As I have mentioned in a previous post about the the Community Dental Services (CDS) in London have changed in the past year and GDPs are expected to take on treatment of children according to the Paediatric Commissioning Guidance.
My experience of talking to GDPs as well as the impact on the rejecting of referrals on patients is that some GDPs do not feel confident in managing children or do not see it financially viable to treat them in general practice.
However, prior to working in CDS I didn't have much experience treating children and alongside working in CDS I also work in general practice. I have learnt with practise and patience, that actually treating children can be just as efficient and effective as treating adults! Here are my top tips in managing children:
1. Try!
I can't count the number of referrals I get in CDS where the dentist has not even tried any treatment with the child. In some cases, any attempt may not be possible e.g. children with autism or a severe phobia, but there are so many cases I have treated where initially, the child wouldn't even sit in my dental chair and eventually I have managed extractions and restorations with just local anaesthetic (LA).
Sometimes children surprise you. It can be overwhelming seeing wall to wall caries in a child, but even attempting atraumatic restorative technique (ART) to place restorations can be successful in stabilising a patient to a certain extent. You do not know how a child will react to dental treatment unless you try!
2. Take Radiographs
I have written a
post on tips to take radiographs in children so check it out.
Radiographs are essential in the diagnosis of caries in children as without them, you sometimes do not spot caries until it's cavitated and its much more progressed. Also in interproximal caries, in Ds especially, the pulp horns are so superficial that apical infection is present where you may just think from looking clinically a restoration is needed.
I would recommend bitewings are routinely taken from 6 years old if possible, or where there is suspected caries. Depending on if you have an OPG machine and how diagnostic they are for caries you could consider taking one if a patient doesn't tolerate bitewings. Tolerance of taking bitewings is usually a good indicator of whether they will tolerate dental treatment.
3. Get them in early
The most recent public dental campaign is
Dental Check By One from the
BSPD. It's very important to get children into a dental setting early, hopefully before any problems develop so that preventative messages can be delivered and children are acclimatised to the dental setting.
I always try to encourage parents to book in their babies for dental check-ups when I see them coming in with older siblings or when I see any pregnant women. Emphasise that check-ups are free for children and that even if the dentist doesn't get a proper look in their baby's mouth, that it's important to get them used to coming to see the dentist.
4. Use their Siblings or Parents
If a child is particularly anxious or not cooperating, I try to demonstrate or do tell show do on their parent or sibling.
Often in practice I will have a family booked in with more than one child. If one is scared, I will see another child first to build up their confidence. Demonstrating taking radiographs on their parent or sibling can be useful. If a child also doesn't like me applying fluoride varnish, I will ask the parent to practice painting on the varnish with a dry brush.
5. Prevention, Prevention, Prevention
I cannot emphasise the importance of prevention. Even if you do not do any treatment on the child, please make sure you dedicate time to discuss with them and their parents the cause of decay and how to prevent it.
6. Hall Crowns
See my
previous post with specific tips for using stainless steel crowns in the management of caries in children.
Honestly, Hall crowns will change your practice with children. Children prefer them, often parents do once you explain the evidence behind them. I understand there is an initial cost implication of buying the kit, but in the long term just think of all those GICs or composites that need to replaced after they fall out and the repeated visits. Once you get good at Hall crowns, they are also much quicker to place than a conventional restoration.
7. Child-friendly Language
Although we know to avoid jargon in adults, it's also very important to adapt your language for children. Never talk about injections or needles, but adapt appropriately depending on the age the of child. Some of my favourites are:
LA = Sleepy Juice
Topical = Magic Cream
High Speed = Water Cleaner
Slow Speed = Buzzy Bee
Suction = Hoover
Etch = Shampoo
Excavator = Tiny Spoon
8. Fissure Sealants
I don't understand why more GDPs don't do fissure sealants. They have been shown to be clinically effective and are a simple procedure that can be very useful in acclimatising a child to treatment in a dental chair.
If you are sealing in caries or performing a PRR, it is also a very simple band 2 treatment. Please make sure you have radiographs beforehand to check for caries. Also remember you can also consider placing them on primary teeth as well as adult teeth.
9. Know when to Refer
No matter how much you try, sometimes treating some individuals is not possible with just LA. This is when you should think about referring patients onto your local CDS or hospital where behaviour modification techniques, inhalation sedation or GA could be considered.
Make sure you know your local services and create close links with them as many services how employ shared care. In London all children have to be referred to the CDS who are the gatekeepers to hospital services.
Think about how much treatment is required and the child's age when deciding whether to treat in practice or refer on. If I see a 4 year old who needs 4 teeth out, even with inhalation sedation it's highly likely I will lose compliance throughout the treatment plan and therefore a GA referral is most appropriate. This of course, depends on the patient and also their parent's opinions and preferences.
10. Practise
My last tip is to really encourage you, even if you have barely seen any children, to not shy away from seeing them. The more you treat them and treatment plan them, the more confident you will become!
If you want more support, pair up with a mentor perhaps one of the dentists in your practice, or a local contact in your local CDS to help support you with tips and assist in treatment planning cases.
Ultimately, remember if you can treat children effectively in practice, then you could stop a child from having to experience a GA for their dental treatment!
What tips work for you when treating children? Let me know in the comments below.
