Brushing up on looking after our littlest patients: A guide for general practice

Treating children in the dental chair can be an incredibly rewarding and enjoyable experience for clinicians. With the right approach dentists can learn to love treating children because they are resilient, full of potential, and often hilariously honest and fun. You can build confidence in an entire family by successfully treating just one child. Treating children in the dental chair extends beyond clinical skills – it requires empathy, patience, and an understanding of child psychology. As dental professionals, we know that a child’s early experiences at the dentist can shape their attitude toward oral health for life. Yet, many practitioners still find it daunting and may lack confidence in creating a positive and fear-free environment for young patients.

Informed consent and autonomy: More than a signature  

Valid informed consent is paramount before providing any dental treatment to children. This means the person giving consent must fully understand the nature, risks, benefits, and alternatives of the proposed treatment, including the alternative of no treatment if this is a feasible option, and agrees to it voluntarily. In children, consent is more nuanced. In most cases, a parent or legal guardian provides consent for a child’s treatment. Either parent can typically provide consent, unless there are court orders in place limiting this right. However, some children, if deemed mature minors (or ‘Gillick competent’), may be able to consent for themselves if they demonstrate adequate maturity and understanding. While those under 18 years require an assessment of capacity to consent, it is generally accepted that those aged 16 or older do have the capacity to consent. In some jurisdictions, laws allow for those 14 years and over (NSW) and 16 years and over (SA, TAS) to consent to their own treatment. It is important to check with your indemnifier or jurisdiction for clarification, and to understand that some Gillick competent minors can both agree to, and refuse treatment. 

Child abuse and neglect  

Dentists are in a unique position to identify signs of abuse or neglect. Behavioural indicators, unexplained injuries to the face or mouth, repeated missed appointments, or unusual behaviour from parents can be red flags. The dental team has an ethical and moral obligation to report suspected cases of child abuse and neglect to Child Safety Services. It is important that the dental team are able to recognise signs of maltreatment and document observations factually. 
 

Legal obligations vary depending on jurisdiction, with dentist in the ACT, NSW, NT, SA and TAS being subject to mandatory reporting. QLD and WA are not subject to mandatory reporting. VIC requires that only cases of sexual abuse must be reported but any adult.

Know who you’re up against  

Anxious children 

The dental clinic is often a new or infrequent environment for children, full of unfamiliar sights, sounds, and expectations. We should assume some level of anxiety in children attending. Fear may occur due to perceived lack of control or potential for pain, especially when a child is aware of a dental problem or has had a negative healthcare experience in the past. Importantly, not all fearful children exhibit disruptive behaviour, and not all uncooperative children are fearful. Thoughtful behaviour guidance, which we will discuss below, can aid to reduce fear and apprehension in children attending the dental clinic and improve cooperation.

Developmental stages 

Different developmental stages require different strategies: 

• Toddlers (1-3 years old): Keep visits short, use a knee-to-knee approach with parents (you and the parent will sit knee to knee, and the parent then leans the child backwards into your lap for examination), and focus on familiarisation with the environment. 

• Preschoolers (3-5 years old): Use playful language, keep explanations simple, and positively reinforce good behaviour with rewards. 

• School-aged children (6-12 years old): Give them a sense of responsibility by explaining the importance of oral hygiene, show them how they can improve and help them strategize ways to improve their oral hygiene. 

Partner up with the parents  

Parents can be a huge asset, or a massive liability. Challenges with parents are typically overinvolvement, transfer of anxiety and/or lack of oral hygiene knowledge. It is important to discuss the treatment required for their child, and the expectations of them and their child, as part of the informed consent process. During this time, it is a great idea to have your dental assistant distract the patient so that you can have an uninterrupted discussion with the parent and reduce any potential anxiety in the child that could be caused by listening. Discuss their child’s behaviour and set clear boundaries about their role during the visit, whilst also reassuring them. You should elaborate on the fact that children can perceive sensations differently, for example you can explain to the parent that, “it is often difficult for kids to differentiate pressure from pain, and that there may be a little bit of a reaction to the pressure from instruments. If that reaction doesn’t feel comfortable to you then please stop me”. Some children do better with a parent nearby, while others might respond better to one-on-one interaction with the dental team.

Manage the environment and patient 

Create a child-friendly environment 

Looks do matter! A bright, welcoming dental office with warm, friendly reception staff can put young ones at ease.

Consider including:

• Playful wall pictures and a ceiling-mounted TV. 

• Kid-friendly music. 

• Sensory and fidget toys. 

• Ceiling stickers and posters. 

• Light projectors.

Children can often have aversion to taste, texture, foaming and smell of dental products so where possible have child-friendly flavours and choices to reduce sensory discomfort and promote autonomy and control.

Communicate in language that is relatable  

Use simple, positive, and imaginative language. For example: 

• "Tooth tickler" instead of "drill". 

• "Sleepy juice" instead of "injection" or “needle”. 

• "Princess tooth" or "robot tooth" for stainless steel crowns. 

• Avoid words like “hurt” “pain” or “needle”; use “tickle”, “push,” “brush,” or “cold” instead.

• “Disco light” instead of “curing light”. 

Use the “tell-show-do” method to build trust and confidence  

This is a generations-old method to build confidence: 

• Tell the child what you are going to do in simple language. 

• Show them using a model or their finger e.g. paint a smiley face on their fingernail with a micro brush or flowable and show them the curing light.

• Do the procedure whilst keeping them involved and informed. Be sure to give child friendly measurements of time left (e.g. ask them to count to ten in their head) and give breaks where possible. 

Allowing children to take home some instruments e.g. micro-brushes or a nitrous oxide mask to practice at home with a parent can improve confidence. 

Add distraction techniques to your armamentarium 

Distraction is a powerful tool for managing children when they are likely to experience some discomfort, unusual sensations or tastes. Try: 

• Counting games e.g. count the number of stickers on the roof. 

• Drawing shapes with feet/hands. 

• Storytelling.

• Asking questions about favourite things e.g. favourite ice cream flavour.

• Letting the child watch TV or wear headphones. 

• Having sensory or fidget toys to hold/play with.

Be patient and reward cooperation  

Praise children regularly throughout appointments. Stickers and a prize box are a fantastic tangible way to celebrate cooperation. Be patient with fearful or defiant children and commend even small wins with rewards to build confidence. Keep your demeanour calm throughout appointments to minimise tension and model confidence for the child.

Educate through play 

When children feel in control and involved, their anxiety and apprehension often melts away. Turning education into a game can be particularly useful. Try:

• Glove balloons or balloon animals to break the ice initially.

• Pretend play with models, mirrors and brushes.

• Brushing the teeth on a toy. 

• Counting their teeth and fingers and comparing it to an animal of their choosing.

Sedation in general practice  

This has a place in the treatment of all anxious patients, and children are no exception.

• Inhalation sedation (Happy Gas)

• Nitrous oxide gas + oxygen via nasal mask 

• Safe, reversible, and fast-acting 

• Keeps child awake and cooperative. Best for mild to moderate anxiety 

Remember, however, that inhalation sedation does have some limitations and is not suitable for very young children or patients with nasal obstruction. Also, its use requires training of both clinician and staff.

Refer when appropriate  

Children are considered a vulnerable population, and as such the standard of care owed to them may be higher. If disruptive behaviour is likely to impair your ability to effectively and safely perform your task, then referral for general anaesthetic is the best option if the parents’ consent.

Reflect and realign  

Take a moment to reflect after each paediatric appointment. What worked well? What could have gone better? Discuss appointments with your dental assistant to gain other insights. Using this information, you can adjust your approach over time to grow and improve patient care. Remember to celebrate your wins and learn from your losses. 

Maintaining efficiency in a busy practice 

Balancing the needs of young patients while running a smooth dental practice can be challenging. Uncooperative children can lead to longer appointments, delays, and frustration for both staff and other patients. Some time management solutions include allocating specific time slots for paediatric patients (morning appointments can be better), training staff in child behaviour management to improve efficiency, and having a designated paediatric surgery with a child-friendly atmosphere and all the necessary equipment set up. This allows for quick and efficient workflow to minimise chair time.

References  

American Academy of Pediatric Dentistry. Behavior guidance for the pediatric dental patient. The Reference Manual of Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry; 2024:358-78. 

Royal Australian College of General Practitioners. Children and consent for medical treatment. Royal Australian College of General Practitioners. August 8 2018. Accessed May 5 2025. https://www1.racgp.org.au/newsgp/professional/what-is-too-young-children-and-consent-for-medical