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885: Pediatric Dentistry for the General Practitioner – Dr. Carla Cohn

Working with kids — and their parents — can be a nightmare. But it doesn't have to be! In this episode of Clinical Edge Fridays, ACT shares their Master Class with Dr. Carla Cohn, founder of Lit Smile Academy. She shares her proven techniques and strategies so you can manage the most difficult cases and effectively perform treatment. Start early, and turn difficult patients into easier, lifelong patients! To stop dreading and start enjoying the kids who come to your practice, listen to Episode 885 of The Best Practices Show!

Learn More About Dr. Cohn:

Learn More About ACT Dental:

More Helpful Links for a Better Practice & a Better Life:

Episode Resources:

Main Takeaways:

  • Give yourself a time buffer when working with challenging children.
  • Not all children are the same. Do a behavior risk assessment analysis.
  • Don't take kids for granted. They are the key to a thriving adult practice.
  • Ask questions and listen to assess a child’s anxiety level and coping ability.
  • Know in advance whether you're working with a “dandelion” or “orchid” child.
  • Learn to think outside the box with coping strategies for challenging children.
  • Start behavior management early so difficult patients can become easy patients.
  • Establishing a dental home as early as possible is part of behavior management.
  • Fear is both objective and subjective. It can be passed on from parents and others.
  • Understand the material choices that are appropriate for each child and their needs.
  • Use age-appropriate language to explain your dental tools and how they will be used.
  • Don't disregard children’s fears and reactions to pain. Address them and offer choices.
  • Tell, show, and do. Children should know what will happen in advance, not right before.
  • Manage expectations by communicating properly. Don't just talk at parents and children.

Quotes:

“Kids really are the life of our practice, and you hold that as general practitioners, literally, in your hand. If you don't have kids in your practice, you're not keeping the kids in your practice, you're not growing your practice in order to be able to have a thriving adult practice as well. So, the kids come into your practice. You need to know what to do for them, how to do it, and how to treat them well. It doesn't mean that every single kid that comes into your practice you're going to be able to treat, because there are kids that are going to need to be referred out to a specialist or somebody that has the expertise in that pediatric dentistry in certain situations that you don't have. But the vast majority of the kids that come into your practice, you should be able to keep in your practice and to treat them well.” (4:50—5:44) -Dr. Cohn

“When we have children in our practice, we are dealing with a triangle. That triangle is the parent or caregiver, the child, and your dental team. So, although we're treating the child as our patient, we are looking to the parent and the caregiver for consent, for their chief complaints, and for their direction. So, it becomes a triangle that we as a dental team manage in our practice for that child and for that parent, and it can be a bit of a juggling act. It can be challenging at times when we have to manage a child and parent or caregiver. When we put it all together, we put it all together with materials and techniques. The profession that we have is one that is really based all upon equipment and materials and technique. None of what we do in our practice, restorative-wise, even prevention-wise, can be done without having proper materials and knowing how to use them. So, that's really at the base of what it is that we do, is to have great materials, know how to use them, know what their properties are, great techniques and procedures, and know how to do them.” (6:55—8:25) -Dr. Cohn

“When we bring a kid into the practice, that kid can be challenging. And it's not just the kid that can be challenging — a parent can be challenging as well. So, we've got the kids, they come into the practice, and they're all cute and cuddly. Sometimes, they get in there looking that way, and we add a little bit of light, water, and our dental chair, and then they turn into something that can quickly become a challenge, behavior wise, to manage.” (8:27— 8:58) -Dr. Cohn

“It’s not just the kids that can be challenging in our practice, but parents that can be challenging in our practice as well. There are entire books and webinars and seminars written and done on challenging parents and the different types of challenging parents, whether that parent has got their own attitude, or they are overprotective of their child — a helicopter parent — somebody that's really in the best interest for their child but they come across in a way that is maybe not so nice for us, and aggressive, and makes our lives difficult as well because it gets in the way of the child having proper treatment.” (9:00—9:45) -Dr. Cohn

“When we see kids in our practice, they're immature. Sometimes, we see adults in our practice that are immature as well, but that's a whole other story. But really, the kids are immature by the fact that they're young. I talk about the use of the word a lot, pre-cooperative. Maybe the word premature is really a more reasonable word here to use because we assume that they're going to grow and become mature and cooperative people. That's not always the case. But [G. V. Black] writes that their nervous system, their power of reasoning, their self-control, aren't developed. So, we have all of those difficulties that belong to that period of life when we have the kids in our practice.” (13:38—14:26) -Dr. Cohn

“Not all five-year-olds are created the same. They're not all created equally. We have some five-year-olds that can come into our practice and they're going to be that golden patient who is going to do what we need them to do to get the job done. Then, we have the other five-year-olds that are not. I pick five-year-olds, and I use that very frequently throughout my presentations and my teaching because that's usually the average age when kids come into our practice, and you feel comfortable as a general practitioner getting done what needs to be done. By no means is it across the board that we have every five-year-old being the same and created equally.” (18:02—18:50) -Dr. Cohn

“Many times, when we start with our kids in our practice at a very early age — and standard of care to see our kids is within six months of the eruption of the first tooth. So, when we see kids in our practice that are slow to warm, when we start with them that early in our practice, we are training them to be a great dental patient. The challenge is to turn those difficult patients into easy patients, and the thing that makes that so much easier for us as a dental team is to start when they're early in our practice.” (22:26—23:07) -Dr. Cohn

“Eighty percent of our kids are dandelions. They're easy to treat, they're going to grow, and they're going to flourish in any environment. Essentially, they're unaffected by the environment. So, that dandelion kid is the kid that's easy to treat. We can do that mandibular block, we can do that restorative, and we can do what it is that we need to do to get that ideal job done. Then, we have the orchid children. Orchid children are affected by their environment. They have to have a certain environment that is going to allow them to thrive, and they're very sensitive to any type of changes. So, the orchids in our practice are especially susceptible to the environment. They can have a profoundly negative response to adversity . . . So, we have those dandelion kids, and we have those orchid kids. Not surprisingly, the dandelion children have dandelion parents, and the orchid children have orchid parents. They become the same type of child that is sometimes challenging to take care of. The parent is sometimes challenging as well.” (24:37—25:59) -Dr. Cohn

“Orchid kids, you can tell when they come in because the parent reports that, ‘Ugh, I can't cut their fingernails. It's difficult to brush their teeth. They don't like it. When they go for a haircut, it's like the world has ended.’ So, you look at that kid, and you know that that kid is also going to be challenging in our chair to get done what it is that we need to get done. So, to know ahead of time that you've got an orchid child or you've got a dandelion child is going to make it so that you can do your treatment planning . . . knowing that I can do a procedure that is more technique-sensitive for this child, and I'm going to be able to isolate, and I'm going to be able to anesthetize this child.” (25:59—26:51) -Dr. Cohn

“Inside that category of orchid kids are our patients that have sensory processing challenges. So, the umbrella of children that have actual diagnoses of sensory processing challenges — the kids that are medically compromised because they have these challenges — these are all of the kids in our practices that have autism, a spectrum disorder, ADHD, all of these challenges. These kids get into the category of our orchid kids because they are highly sensitive because of their medical challenges. So, the way that we treat our orchid kids, regardless of whether this is a child that is simply pre-cooperative, premature, a sensitive child, or an actual diagnosed sensory processing challenged child, is really all the same. The techniques that we use are very similar for all of these kids, regardless of where this challenge comes from for our challenging kids.” (26:55—28:04) -Dr. Cohn

“You have the unique ability to have a captive audience where you can grow that patient that you need to have in your practice to be able to deliver effective dental care. Part of that is the comfort in the dental office, the comfort in the dental home. So, we want to have that kid early in our practice. That's not always the case. That's not always the ability that we have — to have that kid in our dental practice. But we can work with that later, after that kid has come into our practice at a later age, a later stage, to bring that child into comfort. It's a little more difficult, but it's not impossible to do.” (29:47—30:33) -Dr. Cohn

“We have somebody that comes into our practice in pain — and you know that from your adult patients as well — that is an indicator of how things are going to go. You have a kid that's in pain, you have an adult that's in pain, and your local anesthetic is not going to work as well. They're already anxious. It's already hurting. You're going to bring them into a situation where it's not going to be great, regardless of how great of a dentist and practitioner you are. So, the kid that comes in that looks like this, and it's like, ‘Now, what am I going to do? How am I going to manage this child for pain? How am I going to manage this child for behavior?’ It is very different than the kid that looks like this where we've got a little incipiency with so many options that we can treat them pain-free. So, it makes a great deal of difference whether they've come to you with pain or without pain.” (31:44—32:46) -Dr. Cohn

“I spoke of our kids that are behaviorally challenged due to their diagnosis, medically, for the autism spectrums, et cetera. But then, we have other kids that are medically compromised because they have developmental delays. So, here I'm talking about the developmental delay in their medical realm. So, these are also kids that are particularly challenging to us in the chair because they do require that same amount of delicate — if we want to use that term — care where we're going more slowly, where we're taking more time to explain, where we are looking at stepwise treatment, desensitization, and bringing them into our practice very slowly so that we can get the job done.” (32:49—33:49) -Dr. Cohn

“Language delays are barriers. I'm talking here about the kid that comes to us as somebody that is not necessarily new to our respective countries and doesn't have a grasp of English as their first language, or maybe they have no grasp of English at all yet. But certainly, those kids that come to us as new to our country where English was not their language and we can't communicate with them in their language, that's a concern for us to deliver care.” (33:50—34:26) -Dr. Cohn

“We have kids that are in families where they are brought up with their first language as the language of their family or their culture, and they don't speak English until they come to school. So, when we have that language delay or we have a barrier, regardless of how it comes to us, that's a concern because we use part of our behavior management for our kids by using — and I don't love that term, but it gets the point across — child-friendly language to our patient. So, for example, I'm going to talk about the local anesthetic in a syringe as “sleepy juice”. I'm going to talk about the handpiece as a “toothbrush”. When I can't convey that language to my child and I'm relying on the parent to translate it into whatever language it is that they are speaking, I have now lost control over that patient and the way that I'm communicating to them. A huge part of what we do for our behavior management strategies is with language and how we are getting our point across to the child. If that's taken away from me, then I also have a tool that's taken away from me.” (34:52—36:21) -Dr. Cohn

“We've got lots of kids that come into our practice with social insecurity. This is a super broad term that I'm using here for a lot of situations. So, the kid comes into our practice and they're not in a safe home environment, whether that kid is in an abusive home, whether they don't know whether they're going to have the next meal, or whether they're fearful of whatever adult has got control over them, they're in a bad situation. Or they're in foster care, or they’ve been removed. Whatever the situation is, when a child has experienced social insecurity, they become very fearful of anything that's surrounding them, for good reason. So, when they come into our offices at the beginning — and this is one of the things where we have a very unique opportunity to help patients and children when we've had that child that's got that social insecurity, and we have that opportunity to see them frequently over a short period of time, to be able to gain some trust and to be able to be that figure for that person that is going to give them some sense of security and some sense of safety.” (36:22—37:44) -Dr. Cohn

“Typically, if you're in a situation as a child where you're in a socially insecure situation, your teeth are neglected, your oral health is neglected, and you wind up in a dentist's chair with a lot of work that needs to be done. So, I have had the opportunity where I have been able to see these kids over and over again, week after week for dental treatment, and to be able to give them, not just for the sense of satisfaction of knowing that you've been that person to someone where they could feel comfortable, but to give that person some hope for their future in other ways. So, don't dismiss those kids that are in situations with social insecurity.” (37:52—38:38) -Dr. Cohn

“Parental anxiety is a huge one. I talked about parents that are challenging. And when I spoke of parents that are challenging ten minutes ago, what I was getting at was that parent that comes in that is the helicopter parent that is not intentionally always trying to make our life difficult. They want to make their child's life better, and that's why they behave in the way that they do, many times. But we have the parent that comes into our practice that is anxious themselves. So, they are an anxious dental patient, and they have passed that anxiety on to their child. So, nine times out of ten — and I want to say ten times out of ten — when you have an adult in your practice, whether that's that anxious parent or whether that parent is the patient themselves, and you look back at the root of their anxiety, no pun intended, the root of their anxiety comes from an experience when they were a child. Very few adults become anxious parents as adults. They're anxious as patients because of something that happened to them as a child. So, even more reason for us to be managing that child properly at a young age so that they can be that calm parent.” (38:40—40:13) -Dr. Cohn

“That parent that is anxious, that's the parent that it becomes more critical to communicate with them properly, but also much more critical to remove them as the parent that is bringing that child to the appointment and remove them as the parent that's in the operatory with your child. Because try as they may, and I've had this happen so many times, knowing that they're anxious, to not give that anxiety to their child — the kids know. They can feel it, and they know. The parent doesn't need to say anything. They can feel that anxiety, and we don't want that to be carried on to their child.” (40:18—41:03) -Dr. Cohn

“Fear and bad experiences can be objective and it can be subjective. This goes back to the principle that, is that objective that that child has, which now we lump into a white coat syndrome because it can be a fear from a previous dental experience, or it can be a fear from a previous medical experience. You'll have a kid that comes into your practice, and the mom will say to you, ‘Oh, they're anxious because we were just at the physician. They just had their immunizations.’ They've felt the immunization. And medical doctors — not to throw them under the bus — a lot of medical doctors make no effort to make that injection feel okay. Our whole thing is to make that local anesthetic injection that you don't feel it . . . So, objective fears are produced by direct physical stimulation, something that they felt, seen, heard, smelled, or tasted. So, a kid that's had a previous painful experience, whether it's at the dentist or whether it's their medical doctor, has a similar situation, white coat syndrome. When they get to the dentist, that fear is objective versus subjective.” (42:39—44:09) -Dr. Cohn

“Subjective fear can also come from a sibling or from a friend. They're talking to whoever they have been playing with on the playground, if kids still do that. Or on social media, actually, I think is much more common. And if that friend said, ‘Oh my God, I went to the dentist and it was absolutely horrible. Terrible, terrible, terrible.’ We don't want that subjective fear to be passed on to their child.” (44:25—44:52) -Dr. Cohn

“Causes of dental fear beyond the objective and the subjective is the anticipation of what is going to happen. So, the fear of the pain, the anticipation of the pain. We feel that as adults too. Being a child, though, they often have that feeling denied and disregarded. You'll say to the child, ‘You're not going to feel this injection,’ and then they tell you, and you disregard them. That is very damaging to a child, to disregard their pain . . . We need to really be sure that we are listening to our child and not dismissing their concerns and not dismissing their feelings — their literal feelings. Not the feelings that are in their head and in their heart, but their actual feelings.” (44:54—46:00) -Dr. Cohn

“When we have a child that has dental fear, we need to address it. They also fear their loss of control. So, we offer our child choices. But the choice isn't, ‘Do you want to get this tooth removed today, or not?’ The choices are, ‘Do you want to listen to music while we're doing this? Do you want to watch something on the screen while we're doing this, or not?’” (46:01—46:30) -Dr. Cohn

“Fear of the unknown also is a huge thing for children. And depending upon the developmental age, that information that we're going to give the child on what's going to happen varies. It varies from their developmental age, but also varies depending upon their medical situation. So, I say that because kids that are on certain spectrums, kids that have sensory disorders, for example, a child that has Asperger's typically will do better knowing way in advance what is going to happen when they go to the dental office rather than immediately before. But nine times out of ten, kids need to know what is going to happen just before it's going to happen. So, I will explain. This is our whole premise behind tell, show, and do, where we're going to tell them what we're going to do, we're going to show them what we're going to do, and then we do it. They don't need to have a lot of information ahead of time. Many kids are dwellers on what is going to happen. If they have that information two weeks in advance of the dental appointment, they're going to play it over in their heads two weeks in advance over, and over, and over again.” (46:32—47:53) -Dr. Cohn

“Know what we're going to do and make it age-appropriate. So, considerations prior to treatment are, what can we do to help our child to cope? So, that coping strategy is going to depend upon what the parent is going to be telling us their child is capable of coping with. So, coping strategies, external coping mechanisms, things that we can do while the child is in the chair: this is when we get the kid into the chair and things are maybe not going as we had planned them to go, or maybe you do know these things ahead of time. Kids get in the chair, and they can't stand the overhead light. Or we have a headlight on our glasses, on our loupes. They're sensitive to the light. You give them a pair of sunglasses. All the kids in your office should be wearing sunglasses anyway because that's eye protection. The fact that they're sunglasses and not safety glasses gives them that layer of protection against the sensitivity.” (47:53—49:04) -Dr. Cohn

“Sound sensitivity. Lots of people don't want to hear the sound. You don't want to hear the sound of the suction. You don't want to hear the sound of the drill. We do need to have them hear well enough so that they can hear me, or if it's my assistant that is giving the direction, so that they can hear the direction that we're giving them, so that that sound sensitivity is not based on sound canceling. We do need them to be able to still hear me.” (49:32—50:03) -Dr. Cohn

“Taste sensitivities. Lots of kids come in and they have taste sensitivities. They can't stand the taste of whatever. I mean, there are lots of things we don't like to taste, like the bond or the silver fluoride. But there are kids that are hypersensitive to taste. There are non-tasters, and then there are super tasters. There are people that are very sensitive to taste. If you are a sensory child, for whatever reason, you can be uber sensitive. So, these are the kids that we start looking to see, what can we do to make their experience better for them? If they're a sensitive kid and we're doing a prophy, I have them bring in their own toothpaste and we mix it with some pumice paste. Or use an unflavored toothpaste. There are unflavored toothpastes out there on the market.” (50:05—50:55) -Dr. Cohn

“Sometimes, [children] don't like the way the gloves taste. Wash your hands. I had a child in my practice, and I knew that he was a very sensitive patient. So, he would come into the practice, I would put my gloves on, and then I would wash my gloves to get whatever residue off of the gloves that was setting him off. Why set them off on something so simple that you can control?” (51:06—51:32) -Dr. Cohn

“We need to look at what the expectations versus the reality are. What are the considerations prior to treatment? What is the parent expecting? What is it that we can deliver? And have these conversations ahead of time.” (52:07—52:21) -Dr. Cohn

“Tell, show, do. That's standard. I learned this in school. I'm pretty sure they're still teaching this in school. We tell them what it is that we're going to do. So, that verbal explanation of the procedure, make it age appropriate to the level the patient can understand. Show them what we're going to do, within reason. I'm not waving my syringe around to patients. Then, do it without deviating from your explanation. So, our tell, show, and do, as I mentioned before, we look at the handpiece. I use the handpiece. I talk about it as a toothbrush. I'm not going to tell them, ‘This is my high-speed drill. It can go for tens of thousands of rotations,’ or whatever it is per moment. My air water, ‘We're going to wash your tooth. This is the tooth washer. This is the tooth dryer.’ Up on the top right of your screen, that's an isolation device. We call it a snorkel. My curing light, I call it my flashlight. The etch is blue shampoo. The rubber dam is a raincoat. The list goes on, and on, and on. Tell, show, and do.” (53:02—54:15) -Dr. Cohn

“Ask, tell, ask. So, this is the part where we don't dismiss the patient's feelings. We don't dismiss their concerns. We ask them, we speak to them, and we communicate to them. We're not communicating with a six-month-old. Not in the same way, obviously. We tell them, we explain that procedure, and then we ask if they understand. So, this is the engagement that we have to have. Ask, tell, ask. Ask that patient, tell that patient, and then ask them. That way, we are communicating properly — not just us talking at them but hearing back from them, assessing their anxiety, calming their fears, and confirming them.” (54:16—55:01) -Dr. Cohn

“Distraction, we use this all the time. This is an easy one. We distract them from what's going to be happening. When I'm injecting them with local anesthetic, I'm not telling them, ‘I'm injecting you with local anesthetic.’ I'm telling them what they're going to feel, but then I'm distracting them with something else. Desensitization. So, how does desensitization work? What does that all mean in the dental office? One of the best tools that we have for desensitization is a dental prophylaxis. And hygiene is an excellent introduction to that patient for their dental experience. They can have something in their mouth that's non-threatening. It's going to expose them gradually through a series of interactions. But desensitization also means starting off with something that is easy, something that they can “win” the appointment for. So, unless we have a patient that's in pain, we can start off with an easy procedure, win that appointment, that sealant, win that preventive resin restoration, rather than going in for an extraction right away. Unless, of course, they're in pain.” (55:03—56:16)

“Don't dismiss a child's poor cooperation for the fact that they are a challenging or an immature patient. Sometimes they are feeling it, and we absolutely must take them very seriously when they say that it's hurting.” (56:49—57:06) -Dr. Cohn

“When you're scheduling the kids that you know are going to be a challenge, those kids are the first thing in the morning. Those kids, you don't give them the option of coming in after school. Because after school, they're tired. We're tired. Nobody is fresh. Nobody is at their best. So, bring these kids in first thing in the morning, and you're going to have better chances of success.” (1:35:53—1:36:17) -Dr. Cohn

Snippets:

0:00 Introduction.

1:08 Dr. Cohn’s background.

3:30 Disclosures. 

4:45 Kids are the life of your practice. 

6:55 The parent/caregiver, child, and dental team triangle. 

8:26 Balancing challenging children, challenging parents, and challenging clinical situations. 

11:12 Behavior guidance and behavior management, explained. 

17:11 Do a behavior risk assessment analysis. 

18:50 Factors for a successful appointment: Patient age. 

20:01 Factors for a successful appointment: Developmental and functional age. 

20:46 Factors for a successful appointment: Temperament styles. 

23:07 Dandelion children and orchid children, explained. 

25:59 Signs of an orchid child.

26:53 Orchid children with sensory processing challenges. 

28:22 Establish a dental home for children as early as possible. 

29:59 Provide comfort in your dental office. 

30:33 Know the amount of treatment that is required. 

31:37 Be mindful of the pain scale. 

32:46 Challenges: Developmental delays. 

33:50 Challenges: Language delays. 

36:22 Challenges: Social insecurity. 

38:40 Challenges: Parental anxiety. 

41:03 Challenges: Previous bad experience. 

42:39 Fear and white coat syndrome, explained. 

44:53 Causes of dental fear and how to address them. 

47:57 Coping mechanisms for various sensitivities. 

52:22 Basic behavior guidance/management. 

53:02 Tell, show, do. 

54:16 Ask, tell, ask. 

55:02 Distraction. 

55:24 Desensitization. 

56:24 Treatment deferral. 

56:45 Local anesthetic. 

58:08 Understand pediatric behavior types. 

59:30 A structured approach to treatment planning. 

1:00:54 Restorations on children do not perform the same way on all children. 

1:02:20 Material choices for intra-coronal restorations for pediatric patients. 

1:08:03 Material choices for extra-coronal restorations for pediatric patients. 

1:09:13 Outliers: Silver fluoride and resin infiltration. 

1:11:16 Material choices for intra-coronal restorations: Clinical examples. 

1:30:18 About Dr. Cohn’s future courses and Lit Smile Academy. 

1:35:21 Q&A: How to manage dandelions and orchids in your schedule. 

1:38:04 Q&A: Dealing with pushback from parents. 

1:39:28 Q&A: Using child-friendly language and the slow speed handpiece. 

Dr. Carla Cohn Bio:

Dr. Carla Cohn is a general dentist devoted solely to the practice of dentistry for children. She maintains a private practice at Kids Sleep Dentistry Winnipeg at Western Surgery Centre in Winnipeg, Canada.

Dr. Cohn has published several articles and hundreds of webinars and live courses. She enjoys teaching all aspects of children's dentistry to the general practitioner and has had the pleasure of doing so both nationally and internationally. She teaches in the clinical undergraduate pediatric program at her alma mater, the University of Manitoba Dr. Gerald Niznick College of Dentistry. She is proud to be an active member of several dental organizations and societies and has served as president of the Manitoba Dental Association. She has been invited as a fellow to Pierre Fauchard Academy and International College of Dentists, and has been recognized as Dentistry Today's Leader in Continuing Education multiple years in a row as well as Top 100 Docs.
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