
9. Thumb sucking often occurs when the child is bored. Encourage child to let Mom know when this happens. Mom will need to find an activity to stop the boredom.

Oral piercings
1) Becoming a more common practice
2) Don’t offer moral judgment to the child
3) Procedure (usually without anesthesia)
(1) Tongue is pierced with a needle
(2) Temporary oversize piece of jewelry inserted for first few weeks until swelling gone and tissue heals.

4) Risks
(1) Without sterilization: hepatitis, HIV
(2) Pain/bleeding
(3) Metal bars can chip teeth (plastic safer)
(4) Metal will interfere with x-rays
(5) If comes loose can be swallowed or inhaled into a lung
(6) May increase salivary flow
(7) Eating, drinking, speech can be impaired
(8) Permanent numbness of the tongue may develop
(9) May trap food and cause bad breath
(10) Allergic metal reaction possible if not gold

5) Care for piercing
(1) First 2 months after placement
(a) After eating or smoking
(i) Brush tongue
(ii) Irrigate piercing with antiseptic
(2) After first 2 months
(iii) Brush your tongue and irrigate with Listerine daily
(iv) Keep jewelry clean (regular jewelry cleaner may be toxic)

L. Children with disabilities
1. Types of problems-
a. intellectual deficits
i. caregivers often so overwhelmed they don’t see how they can be actively involved in home care.
b. physical disabilities
i. see section on elderly for ideas

M. Mom skips appointment or won’t make appointment for restorative dentistry
1. Child has multiple badly decayed teeth
2. Realize that your primary responsibility (morally and legally) is to make sure the child has
the necessary treatment – by Healthpark or somewhere else.
3. Find out why the parent is not having treatment done – ask the question directly.
a. Parent doesn’t understand the value of treatment
b. Money
c. Little free time
d. Fear by parent of putting child through experience
4. Adjust treatment/payment arrangements to meet parent’s needs
5. If the parent won’t arrange treatment, dismiss the child from HealthPark.

Age Groups

Each child is an individual. Look for their unique features. However each age group will respond to specific ideas in a similar way.

We like to see the child for the first dental visit at the age of 18 to 24 months, or when the child can handle this situation (boys are a little slower). The parent should be present and usually the child sits on the parent’s lap. Dr. usually just checks for growth and development, decay and the bite.

With the parent
Discuss diet – touch on sugar, encourage parent to read the labels, ask if child gets sugar as treat or habit.
Make sure parent understands the decay process.

At this time parent should be brushing child’s teeth 1 time a day and supervising other brushings.

Your job will be to show the parent that it is OK for them to help their child clean his/her mouth. Many parents are reluctant to do this or will sit in the reception room while you “take care of” their child. Get them involved, talk about “sugar bugs” – this is a concept the child can understand. Help the parent get over the queasiness of putting their fingers in their child’s mouth. Be sure to touch the child in a genuine, caring way to reassure him/her. Show the parent how to get behind the child in a sitting or standing position, stabilize the head and brush and floss – or use a damp terry cloth on the gum pads. Use the “race track” concept to help them avoid skipping areas. Unless the child is having a problem, we would see them at yearly intervals.

Mom should be popping floss to break contacts weekly, daily is better.

Make sure parent gets fluoride sample water bottle to see if child needs a fluoride tablet supplement. The secretary can fill out paper inside.

Does the parent take an interest? Write comments in chart. Our preventive care (PC) approach emphasizes helping kids develop skills in tooth brushing and floss and to avoid decay and gum disease. We do not clean children’s’ teeth until around the age of twelve or when they start to build up calculus.

Birth – age 1
1. Trust in self and others

Age 1-3
1. becoming rebellious, much self-pride
2. need parent to be present
3. attention span 1-5 minutes
4. parent will do cleaning
Messages: You are loved
You are unique
You are safe
At the age of 3
 Introduce toothbrush pattern, the racetrack:
 I stressed the outsides of the max arch, outside mand arch
insides of the mand arch
insides of max arch
occlusals of teeth
 Introduced floss, popping floss when teeth come together, to break contacts, no real scraping of plaque. Generally floss at this stage is a fun thing, technique not all that important. The main idea I stressed is that without using the dental floss, their teeth are not clean and they could get decay.
 Mother still helping with brush & floss daily, attention span 4-8 minutes
 Egostage
Up to age 3 – Am I OK? Gets okayness from others.
Age 3-6 Guilt vs. Initiative – Learning to be appropriately assertive

At the age of 4
Kids get a feel for flossing themselves. I start with the idea of putting 1 finger in the mouth and walking the floss. Be patient and encourage the child.
TB pattern in mind, not skipping around the mouth, review decay, 3 sides of teeth to brush, TB and floss get teeth clean together, and role of sugar eating the teeth.
Disclose their mouth if necessary, find an obvious plaque spot they can see, use mirror to explore their mouth, have them remove their plaque.
Dr. does exam, X-rays if decay, on fl supplement only if can spit.
Messages: You have gifts
You are valuable

At age of 5-7
Feeling very competent
Brushing pretty well. Don’t be overly concerned with perfect technique or results.
Flossing awkward.
Start fluoride gel or office fluoride if child spits effectively. Home fluoride should be on a daily basis. Stress this fluoride stops decay by half (if they would get one cavity, they won’t). Tend to believe everything they hear.
Attention span 12-25 minutes

Age 6-10 industry inferiority – gain favor by doing good things, child solves inferiority feelings by doing more faster. “I can do it myself.” Developing individuality.

At the age of 8 till teen years or when calculus forms.
Brushing down pat, generally they know the routine now.
Flossing pretty well, make sure using finger technique and are reaching molars with ease.
– Influence of peers important
To spice up the sessions I’d have them show me how they would brush a certain area in their mouth ex. linguals on mand. molars ex. linguals of lower anteriors
Disclose and complete plaque removal if necessary
Dr. exam, fluoride and x rays

Plaque concept

Ages 3 6 Decay happens because of sugar bugs which are in your mouth. Sugar bugs begin to eat your teeth immediately after you eat something that is sweet like candy etc., this is a cavity. To prevent cavities you need to brush and floss daily.

Ages 6 7 Introduce concept of germs or bacteria that make acid. Acid causes holes in your teeth.

Ages 12 18 Identity vs. role confusion (who am I?). When child is comfortable with who they are, intimacy is natural. Developing sense of ethics. Understands commitment.
Teenage Prophys (12-17)

When preventive skills are good and they know the routine to the point that they lack interest

Cleanings are usually 1/2 hour

Generally still 6 month recalls so are used to regular care

Review oral hygiene skills; I’d show them red gums, material, decay…

Talk with them, find out about their boyfriends and relate this to bad breath and kissing.

Ages 12 18 Identity vs. role confusion (who am I?). When child is comfortable with who they are, intimacy is natural. Developing sense of ethics, understands commitment.

Orthodontic patients

Stress using the home fluoride regularly

May show topics if gums are enlarged and how to use bridge threaders to floss

While braces are on especially if gums are red and bleeding. May suggest a couple times a week.

Encourage them, show them movement with the x rays

Age Related Ideas

To be successful in counseling in preventive care you must match your attitude, words, etc. to match the level or maturity of your client. This level of maturity relates somewhat to age, but watch out for the person who falls outside the norms. Whatever the age, structure the appointment to foster involvement, reasoning, creativity, and responsibility.

A. Up to age 2 (autonomy vs. shame and doubt: developing self-pride – What’s in it for me?
1. Child will cooperate because he doesn’t know anything else
2. Focus on Mom, she will be responsible for
a. Frequency
b. Nutrition
c. How clean mouth is
d. Attitude of child
3. Develop a climate of safety for Mom and child
a. Tolerate imperfection, even failure
b. Look for good qualities self confidence, calm, independent, self trusting
c. Reasonable standards
4. Begin cleaning the gum pads a few days after birth. Lay the child down with the head in your lap. Wipe the gum pads with a wet washcloth after every feeding. With a little practice you will be able to
a. Maximize visibility
b. Provide support and safety
c. Limit movement
5. As soon as the teeth erupt, begin brushing. Don’t use toothpaste (can’t see as well, chance of swallowing too much fluoride. Cradle child’s head from behind when brushing don’t face them.
6. Listen to what parent says if they can’t (won’t) invest time in helping, don’t judge just accept and focus on the child

B. Age 2 to 4 (initiative vs. guilt: developing a sense of purpose)
1. Beware of the Terrible Two’s Now the child is learning independence. Avoid head on collisions of will. When I examine, the child may not even open that’s okay as long as you got a look and Mom understands. Remember their rebellion isn’t disrespect. It is their first step in developing as an independent person!
2. Keep the environment as frustration free as possible
a. Give lots of time when shifting activities
b. Use lots of games: toothbrush race track, string game, etc. (choo choo train)
c. Don’t give orders, make positive suggestions
1) Not Brush your teeth
2) Better Show me how you get the sugar bugs off your teeth
3) Give the child some degree of control through choices (ex. Which color toothbrush do you want to use today?)
3. It’s hard to force 2’s to do anything. If you need major changes have Mom work on his diet and fluoride and you wait to work on skills until he’s 3.
4. This is a walking question box
5. When the child has achieved a separate identity (usually by age 3 4) work on achievement and recognition as he learns to master himself and his environment
a. Give lots of praise, encouragement, recognition
b. Easily frustrated by lack of muscle control support them
6. Use terms that they can understand
a. Race track pattern
b. Sugarbugs
c. Brush the big teeth model (Sam and George)
d. Back and fort brushing like choo-choo train
7. Look for all signs of personal initiative recognize and praise even the screw ups! This leads to success in later years
8. Expect child to be self-centered. Don’t make him fee guilty about it
9. Skill expectations
a. Understand why they are here
b. Sugarbugs
c. Racetrack
d. Hold brush like baseball bat and brush with teeth together
10. Most important develop a good attitude in parent and child
11. Mom will do the flossing up to 3 4 then child will take over with floss holder or a piece of floss tied through the hole in the end of the brush.
12. Technique ideas
a. 2 3 year olds you will probably need to teach them how to spit
b. They need to learn to brush with their teeth apart
c. Listen for the brush on the teeth. It sounds different than when it’s riding on the gums.
d. On age 3 5 you may want them to brush with 1/2 the brush on their gums and the other half on their teeth. It may help guide them.
e. If parent must brush, have child kneel between parent’s legs and tip head back in parent’s lap. This keeps tongue back.

C. Age 4 – 7 (industry vs. inferiority: developing confidence)
1. Conscience begins to develop around age of 6 first ideas of right and wrong (before this obedience comes only to avoid punishment or to please: other directed)
2. What you say matters less than what you do
3. During the first 6 years the child learns autonomy, mastery, initiative, attachment to others, self centeredness, and preference for the same sex while they are learning language, muscle skills, modern contraptions, and society’s rules. Be kind to them!
4. Slow, non pressure learning
5. Time to wean kid from Mom work on independence
6. Only teach flossing to break contract
7. Show interest in the child’s world. Ask questions “Are those new shoes? What do you like on TV?
8. What others think about them becomes important.

D. Age 7 – 13 “The Gang” (identity and roles: developing individuality)
1. The middle years that follow the rapid physical changes of the first 6 years and don’t have to deal with the sex pressure of puberty.
2. Child’s primary task is to define himself outside of the family.
3. Child needs group support to stand eventually on his own
4. Sense of competence comes from peer acceptance and mastery of physical and social skills
5. “No Decay Club” has added significance if it includes his friends. Ask him if his friends are in.
6. Wants to be like his friends (conforming) decay and fillings stand out as different and bad
7. Skills start to take hold
a) Work on brush and floss angles, etc. now is the time to work on complete technique
8. Good age to work on thumb sucking
9. Words
a. Garbage rather than sugarbugs
10. Allow child to be assertive give choices- give them as much control as possible
11. Easy to feel guilty, inferior be careful!
12. Mom is now only an observer and by 11 12 may not even be with you
13. Develop positive self image: give up shame and doubt
14. Try to interface as little as possible “It’s your show, Rose, take it away and show me your stuff!”
15. Great age to collect things stickers may have great value. Find out what the kids are collecting this year. We may get some to hand out.
16. Secrets are important keep a secret from Mom
17. Apparent dislike of opposite sex, but perhaps a secret boy/girl friend
18. Avoid pressure, comparisons to others, humiliation, withdrawal of approval
19. Don’t force activities she genuinely dislikes
20. Cherish the child, not the performance
21. Conscience develops, but still needs support
22. Remember the child sized tensions they are dealing with now are every bit as important and big as our are to us!

E. Age 11 – 18 (intimacy vs. isolation: developing the ability to love)
1. This group will be shifting over to regular adult cleanings very quickly.
2. They will be uncomfortable involved in activity they associate with little kids.
3. Even if their skills aren’t fully developed, when they ask to terminate PC their request should be honored.
4. They are rapidly becoming adults. Bodies change shape; parents are less heroic, more human.
5. Everything they have learned must now be reevaluated. Prevention must be made relevant to them as an adult – not a child.
a. Avoid pain of fillings
b. More attractive to opposite sex
c. Good appearance means a better job
6. Accept them as they are don’t try to change them only clarify and facilitate what they want to be that meets your goals also!
7. From day to day or hour to hour you don’t know whether you’ll be dealing with an adult or a child.
8. Everything is black and white, right or wrong, heavy judgments, much idealism
9. Maintain a sense of humor but no humor at their expense
10. Often a teen will be asked to return to a PC appt. to control a specific decay or gum problem. Be careful to establish your contract carefully and don’t overstep it.
11. Listen actively to their feelings and point of view.
12. Use the ultraviolet dye rather than the red tablets and explain that this is to avoid their embarrassment.
13. They may risk some intimacy/sharing with you. This is great. It is a step in giving up isolation and shows growth.
14. Limit your praise. Accept their behavior. Give your ideas and feelings. This will serve as a model for them to do the same sharing.
15. When finish PC great time to let them know they have now mastered their skills and its time to move onto an adult type appt.
16. This is the age of rebellious independence. Expect it. It’s okay.
17. Don’t ask “How are you doing in school?” Teens can feel you are prying.
18. Expect negative comments. Acknowledge them good naturedly.
19. Teens don’t want to be treated as “children.” Don’t offer them stickers or “no decay club” starts, etc.
20. Avoid comments about their physique such as:
“You look just like your mom!” (Especially to boys)
“You’re really getting tall!”
21. Oral piercings (tongue)
a. As of 2001, there are no certification or training standards for those doing piercings.
b. Accomplished at beauty salons, tattoo parlors
c. Risks
i. Hepatitis due to contaminated needle
ii. Jewelry can come loose and be swallowed or aspirated
iii. Cracked teeth – recommend plastic, not metal tongue bars
iv. Nerve damage to tongue
v. Allergy to metal of jewelry
22. Autism – don’t expect child who learns at one appointment to remember it at the next appointment.

When you feel you have mastered the PC appointment. Set up a small recorder (can even use your cell phone). Record your entire appointment and review it. When you are satisfied you have everything correct give your dentist the tape and set up an appointment to review it with him.

Also, read Your Child’s Self Esteem and plan to discuss it with the dentist.


If a child lives with criticism,
He learns to condemn.
If a child lives with hostility,
He learns to fight.
If a child lives with ridicule,
He learns to be shy.
If a child lives with shame,
He learns to feel guilty.
If a child lives with tolerance,
He learns to be patient.
If a child lives with encouragement,
He learns confidence.
If a child lives with praise,
He learns to appreciate.
If a child lives with fairness,
He learns justice.
If a child lives with security,
He learns to have faith.
If a child lives with approval,
He learns to like himself.
If a child lives with acceptance and friendship,
He learns to find love in the world.

Dorothy Law Nolte

The PC Experience – Review

1. Instructor (facilitator) – friendly, concerned, knowledgeable, confident, gentle, honest feelings, sense of humor
2. Everyone is different
3. Have enough time – not rushed or preoccupied
4. Kid should feel important, unique
5. Be honest, empathetic, straight forward
6. Use words pt. can understand
7. First names to be more personal
8. Remember whose problem it is
9. Be a good listener
10. Be a good role model
11. Non verbals – tone of voice in portraying #1 above
12. Touch – take hand to guide to room
13. No interruptions
14. Praise

Get Information
1. Who is this person?
2. What are patient and parents beliefs?
3. How to avoid 20 Questions
4. Time to develop trust – accept their attitudes
5. We develop beliefs from our experience and this becomes our philosophy and makes it easier for us to be consistent and make decisions easier.
6. Only ask and listen – don’t judge.
7. Know as much about the person before you meet them as possible
8. Develop focus, clarify
9. Feedback in their terms
10. Call parent ahead of appointment
11. Behavior matches self-image

Specific Instructions / Develop Commitment / Contract
Commitment: Why should pt. and family change?
1. Options – always options – shows respect
2. Rewards – positive
3. Purpose in life – primary – learn in order to grow – kid secondary – help others to grow – parent
4. What motivates pt?
5. Recognize pt./ parent emotions
6. Dental IQ
7. Interests of patient/parent adults – associated improved oral hygiene with:
appearance – pretty smile
better chewing
bad breath – teens
independently healthy
8. Instructions on their terms
9. Lovable, worthwhile
10. Active involvement – models, red tablets

Develop Attitude / Confidence
“Can Do” – believe they can be healthy
1. How solve problems preventing good health
2. How do people learn? Remember?
3. Hear not as good see not as good as do
4. What specific plan will meet this person’s needs
Material – open up PC book and relate to person
5. Give constructive criticism
6. Be aware of maturity level and self-esteem (image)
7. Be aware of emotions
8. Lots of praise
9. If neg? asked – ask not to repeat (give you a chance to think)
a. Relate disease process to pt. – involve pt.
b. Real process
1. Praise small accomplishments – don’t push for your standards
2. Stickers / no decay club
3. Facilitate enthusiasm

Action / Repetition / Follow up
1. Call one week after appt.
2. Send card
3. People will forget 80-90% of what you tell them
4. Establish given time for home care. Establish daily reminder.
5. Name in Newsletter
6. No decay club

Points to Remember
1. Let the child tell you how s/he believes the problem occurred.
2. The client must tell you the contract. Clarify it until you are satisfied.
3. Find the diet connection to the decay.
4. Don’t evaluate / judge what you’re hearing.
5. Don’t explain – lectures are out. Avoid Health 101.
6. Let child show you what s/he is doing and modify this.
7. If you want to modify diet, ask what child can change. If the ideas are an improvement, live with them and avoid offering more ideas.
8. You don’t have to brush for 1 minute. Just use good technique. Focusing on how long rather than how well focuses on the boring, non important part.
9. Be sure to enter child’s name in No Decay Club monthly contest
10. Determine need for fluoride (see section 16)
a. Topical for decay
b. Under 12 – fluoride supplement


Baby Food

1. Homemade is better
2. For 1st few months of life baby’s digestive tract handles milk best (all that’s needed for 1st 3 4 months)
3. After 3 4 mo.
a. Need Fe and Fe fortified cereal
b. Orange juice (20 oz = 100% of Vit C RDA)
c. Vitamin supplements
4. At 5 months
a. Strained fruit and vegetables
b. Strained meat and poultry
5. Homemade vs. commercial
Less sugar and starch
More fiber, protein, vitamins, minerals
6. Commercial preparation
a. Processing and heat lose texture and flavor
b. Then add ingredients for
Starches —-+
Sugar —–+— added for parent’s taste
Salt ——–+
7. If buying commercial foods
Don’t buy if water listed 1st or salt added
Meats are best buy
Avoid dinner and high meat dinners added starch, sugar
Avoid desserts high calorie, low nutrient
8. Homemade
Make family meal, take out baby’s portion before add condiments, puree
Fruits banana 1st, all rest cut in small pieces, steam till soft, puree
Vegetables baby likes carrots, zucchini, peas, avoid spinach and beets, cabbage, broccoli, cauliflower, corn cut, steam, puree
Meats, poultry, fish don’t fry: cook, cut, puree
Eggs avoid

Refrigerate unused food good for 3 days in refrigerator or 1 mo. in freezer.

Introduce solid foods 1 at a time to check for allergies: diarrhea, rash, spit up check with doctor.

Infant Guidelines (age 1 3)

General Guidelines

A. Build a variety of foods
Food variety not necessary for first 6 mo. (breast milk, or if not possible, infant formula is enough)
Three stages
Nursing (birth to four months) baby’s intestinal tract not fully developed and not ready for foreign protein
Transition (4 12 months)
1. Add one new food at a time and watch for hypersensitivity (vomiting, diarrhea, rash)
2. Begin adding foods when:
Baby’s birth weight has doubled
Baby wants to be fed more than 8 10 times per 24 hours
3. Encourage infants to feed themselves (start at 6 7 months). Don’t be overly concerned about the mess or choking.
Modified adult stage (12 24 months)
Infant completes transition to adult foods
Use small portions and little seasoning

B. Pay attention to the infants demands don’t over or underfeed
Every infant has a different and unique caloric need, but his/her appetite is the best way to understand when food is needed
The average infant adds 22 grams/day
If infant is becoming fat, evaluate overfeeding ignoring infant’s appetite cut off warnings

C. Don’t restrict fat or cholesterol too much Restrictions of fat and cholesterol in infants will reduce growth and development

D. Don’t overdo high fiber foods
Fiber is: lignin, cellulose, hemicellulose, pectins, plant gums, mucilages, and algal polysaccharides
Most fibers are carbohydrates
Most low fiber diseases occur in middle age +
Don’t supplement an infant’s diet with additional fiber

E. Sugar is okay in moderation
Sugar adds calories that are needed for weight gain and growth
The only infant disease sugar causes is decay, and this is controlled by
a. Brushing the teeth
b. Avoiding nap/night sugar bottles only plain water for pacifying
Don’t use artificial sweeteners
Sugar treats are okay 1 2 times per day as long as the infant is getting a balanced diet

F. Sodium is okay in moderation
Infants need very little sodium
Limit feeding infants high sodium foods: sausage, ham, luncheon meats, and cheese

G. Infants need more iron pound for pound than adults
Iron deficiency anemia is the most common nutritional problem of infants
Birth to four months breast milk is enough
Avoid this deficiency after four months by:
Iron fortified infant foods
Vitamin C helps iron absorption

1. Kids eat what their parents like to eat
2. Go through cycles eating only 1 food: offer kid that food and a couple others also
3. Serve vegetables in small portions
4. Serve vegetables in casseroles and stews rather than separate
5. Don’t demand “clean plates” promotes overeating
6. Serve a variety
7. Have kid help prepare food
8. Make meals look good
9. 20% of kids are obese (20% or more above ideal weight)
10. Start at age 2 to serve large variety emphasize fruits + veggies, not meat
11. Picky eating use a vitamin supplement no more than RDA
12. Occasional skipped meal no problem, but no snacking until next meal
13. Use good snacks anytime they want them
14. Start with a good breakfast
15. Very few sugar treats
16. Allow kids to prepare menu, meal, do shopping
17. Give small portions and encourage seconds
18. Parents must eat better than they want their children to eat
19. Women, beginning as teenagers, need an iron supplement (18 mg/day)
Key variety in food groups, moderation in portion size
Notes from other Hygienists

1. Don’t use questions as a controlling device. Asking too many questions and getting only informational short answers has the same effect as lecturing. Use your questions to initiate a dialogue that opens up insights into both your personalities.

2. Enjoy the child. Talk about things that interest the child. Don’t be too “official”.
3. It’s not necessary to brush after every meal.
4. Sugar isn’t bad. Eating it more than twice a day is a bad habit. Less than twice a day is an okay treat.

5. Don’t forget to establish a clear contract with Mom and reinforce it during or at the end of the appointment.

6. Don’t use “shoulds” and “oughts”

7. Must have a clear contract with the child. This means that it is meaningful to the child and the child agrees to it.

8. Small children do well with floss holders, but let them use their fingers first.

9. Try to avoid red tablets. Red tablets for you to judge and focus on teeth. Only use them on your “tough” kids or parents.

10. Get Mom involved. Lots of show and tell. Get child to demonstrate to Mom. Discuss choices: flavors of fluoride, color of toothbrush, which sticker, etc.

11. Electric toothbrushes are good for children who
a. have significant decay
b. don’t like to use a hand brush

Review of PC Experience

After you have a few of these PC appointments completed, get out a tape recorder and tape an experience for Teresa and Dr. Smith to review. Here’s an outline and some tips so you’ll know what we are looking for.

1. Explain to mom the purpose of the tape recorder “Mrs. Witt, would you mind if I record our appointment with Matt today? We record our visits occasionally to discuss among ourselves for quality control.”
2. Begin with mom. Find out why she has brought her child to you. What does she expect you to accomplish? I want to hear you say, “So, Mrs. Witt, what I’m hearing you say is that you want me to . . .” You’ve read the child’s folder, if mom draws a blank, give her some suggestions: economics, no decay, better/more frequent brush/floss, etc. The mom needs to agree with this contract.
3. Next, talk to the child. Again, make a contract. This is more difficult. The child is there because the mom says so. If you’re going to be successful, particularly if you want to make changes, you will need a good reason for this child to change behaviors. Again, I want to hear, “So, Matt, you want . . .” and the child agrees.
4. Review what he says he’s doing now. Is he satisfied with what he’s doing?
5. Have him brush/floss for you. Don’t jump in. Let him go through his routine. Enjoy him. Keep the atmosphere light. Fill out your pink sheet while he shows you how he’s doing.
6. When he’s finished, suggest no more than 1 or 2 changes and tie them to his key needs and his mom’s.
7. Review your findings in terms of their contents. Ask mom if she has any questions.
8. Concepts
a. Some children brush quickly and do well. Don’t get hung up on 1 minute brushing. You don’t care how long they brush, just that they get the plaque off and don’t get decay/gum disease. I’ve seen some 20 second brushes do a great job.
b. Disclosing solution – optional unless child has “show me attitude” or is doing a bad job or parent needs to see. These tablets force you into a nit-picky tooth by tooth judgments/analysis.
c. Don’t use questions as a controlling device. Asking too many questions and getting only informational short answers has the same effect as lecturing. Use your questions to initiate a dialogue that opens up insights into both your personalities.
d. Enjoy the child. Talk about things that interest the child. Don’t be too “official.”
e. It’s not necessary to brush after every meal.
f. Sugar isn’t bad. Eating it more than twice a day is a bad habit. Less than twice a day is an okay treat.
g. Don’t use “shoulds” and “oughts”
h. Small children do well with floss holders, but let them use their fingers first.
i. Get Mom involved. Lots of show and tell. Get child to demonstrate to Mom. Discuss choices: flavors of fluoride, color of toothbrush, which sticker, etc.

*Listen to your tape. Make your comments. When you have a good tapes give it to Nikea to review.

PC Experience CheckList
I. Initial Contact: important to gain trust and rapport at the beginning of appointment:

1. Shake hands/smile – in a private office
2. Ask permission to record
3. Small talk to get to know the child- parents

II. Contract:
Parent 1. Obtain chief concerns for appointment. ( Why they are here.)

Child 2. Establish belief system attitude and motivation for parent.

3. Ask child also what their goal for the appointment is.
4. Establish what motivates this child.
5. Mirror back and clarify appointment focus for both parent and child.

III. Brushing IV. Flossing
1. Why brush, how often 1. Establish routine and technique ( Flossman vs.fingers)
2. Brush before came in( if not brush) a. Any need to help?
3. Stain, look at how well brushed b. Parent supervision
4. Try again with ideas 2. Why floss?
a. parental help? 3. Establish time and habit to tie flossing into.
b. power vs manual 4. Tie flossing into contract ( reinforce goal)
c. pattern Comments:___________________________________
5. Tie brushing into contract (reinforce goal)

V. Fluoride: Using now?
1. Why we use fluoride. What its function is and how it can benefit us.
2. Discuss topical fluoride – age, spitting ability
3. Discuss systemic fluoride – age, home, location ( city vs. home well water)
4. Discuss supplementation where needed.
5. Establish routine and parent supervision
6. Tie in fluoride with contract (goal) of the appointment.

VI. Nutrition- low sugar now?
1. Establish idea of eating habits
2. Sugar intake- level( what kind, candy, soda, juice, etc)
3. Relationship of sugar with sugar bugs and decay process.
4. Discuss good foods and bad foods for teeth.
5. Diet suggestions- include child participation.
VII. Summary:
1. Restate contract and affirm with parent and child that appointment goal (contract) was
2. Summary of what they are doing right.
3. Summary of behavior changes that was covered in appointment ( limit 3 max)
4. Ask for any questions