Pedo Rant

[gryffindor]

I have pedo at school this week. Quick glance at the treatment plan and there are class II lesions galore (like 15 of them). Note in chart from the #20 DO done last week says the patient was very nervous during the procedure. Kid drags himself in, 16 years old, promptly declaring "I aint gettin' no fillings today, they said I only gotta come here for a check today." I tell him we have to do a filling unless something really hurts in his mouth. Again "Nuh uh, I don't need fillings." I go over to the faculty and mention that the patient is not interested in listening to me and would be a good nitrous candidate if we were allowed to do that in our Pedo clinics. She says "Oh, he's just being funny, he'll be fine."

Some whimpering during anesthesia, but nothing out of control. Rubber dam clamps #1 & 2 refuse to stay on the tooth. I get a third clamp on there, go after the old amalgam with my high speed, kid throws both hands up and jerks his head away. First I think he's not numb, then I see blood everywhere and I'm thinking I pulped out already. Luckily it was just a gingival cut from the clamp (which also flew off); we get a new clamp, and start again.

Any time I picked up and used the hand piece, the kid whimpered. Everytime I put it down, the whimpers would stop and he'd say it DID NOT hurt. I ask "Why are you crying?" No response. After 10 minutes of the assistant trying to be tough, I get stern with the kid (very unlike me). When I switched to low speed to get the remaning decay out, he refuses to cooperate anymore. Takes me, the assistant, and mom 20 minutes to convince him to let us finish the filling.

Seriously, this teen needed a good yelling to get him to cooperate. And I was ready to do it (I was seething under my mask & loupes), but I was afraid that the teachers would think I was totally inappropriate and the assistants would accuse me of child abuse or something outrageous like that. The only time I've every seen anyone be totally mean and stern was the residents in oral surgery when they get the belligerent patients at the county hospital. At the end of today's appointment, the assistant & I are convinced that this kid needs to go see a resident who can give him nitrous and get his fillings done faster. Of course, the faculty, who has been on the phone and out of the room most of the time, still thinks he can have a third chance at our clinic.

Sure, after a third filling experience like this, I'd bet the patient will not be coming back for the 14 other fillings he needs. See you at the county hospital for an extraction in 10 years.

Just needed to get that off my chest. I've never had to get stern with a patient till today. Anyone else ever go through this? Where you really want to yell at a totally unreasonable kid and set them straight so you can get your work done, but you can't b/c of the authority (teachers, parents) hovering above you? What do you do?

Edit: This was a #19 MOD Amalgam.

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[drPheta]

Hmmm, any interest I had in Pedo is now dwindling.

 

[endotom]

Hey Griffin,

This kid is 16? That's ridiculous. Tell the kid the truth. Tell him he has to cooperate with you or you can't get your job done right. If he doesn't get this done the easy way now, he's going to be in big trouble later. He's going to the dentist and he has a lot of problems. You are trying to help him with his problems. Make him get this. Keep his Mom out of this. Tell him his alternatives are much worse than what you are going to do to fix this mouth. Tell him you have to do it one way or the other. He's trying to control the whole thing. Nip that in the bud and get him to grow up.

endotom

 

[aphistis]

Originally posted by drPheta
Hmmm, any interest I had in Pedo is now dwindling.

16 years old pedo? That's pretty marginal. Give him the grown-up treatment next time, with plenty of palatal injections.

 

[ItsGavinC]

Originally posted by drPheta
Hmmm, any interest I had in Pedo is now dwindling.

In school dental clinics you'll get patients like this from time to time, and it rarely has anything to do with their age.

Don't let this discourage any interest in Pedo or any other specialty, for that matter.

 

[gryffindor]

I think our school accepts Pedo patients till they turn 18.

I had a pedo patient (16 y.o.) once who had a little pedo (1 y.o) of her own at home.

 

[no2thdk999]

Griffin04,

The first thing I would recommend is making sure you have profound anesthesia. You didn't say what tooth it was but #17-32 are notorious for being a little trickier to numb. A way to test the patient is to rev up the drill to max speed and put it on the tooth upside down so that it vibrates the tooth but the bur is facing the opposite direction. If they still complain of it hurting then you need to talk with them about being able to feel "something" (which they will, novocaine is not general anesthesia) and feeling something that is painful. If you couldn't trick them and it only hurts to painfull stimuli, try some alternate or additional anesthesia techniques.

That being said I don't think that was your problem today. Unless he was MR, 16 is old enough to communicate intelligently and not just pout. Sounds like you had a big punk, baby, whiner and please tell him I said so. The main thing that sucks about this is your temporary lack of autonomy. Right now you have to play by the school's rules, that won't last forever. In your office you'll be able to get up and tell Mrs. Whiner "I'm not the right dentist for your son, but I know who is let me give you their number."

I do enjoy winning over the scared pedo patient that maybe had a bad experience somewhere else. That can make a sealant feel like the best dentistry you've done all week!


JMHO
Rob

P.S. I agree with Gavin and can assure you a bad attitude is not limited to patients under 16!

 

[gryffindor]

Edited my original post, forgot the tooth.

It was #19 MOD, and he was numb for sure b/c those weren't whimpers of pain. I didn't have to touch the tooth and the waterworks went off.

 

[nug]

Originally posted by griffin04
I think our school accepts Pedo patients till they turn 18.

I had a pedo patient (16 y.o.) once who had a little pedo (1 y.o) of her own at home.

 

[DrJeff]

Sounds like a good time for you to have gotten stern with him. Sometimes its even "fun" for you to mock patients at that age that are being completely age inappropriate, you'd be suprised at how quickly you can shame an obnoxious male teenager into a compliant patient, especially if you have an early 20 something cute female assistant

Another good way to tell if they're reacting to noise/vibration verses pain while your working is will they open up again for you after they react. If they open again, 9 times out of ten, they're feeling nothing, if they won't open again, break out more anesthesia.

Also, for that age, tell them that the high speed that your holding in THEIR MOUTH has something SHARP that is SPINNING VERY FAST Then they generally get the idea to cut the BS and start acting their age. Sometimes, if the patient is acting like an brat, then you need to act like a bigger, stubborn brat and let them know that it's you thats in charge and that this procedure will be done. If you cut them some slack once, then they'll realize what they need to do to get out of it in the future again.

 

[larryt]

Originally posted by DrJeff
Sometimes, if the patient is acting like an brat, then you need to act like a bigger, stubborn brat and let them know that it's you thats in charge and that this procedure will be done. If you cut them some slack once, then they'll realize what they need to do to get out of it in the future again.

Worked out fine for me with my 4 yrs old patient today. I pretended that I was so angry and asked mom to step out of the clinic so I could deal with him alone. That kid shut his mouth immediately and let me do my work for the next 4 hrs without any move... hehe feel so good.... I wasted nearly 20 min in the beginning to pamper him. By the way, I did reward him a big gooddies bag at the end for his good behavior.

 

[gryffindor]

Thanks everyone for your responses.

Today I had the pleasure of treating the 8-year-old pulpotomy screamer. This week is really turning me sour toward Pedo. However, I think half my problem is I'm not in control of the entire situation. In my efforts to get the kid to stop sobbing, I got stern with her, but still maintained a tone that I cared. The assistant interrupts me and says "You can't talk like that with her!" Great, now the kid realizes I have no real authority and continues to sob. When her mom showed up, the kid really turned the waterworks on and now mom thinks little angel isn't numb - not true b/c I practically dug the explorer into the gingiva and go no response. I had to tell mom to please step away but now mom is giving me ugly glances like I'm the bad guy b/c the faculty is the good guy, what the heck do I know about dentistry?

I didn't think this pedo rant was going to go longer than one episode. Let's see what happens on Friday, the national Give Kids a Smile Day when they're gonna bring the kids in by the busload so we can provide - who knows? I'll find out Friday morning. Of course, I may have another little waiting room angel/dental chair devil tomorrow, I may just snap and walk out if that happens.

 

[aphistis]

You might mention to the assistant (and maybe your clinic director) that that kind of stuff won't fly at all once she's out of the school. Probably won't do anything, but it can't hurt.

 

[DrRob]

Is larryt practicing without a license again?

 

[DrJeff]

Originally posted by griffin04
Thanks everyone for your responses.

Today I had the pleasure of treating the 8-year-old pulpotomy screamer. This week is really turning me sour toward Pedo. However, I think half my problem is I'm not in control of the entire situation. In my efforts to get the kid to stop sobbing, I got stern with her, but still maintained a tone that I cared. The assistant interrupts me and says "You can't talk like that with her!" Great, now the kid realizes I have no real authority and continues to sob.

Remember the dental school assistant is the all knowing supreme authority about everything dental related. Not!!!!

When her mom showed up, the kid really turned the waterworks on and now mom thinks little angel isn't numb - not true b/c I practically dug the explorer into the gingiva and go no response. I had to tell mom to please step away but now mom is giving me ugly glances like I'm the bad guy b/c the faculty is the good guy, what the heck do I know about dentistry?

Next time a know it all Mom shows up thinking your torturing her little angel whom she likely believes has all those cavities do to "soft teeth", give her the origin of caries and diet lecture, and you'll cut Mom back down to size

Let's see what happens on Friday, the national Give Kids a Smile Day when they're gonna bring the kids in by the busload so we can provide - who knows? I'll find out Friday morning. Of course, I may have another little waiting room angel/dental chair devil tomorrow, I may just snap and walk out if that happens.

I'm in the same boat, me, my partner and 2 of our hygenists are turning the office over for the afternoon for the "pedo patrol" (we do the same thing every 6 to 8 weeks for all aged welfare patients in my area, so we have a little bit of practice at what we call "mass casualty dentistry". Nonetheless, come 4:30 PM or so when the last of the GKAS kids have left the office, its time to fire up the grill, throw on a beef tenderloin and grab a few(potentailly ALOT of the kids were REAL crazy) Bud Lights and have a staff party Afterall it will have been an entire week since we had the staf out bar hopping in Boston at Yankee Dental

 

[DcS]

We got the ball rolling today for the Give Kids a Smile program by going out to daycares and doing screenings/duraphat. Friday we will have a ton of kids come up to school. It should be fun. Today I had my 1st experiences with kids in the 1-2 year range. Just about every one of them clamped down their little lips when we came near It was a lot of fun.

 

[no2thdk999]

Griffin04, I would hate to see your taste for pedo ruined before you even get out of the gate. Treating kids can be fun, rewarding, and lucritive. Like I said earlier I see a LOT of Medicaid kids and probably only refer 2 or 3 every month. Of the 2 or 3 I have to refer probably 2 are due to the kid being under 2 or 3 years old and only 1 that won't "behave" for treatment. And I don't try real hard to win them over, if your basic tell-show-do, a painless shot, and a LOT of praise and attaboys doesn't work they can waste time at another doc's office.

There is not a lot of good CE for treating kids. I have really enjoyed Marvin Berman's lectures and his techniques have worked well for me. He is a pedo in Chicago and treats all kids regardless of age or attitude (with exception to MR) without N2O-02 or sedatives. I have seen tapes of him take 7 year old demons that I thought had an acute ketamine deficiency (one kid told him to F*** off!) and turn them into well behaved if not happy patients. I would recommend seeing him if he comes to your neck of the woods.

Here's my take on your latest experience, take it for what it's worth (less than you paid). Pulpal anesthesia is the last thing to come and the first to go. You can have profoundly numb gingiva and still have sensation to pulpal stimulation, especially if the pulp was hyperemic/inflammed from needing a pulpotomy, and especially if things drag along a the warp speed of dental school. You have to figure out if the kid's in pain. If they are you have to fix it. If they aren't and they're just responding to the vibration or are scared or whatever then try to explain that to them. Some kids just have a compensatory cry. They're not hurting, they just cope with the stress of all the stuff that goes with being at the dentist by sobbing. As long as they'll stay still and open (they won't if it hurts) just plug away, they'll tire out or you'll finish one. If mom is standing there while Junior is screaming I'll look her in the eye and say "I promise I take your child's pain control very seriously. I am confident he is not crying because it is painful. Sometimes kids react to the stress of new circumstances and surroundings (like bright lights and a numb lip) with crying. If you're not comfortable with this we can send her to a doc that can sedate her."

You are hamstrung in your clinic now because you can't really be the authority figure and it sounds like you get assigned the patient for that period so you can't really build a relationship. So it might be the first time you meet the kid and 3 minutes later you're sticking 'em with a needle and putting on the rubber dam. It also makes all the difference to have an assistant that is good with kids.

Here are some of what works for me. Talk to them like a kid, ask about their siblings, pets, favorite games. Keep their attention with something other than what's going on. If they do anything good praise the heck out of them even if it's "Jimmy you did a real good job of not biting me anymore after I put the bite block in." I can always find something positive they did. Give a pain free shot and then show them the needle and tell them what a good job getting the shot they did (even though you did all the work). Basic tell show do, for everything. Don't try to do 4 pulp/SSC's the first time you meet them. I try to do nothing the first time that might remotely be scarry or hurt, a bad first impression is hard to overcome. Don't use up their attention span, if it takes you an hour to do one quadrant see them four times about a week apart.

Don't give up!

JMHO
Rob

 

[larryt]

Originally posted by DrRob
Is larryt practicing without a license again?

Nah... It was for my dental hygiene program. I did a heavy class 3 calculus cleaning today and my instructor didn't let me request for the local anethestic or use Calvitron. I was so pissed. I had to let my patient go early after finishing 2 quads. Whatta bloody procedures using scalers and curets. Hope she'll come back next week for me to finish up or else I would lose all the credit. Not a good day for me at all today also.