Jon Benton is a 4th Year dental student at Manchester. 'My article is designed to give advice and some helpful tips for the first time a young dentist begins treating their new paediatric patients with special requirements, based on my own experience. The purpose of this article is to share my knowledge by giving a helping hand on how to deal with patients with autism, ADHD and other mental health disorders.'
Welcoming your patient
"Hello there, (patient name)! My name is Jon and I'm a 4th year dental student here at Manchester. I will be the dentist treating you today!" This is how I like to greet all my patients, regardless of their ailments or background. Putting your patient at ease and allowing them to trust you is one of the most important aspects of patient-dentist relations. It can be achieved by radiating enthusiasm, confidence, and having a bright smile on your face. It is also vital before the patient enters the room to know their full name, age, and anything relevant from their medical history. If you know this, then you can engage with them and, most likely, begin your discussion and examination without having to turn your back to them. I also highly recommend retrieving them from the waiting room yourself, rather than having your nurse do it for you (at least on their first visit).
My Experience on a whole
It is imperative to say this from the beginning, for yourself and the patients wellbeing, if you do not feel completely confident when the time comes to treating a patient with special requirements, it is best to watch your tutor treat them and afterwards go through how they methodically engaged and dealt with the situations at hand. I can openly say that it is what I did during my first few encounters with patients.
On that note, my experiences with patients with special requirements have been from the last year spent in our Outreach projects paediatric clinic. In this particular clinic we provide treatments for young children and patients with mental health disorders. My own experience has been guided and nourished by my tutor, a fantastic paediatric dentist who has years of experience in this field and has allowed me to learn a considerate amount on the job. I have currently treated over ten patients with a range of disorders such as; ADHD, autism, Marfan's syndrome, or other severe cases of mental health disabilities.
Patients with Autism or ADHD
These are both very common conditions, with 1% of the UK population showing signs of autism and 2-5% of school-aged children being affected by ADHD. Patients with autism may have difficulty understanding the emotions of others and expressing their own. They may also struggle to verbally communicate and have difficulty showing empathy or coping with unfamiliar situations. Children with ADHD may present with hyperactivity, inattentiveness, and poor impulse control. The adverse characteristics of both conditions are exacerbated by stress. This is why it is crucial to work efficiently, effectively, and in a non-threatening manner to ensure full cooperation.
Techniques for Managing Anxiety and Stress
Confident, friendly and non-technical communication is key to relieving anxiety in any patient. Technical jargon will only confuse and worry your patient, so explain procedures to them in a manner they will understand. Giving the patient perceived control by the use of stop signals can put them at ease.
A tell-show-do format to treatment can be accomplished by explaining the procedure using colloquial terms, showing the patient how each of the less ominous tools work (e.g. mirror, BPE probe, etc...), and then performing the described treatment. Distraction techniques can be useful in younger patients and are employed by keeping constant verbal communication regarding anything non-dental throughout the procedure. Modelling good behaviour before treatment is a convenient way to show the child what is expected of them during a procedure.
Throughout treatment, positive reinforcement is an essential tool to ensure your patient understands that their good behaviour is appreciated.
An Example
One of the greatest experiences I've had so far in my dental career has been extracting a lower deciduous second molar for an 8-year-old boy with autism and ADHD. There were three things that made this process incredibly rewarding, they were; that he didn't feel any pain throughout, he didn't see the LA syringe at any point, and, most importantly, that he genuinely enjoyed the whole procedure.
I'll now explain some of the techniques that can be employed for a painless extraction on a child: The patient should be greeted warmly and allowed to voice any concerns. Secondly, explain the procedure in a light-hearted manner ("We're going to be putting your hurting tooth to sleep and wiggling it out for you today"). I explain the procedure by wiggling their shoulders in the same way I'll be loosening the tooth (3 motions; back and forth, followed by one second rest). Locate the tooth you're working on, dry the mucosa of the planned injection site, and apply topical anaesthetic (e.g. benzocaine/lidocaine) for 1-2 minutes. Tell the patient that this sleepy gel will put their tooth to sleep.
Now for the injection; tell them that you're now going to wash the sleepy gel (topical) away now. Ensure that the mucosa is still dry, fully taut, and that the needle is bevelled towards bone. It is crucial at this point that the patient doesn't see the syringe, as this can panic them. Very slowly apply the LA (I would always recommend articaine 4% with a short needle for infiltrations) buccally first. Wait for 30 seconds to one minute and then administer it with the inter-papillary technique, until the papillary tissues blanch. Follow this with a palatal/ lingual infiltration close to the tooth. After two minutes the patient should be totally numb in that area (check this with a sharp probe down the gingival attachment of the tooth).
When using the forceps, a three motion movement back and forth is a reliable way for the child to feel comfortable with what you're doing. Once the tooth is extracted, try to remove the tooth without the child seeing it and aspirate any excess blood from around the socket to prevent the child tasting it. Finally, give the post-operative instructions, as well as a lot of praise and stickers!
This same technique led to another two painless extractions for a 14 year old with ADHD and autism.
To conclude, I have to say that treating children with special requirements has been one of the most fantastically rewarding experiences that I've had the pleasure to be a part of. It is a brilliant and rare feeling to instil happiness in a child when they visit the dentist; one that I would highly recommend!
Jon Benton
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