“You know too much”, was the innocent response from my dentist’s receptionist to the questions I asked my dentist about my own dental treatment. Her words were ringing in my ears for days. Telling readers to get information prior to treatment has always been a major focus of my articles. Yet, his hygienist had already caught me by surprise by doing an “unauthorized” fluoride treatment on my five-year-old. And, without my knowledge, the dentist had previously placed a formocresol-medicated cotton pellet into my tooth between root canal therapy visits. I was making an appointment to re-do a crown that had fallen out one month after it had been cemented. Attempting to increase the chances of success and decrease the possibility of another violation of my natural dental beliefs, I had merely been attempting to share my extensive crown and bridge experience.
For the first time I understood how intimidated patients must feel when trying to extract knowledge that they can understand from a health professional. Although dentists are required by law to explain treatment and receive “informed consent,” these explanations are often too brief or too technical for the layperson to comprehend. After all, how many patients know what an MODBL is. (Incidentally, after our discussion, my dentist did not use formocresol again and became more open to my crown and bridge knowledge).
I was reminded of another incident in which my family and I personally experienced a dentist’s training and philosophy replacing common sense and courtesy. My son, Justin, had four very small cavities. I felt that it would be better to take care of them while they were all still on one surface of the teeth. In the past I would have done the fillings myself, but, because I was retired from the practice of dentistry, we did what most parents would do with in this situation. Even though he was an hour’s drive from Woodstock, we went to a recommended Pedodontist (children’s dentist)
At the first visit, all the proper child introductory techniques were used. We personally prepared him by telling him about the dentist and what was going to happen. After watching videos in the waiting room, Justin, my wife and I were taken into a treatment room. The dental hygienist gave him a ride on the dental chair and showed him the mirror and explorer (tooth counter.) He had his teeth counted and cleaned and he was given a toothbrush and an appropriate toy for good behavior. The dentist came into the room and examined him. We talked about the probable need to use a local anesthetic to numb the teeth for the fillings and another appointment was made. Justin had been a terrific patient. During the ride home, he asked excitedly when he could go back to the dentist. I knew the first visit had been a success.
At the beginning of the second visit, my wife and I were handed a release form that would give the Pedodontist permission to restrain Justin in a papoose. I was not a specialist, but I did treat a lot of children while I was practicing. I never used a papoose. To me, it is like a straitjacket for children and should only be used in difficult situations with difficult children. We were then told that neither one of us would be allowed in the room while he was being treated, even though 1) we were in the room for the initial examination, 2) our son behaved so well, and 3) I was a dentist. As parents, we knew our son would be a better patient if he was not restrained and we were in the room. He was an adopted child who had lived in a crib in a Russian orphanage until he was thirteen months old. In the first week in our home, he jumped out of his crib and was never confined again. He had also been circumcised at eighteen months, ran around the hospital after the surgery was completed, earned the nickname “the mayor” from the nurses and did not skip a beat during his post-operative recovery.
We were flabbergasted. We felt that we had been deceived because we had not been informed of these parameters at the first visit. If we had been told of them, we never would have returned for treatment. He said that he could do more efficient treatment by doing all four fillings in one visit on a “harnessed” patient. He was not even willing to try treating Justin without a papoose or with either one of us in the room. After ten minutes of heated debate, we left the office right before they were about to restrain my hysterical wife in a papoose and throw us out.
A few weeks later, we took Justin to my dentist, a general practitioner with a good reputation for treating children. In four half-hour visits, he was able to do two fillings without, and two fillings with, local anesthetic. In twenty-five years of dentistry, which included treatment of many young children, I had never seen a better child patient. All Justin cared about was making sure that he got his plastic toy.
In defense of the Pedodontist, his education and training prepared him to handle the most difficult children, who are at times, untreatable without their advanced knowledge. He even had his legitimate reasons for routinely using a papoose on young children and not allowing the parents into the room. It is true that it could be unsafe if the child moves too quickly and touches the dentist’s hand or instruments. The children and their parents always appreciate fewer visits and the Pedodontist always appreciates maximum income production per visit.
When I had my general practice in Middletown, NY, I treated a number of children. Some, however, were either just too young or too difficult for me to treat, so I did refer to Pedodontists in my area. In an emergency on a very young child or in situations when young children are very difficult to treat and there is no alternative, the papoose still has a place in dentistry. However, in my opinion, any impatience or laziness on the part of the dentist resulting in the routine use of the papoose to restrain a child based on age, speed of treatment or maximizing income per hour, or even decreasing the number of visits, without any attempt to treat the child unrestricted, is unacceptable in 2010 and even worse can produce a lifetime of dental scars for the child.
However, even if a papoose is ultimately necessary, the parents should be allowed in the room in most circumstances. Dentists were taught that by not allowing any parents into the room, the dentist replaces them as the authority figure. Therefore the child is more likely to listen to the dentist and be better behaved. In my experience, this separation is only acceptable in rare situations where the parents do not want to be in the room or are a detriment to a positive treatment environment. In most cases, parents are an asset. To think otherwise is ludicrous, as long as parents are coached before the visit and follow simple instructions:
- Parents should allow the dentist to treat the child unimpeded.
- If they speak, they should use calm, supportive, soft-spoken, reassuring language.
- They should be encouraged to replace certain trigger words such as “hurt” or “pain” with “discomfort” and “injection” or “shot” with “feel a pinch.”
- Even though the child may move, cry or appear to be uncomfortable, the parents need to trust that the dentist is doing his or her best and allow them to continue.
The philosophy of “love, trust and patience” instead of “time is money” and the holistic belief that you don’t just treat the teeth but the whole human being who is intimately connected to his parents, can result in successful dental experiences for most children. Often a traumatic dental experience, and I have played my part in some; can teach us a lot about ourselves. From these very personal and trying dental visits, I have learned that no matter how much knowledge and expertise you possess, you must still ask questions until you have all the information you need to make an informed decision. You can never know too much.
Addendum: For your information MODBL are the initials for the five surfaces or parts of a tooth. Mesial is the surface facing the front of the mouth, Occlusal is the part you chew on, Distal is the surface facing the back of the throat, Buccal faces the cheek and Lingual faces the tongue. This knowledge is useful because the number of surfaces very often determines the size of a filling and therefore the fee for the treatment.