Winning Over the Pediatric Patient: Tips from a Board-Certified Expert

And every time I see a kiddo, push them a little outside their comfort zone, because that gives them the mindset of, hey, this was hard, this was a little scary, maybe it didn't feel good, but I got through it, and look at that, I'm a stronger person for it. And that's a huge psychological boost. Welcome to the Phil Klein Dental Podcast. One of the most rewarding and sometimes most challenging aspects of dentistry is managing the pediatric patient. Today we'll be joined by an expert in the field, Dr. Julia Richman, a board-certified pediatric dentist with years of clinical experience and passion for helping both kids and clinicians feel more confident in the operatory. Together we'll explore strategies for reducing anxiety and gaining trust, especially during that crucial first visit. We'll address some common questions. Should parents be in the room? Is nitrous oxide essential? What communication techniques actually work to ease fear and build cooperation? We'll also discuss how to approach those more challenging cases, the children who have struggled to receive treatment in other general practices, and how the right approach can turn things around. When it comes to managing decay, we'll talk about combining the surgical and medical model using tools like silver diamine fluoride alongside traditional rotary instrumentation. to preserve tooth structure while delivering effective care. We'll also talk about the importance of using the right handpiece, one that not only provides the highest level of precision and reliability, but also offers ergonomic benefits, such as improved access for those small, hard-to-reach pediatric mouths. And Dr. Richman will be sharing with us her favorite air-driven handpiece. So if you treat kids in your practice or want to feel more prepared and confident when you decide to do so, you won't want to miss this conversation. conversation with Dr. Julia Richman, a well-respected pediatric dentist. Before we bring in our guest, I do want to say that if you're enjoying these episodes and want to support the show, please follow us on Apple Podcasts or Spotify. You'll be the first to know about our new releases and our entire production team will really appreciate it. Dr. Richman, it's very nice to have you on the show. Thank you. I'm excited to be on. To begin this podcast, I just wanted to ask you what attracted you to pediatric dentistry? Because going by my experience in dental school, which I think was kind of common, it was a tough, tough experience working in the pedo department in, I think it was my third year. I guess maybe, yeah, end of third year of dental school, something like that, or beginning of fourth year where we rotated through the pedo department. I just couldn't imagine doing this all the time because the kids were just very uncooperative. Now, maybe I caught a bad swath of children that were coming in that month or whatever, but it was very difficult to get back there and get the patient to be still, especially for someone who wasn't that skilled at the time, which was a dental student, me. So I thought, okay, when I'm done with this rotation, That's it for working on kids as long as I can. So what actually attracted you to becoming a pediatric dentist? Well, I always like to say that there are a couple of different types of clinicians. There are ones that just absolutely love and adore working with kids. And there are the other ones that say, I'm going to run as fast and as far as I can the other way. A couple of things that I really enjoy about working with kids. One is that I get to... have a lot of fun. I get to use creativity. I get to, you know, make up funny names for things. And I'm a little, you know, I get bored easily. You know, I'm a little kind of high energy. So, so I absolutely enjoy. Just, well, what am I going to call the force up today? I know. How about the tooth hugger? You know, the next day it's them going to give the tooth a handshake. And I love that. Yeah. So you have a relationship. You have a rapport that you are able to develop with the youngster, the young child, which calms them down, I guess. And we'll talk about anxiety a little bit on this program. And I love kids. Like I love being a counselor at a camp. I just love that. You know, I coached baseball. I did a little football coaching and then I ran a tennis tournament at the camp and the kids were amazing. But just working in their mouths were so difficult as far as getting them to be cooperative. And it just seemed like it, you know, by the time you gain their confidence, then the next kid would come in and you have to start all over again. So for me, it was difficult. But hats off to you guys in pediatric dentistry because I... really think you're doing something amazing. So from the perspective of a pediatric dentist, what are the key things that set children's dental care apart from adult care? There are several things. First of all, just, you know, kids are not just small adults, but they are. very small. You know, some of them we might be working on anybody from like a one-week-old doing a phrenectomy, you know, all the way up to your 18-year-old who's, you know, too big for your kid's chair, and they're even extending off the edge of the adult-sized chair. So kids, we really need to think of the child patient as, you know, and the child and the toddler and the infant, etc., as their own entity, you know, almost where we might treat children very differently if they're, say, age three, age five, and all the way up to school age kid and adolescent. It can be a little more challenging because we are constantly having to pivot from taking care of, say, your two year old who's woken up from a nap and is not very happy to your teenage patient who, you know, it's nonstop Mountain Dew and Skittles and they're. not really interested in brushing. But that also is what keeps our job fun. And that keeps us, you know, fresh and young. And it just gives a lot of sparkle and a lot of fun to the workday. One of the things that I think would be most challenging for you as a pediatric dentist is to overcome the fear factor that's kind of inherent to young children that are coming into the office, especially the ones that have never been treated before. What do you find there? Like, do you find that that fear is something where you need to spend quite a bit of time on the front end and get that taken care of and then proceed? And do you think it's a mistake for a dentist to start doing things too quickly before they overcome that fear factor? I absolutely do. I think in pediatric dentistry, sometimes we have to go slow to go fast, and sometimes we have to go very slow to go fast. And that can be frustrating when you've allocated an hour of clinic time to see a child patient, and we struggle and, you know, have a heck of a time, and at the end we have two buckle pits and a sealant done. And, you know, sometimes we have days like that. Sometimes we just have to accept that the win is not necessary. the procedures that we build out, but the win is having a patient who down the road, three months, six months, maybe even the next appointment is going to have trust, is going to feel more empowered, more confident. And then down the road when they're 30 years old or 40 years old, maybe they look back and they say, you know what, I had a great dentist when I was a kid and I was scared, but they helped me to not feel scared. And that's a win. You know, I practiced endodontics for 15 years until I hurt my back and I went into what I'm doing now, Viva Learning and online education. But while I was practicing, you know, I was completely set up to be an endodontist. Everything was there. It was extremely efficient. So a molar root canal to me was no big deal. I had all the isolation tools. I had all the files. I had everything. How is it in pediatric dentistry? Is it similar to like a specialty like endodontics, for instance? incredible setup designed to treat kids? Absolutely. And I think in pediatric dentistry, the setup is even more critical, if anything, because I want to anticipate very fully what's going to happen. If I'm doing a stainless steel crayon, I want to anticipate, could it be a pulp? Do I need to have my pulpotomy materials on the side? I want to always be thinking about, what's my plan B? What if things go south? And I think that, you know, having that set up, I'm very mindful about which instruments I want to have in the setup, which from hand pieces to hand instruments, what I need to have to keep our tray so that we have everything that we need, but we don't have anything that we don't need just cluttering things up or wasting materials. So as a pediatric dentist, Dr. Richman, what are some of the... things you do to communicate with the patient the kiddo to make them feel more comfortable and also if you would address whether you have the parents in the operatory while you work I feel very comfortable with parents in the room. I know not everybody likes that, but I love having parents in the room because I can show them what I'm doing. But from a parent in the room, the staff, I might say, okay, I'm going to tickle on your tooth a little bit. It's going to be kind of loud because it's up next to your ear, but it's going to just feel like a little buzz and a tickle. And all I'm doing is giving the tooth a haircut. And then if mom, if this cavity goes deep and it is into the nerve, then we'll just do a little. bit of nerve treatment it's very easy and I kind of you know like to to talk them bit by bit through the procedure so that there's no surprises for child for staff member for parents and certainly I don't want to surprise myself you know unless it's wow they did better than I thought they would and so I communicate you know from start to finish i also like to uh just show kids what i'm doing because even if an instrument looks scary you know for instance a forcep because i'm going to take out a tooth i'll show them that and i'll say hey look at look at how small this little tooth hugger is compared to my big big fat fingers you know do you think that i could take out your tooth with my big fat fingers and a kid will look and say oh no and then i'll say see this is why i use these teeth little tooth fingers. And all they do is give your tooth a hug and a little dance. And then oftentimes, you know, if I can kind of get a kiddo to understand, hey, there's going to be a feeling, there's going to be a hug, there's going to be the dance. Then when they feel the pressure, you know, this is just the hug and the dance. Remember I explained that to you. So obviously there's a huge psychological component to communicating with kiddos and getting on their level so that they feel more comfortable. And I assume that GPs that are successful with children do this, and the ones that are not are treating kiddos similar to the way they treat adults, I guess, to some extent. But it seems like common sense to follow through with this kind of communication strategy. Yeah, and I think that that... A lot of this stuff is not at a very high, difficult, you know, oh, my gosh, I needed three years of pediatric dentistry to learn this stuff. A lot of this stuff comes more when you just think about it from the perspective of a kid. You know, I don't lie to kids. Like, I mean, if it's a three-year-old and they say, you know, is this going to taste bad? Sometimes they'll say, yeah, not so bad. But, you know, when it really tastes horrible. But, you know, as a general rule, I don't lie to kids. You know, if a kid's old enough to say, is there going to be a shot? I'm going to say, well, yeah, but it's teeny. It's really fast. I'm going to do everything that I can to make it easy. I'm big in trying to not only build that trust by communicating and by being honest with a kid, but also build on that trust. And every time I see a kiddo, push them a little outside their comfort zone. Well, I know that you're a bit scared today, but... Here's what we're going to do. I'm going to talk you through the whole thing. You know, if you're my boss, so you raise your hand and I'll stop right away and we'll figure out what's going on. Even if you need to scratch your nose or whatever, we'll figure out what's going on. And then I also feel that there's a lot of benefit, you know, assuming that the parent is on board with that. pushing a kid a little bit outside their comfort zone because that gives them the mindset of, hey, this was hard. This was a little scary. Maybe it didn't feel good, but I got through it. And look at that. I'm a stronger person for it. And that's a huge psychological boost. So pretty much every general dentist has nitrous oxide in their practice. I assume that's an important component. to relaxing the pedo patient. It absolutely is. And I think, although pediatric dentistry can be done without nitrous oxide, Very much so. And in fact, in many clinics, especially in other countries, that's not an option. But I think that nitrous oxide really does help out a lot. One big advantage to it is that it gives kids something really concrete to focus on. Now I'm going to have you take a big breath, hold it into your belly for a count of four. We're all going to count. And I find that if I get... with parents and you know i have a parent in the room who's anxious i have you know a kiddo who's anxious i can feel my staff member getting anxious and anxiety is very very catching you know once somebody gets anxious and sometimes it's like a a pile of dominoes everybody falls but When I start feeling that anxiety creep up, then I'll just stop and say, let's just do some breathing here. Sometimes it just helps to get back to our breathing and let's all everybody in this room, we're going to take a big calming breath. And, you know, I like overtly, I'm, you know, just recruiting mom and everybody just so that we can, you know, all be on the same page with the kiddo and getting them to breathe. But I also find that that's just calming for everybody. and the more calm everybody is kids get when somebody's calm and they also understand when they feel anxiety you know it's just like killer bees and dogs right kids can sense fear they can sense anxiety so the more that you try to focus on knowing your own body your own physiologic signs of anxiety and you know stress and of how are we going to get through this appointment the better you're able to deal with that and to say okay you know now we're going to take a step back we're going to breathe maybe i'm even going to walk out of the room and you know we'll do a little break for a few minutes um just pausing to reset and have everybody take a big breath and just you know, doing a reset is tremendously helpful. So for most of your pedo patients, you employ nitrous oxide? I do for most of the younger kiddos for restorative procedures, but once they hit about, say, age... 10, 11 or so, oftentimes kiddos say, hey, I'm fine without it. And I say, great. And then, you know, sometimes anxious kiddos earlier, younger will say, no, I don't want to use nitrous. And I say, that's great. But, you know, if you choose not to use nitrous, that's a big kid decision. And that means that you're a big kid. We're going to treat you like a big kid. And we're going to expect you to help us out like a big kid. What about rewarding the patient who's good with a present or toy or something that they get after the visit? Is that something you use routinely? Absolutely. My reward been this is not, you know, a throne of judgment. It's not a court of law. It's not well, you know, you didn't really do good. So I think that you don't get your bouncy ball. No, no, no, no, no. If a parent says that, that's their business. But everybody's a winner. Everybody's a winner. Exactly. Everybody's a winner. It's no skin off of my nose. You know, I'm going to give the bouncy ball regardless of how well or not so well a kiddo did. For restorative, I also buy these Dr. Johns, although I'm not sure he's a real doctor, but these. um xylitol lollipops that are shaped like teeth and they're just fabulous uh kids love them they they really uh you know like the taste and i just find that it's nice to you know have something to get like i think i think a young girl 12 or 14 year old girl invented that and became yeah yeah that's what i read a long time ago that some teenager young even before teenage years 12 whatever i may be wrong here but i'm Pretty sure I read that she invented or started a company that was based on Zolitol lollipops and that kind of thing. So she might have sold it by now. This was a long time ago, but I think that's where it originated, which is very interesting. So as a specialist in pediatric dentistry, I'm sure you've seen your share of very difficult cases that have been referred to you from other GPs, even other GPs that actually treat kiddos, but they've had such... uh a difficult time with this particular patient that they couldn't go further with them and they sent it out to you how do you manage this kind of patient one thing i think is very helpful to a parent is to just sit a parent and a child down and say, hey, I understand you've had some tough experiences. You know, maybe you were held down and it didn't go so well. You know, maybe nobody could work on you because you grabbed the syringe and stuck the doctor with a needle. And then I've had that. You know, maybe this happened, that happened. Or, you know, everybody said this tooth needs to come out. You know, you really don't want to. So, you know, you guys are looking for options. And I tell them, look, I, you know, I can't guarantee that it's going to be super awesome from the moment we start. You know, I mean, this is this is reality where we're going to work. through things though and i like for a parent and a child to feel some confidence that i've faced hard things before you know i've had kids who had a really tough time and we've worked through those problems and we're going to work through it as a team where this is not me against you this is we're going to take a look we're going to see what might the problems be what you know are some potential solutions for those and we're all going to work through those problems and through those solutions as a team and come together as a team. So if you were to talk to a GP right now, and they told you they're interested in building up the pedo side of their practice, what are some of the things you would tell them that they should expect to be most challenging when it comes to treating children, dealing with the parents, the whole bit? I think a lot of what people find to be challenging or some changing dynamics in parenting. And this is not a process that is new. I mean, this has been going on for a while. But I think that there are still kids, especially nowadays, we're getting the cohort of kids who are born during COVID. And, you know, they're early. Years may have been pretty isolated. So I think we're dealing with a little bit of that, you know, kids who just aren't didn't quite get that early socialization, not through anyone's fault. We're also. Dealing with, you know, sometimes parents who have expectations that are unrealistic. You know, for instance, my child's going to have a great time for everything. There are going to be no tears. You know, if a child's 18 months old, well, they may be smiley one day and the next day they may be tears from start to finish. You know, we don't know. I work hard to kind of manage those expectations. I think one thing that helps is just. being a parent and understanding the challenges that parents face. And I don't like to be negative about parents because it is a very hard challenge to parent a child in this day and age with social media and with, you know, everybody is an expert. Just curious, Dr. Richman, not to store up any trouble with parents, but do you have a favorite kind of parent that makes your job easier in the operatory? You know, my feeling is that I take every parent, every child as I get them. I think that some parents make our job easier and, you know, some parenting strategies make our job harder. But I also feel that I play a very important role for parents in sometimes almost giving them permission to be more authoritarian. not wanting any sort of authoritarian treating and, you know, authoritative, not authoritarian. But it's more that they are unsure if they're doing the right thing. You know, everything is very difficult in this day and age. I mean, I When I grew up in the 80s, you know, I was pretty much free range. I, you know, went out on my bike. If I skinned my knee, I would come back home and, you know, my mom would put peroxide on it and send me back out. It was, you know, it was that kind of childhood. And I think that it's much more stressful to be a parent, I imagine, now than, you know, when I was a kid and I'm sure when you were young. And I think that a lot of times it's helpful. For parents, if I say, you know, this is an important thing to do, you're not hurting the baby if you hold them down to brush their teeth. You know, this is just like, like that's helpful for them to have a, you know, figure of some authority, both, you know, professionally and also. I tell them when my child was young, he was very difficult. I had to chase him down the hall. I had to sit on him. He would be screaming bloody murder. You know, I had to do that. And he still seems to like me at age 12. Exactly. They do get over it. They actually appreciate sometimes when you're a little bit firm with them. That's what happened to my family. So I do want to ask you on this episode about conservative dentistry in the field of pediatric dentistry. Do you think the advancements in materials and techniques? have encouraged dentists, not only specialists, but also GPs, to approach pediatric dental problems in a more conservative way? I do, because I think nowadays there's a huge focus on minimally invasive dentistry, you know, doing basically using the handpiece in a way that is more, I almost want to say more targeted, you know, really thinking about combining surgical, which is, you know. going in there with a handpiece and drilling out the problem. And medical treatment for caries, for instance, silver diamine fluoride, nano silver, you know, things of that nature that have come onto the market and are becoming very widely accepted. So I think nowadays, I very rarely will sedate a child, aside from using general anesthesia for, you know, very... extensive cases. I find that I manage pretty much everything with nitrous oxide, with good old-fashioned behavior management, and with using a combination of minimally invasive techniques and just good pediatric dentistry. Yeah, and to do good pediatric dentistry, you certainly need a good handpiece when you're doing the surgical part of it. and you need a handpiece that's going to be able to get back in those tough to access areas in a small mouth. In your practice, do you use air-driven, electric, or a combination of both? So I still prefer the old-fashioned air-driven handpiece. I've tried electric handpieces. For me, it was just not quite enough power, and it was just a little bit too weird. My handpiece, my preferred handpiece, handpiece is just a good workhorse, something that I can depend on and something that's nice, small, and I can, you know, get it where I need to go. Because a lot of times access is an issue. For instance, I had a five-year-old today. Mom really wanted us to push through and get one side done, which was okay. We were successful. But we went through the dry shield, a bite block, and a mold. And even then, I still had to kind of use my fingers to make access wherever I could and try and hold his mouth open because he kept spitting everything out. And I had a very small little area to work with. I like something that holds up well for that. I also had a handpiece, a different brand. I was working outside of my practice and had the whole motor, you know, the whole actually, the top of the handpiece, the whole chuck, just fall out all of a sudden. And I was like... good Christmas, you know, this is like, fortunately, I'm, I'm pretty good at, you know, making sure that I don't have a choking issue with any kiddo. But I'm like, Oh, my goodness. Yeah, thank goodness. That's a rare situation for that to happen. But in your practice, the one you're using, in your own practice, what's your go to handpiece? What do you find to be the most effective in treating pedo patients and also reliability and so forth? Well, I started this office six years ago almost. And when I started, I told my rep way back when that I was looking for like a workhorse, something that was going to hold up, something that was going to take, you know, some abuse and all that stuff and just keep on chugging. And he said, OK, I think you want to go with NSK. So he connected me with a rep. I started using them. I've just been in love because they. I have yet to have one, knock on wood, right? I have yet to even need to repair one in office, let alone send one out. And they just seem to hold up really well. And I like the, they fit very well in my hand. They're not overly heavy and they just seem to work. I know that there's a lot of women dentists that I've talked to that Love the NSK handpiece because they're smaller and lighter. And, you know, these women tell me on the podcast interview, they have small hands, which I understand. Is this a particular model that is smaller that you're using for the kiddos? Well, they actually just came out with a smaller, micro-sized Z, micro handpiece that is small and, you know, just really works well. Little kid, Mal's trying to get that handpiece all the way back there to get those molars. So I gave it a try, and I've just really liked it. Yeah, and I've been hearing a lot of good things about the Timex Z from other dentists. In fact, I just recently interviewed Dr. Miles Cohen, who's a prosthodontist, and he loves it. He said it's a workhorse handpiece. He wouldn't go with anything else. This is the micro version of that, I guess, which is ideal for pedo patients. Absolutely. The electric ones are heavier. They're larger, but they do have consistent torque. But for pedo, I'm not sure that's that critical because they're great for adult prepping, for having this perfect chamfer that goes all around for whatever they're doing. But I don't know if you necessarily need that in a pediatric practice. Is that... Do you agree? Precision is very important while we're not doing chamfers. You know, per se, I've got a little teeny mouth there with a lot of tissue and this mouth is oftentimes in motion. So I want to be dead set. Yeah, exactly. It's a moving target. It's sometimes, you know, we practice what we call rodeo dentistry. And you are wanting to be very dead set that where I aim that bird to go is where it's going to go. You know, I don't have any issues there. Yeah, so that's good. So you've got your hand. piece all nailed down as far as what you like. So before we wrap up this podcast, Dr. Richman, tell us about the phrenectomy procedure, a very common procedure in the pediatric world. What I found interesting was that you're not a real laser fan. And I kind of assume that most pediatric dentists use lasers for these procedures, tongue tie and phrenectomies, et cetera, but you don't. Tell us about that. I actually like, I have a pair of Lagrange, several pairs of Lagrange scissors. And I like these because they have a nice little reverse curvature to them. They're not scary like a scalpel. Like I can show a kid. And in fact, you know, when I get my new pair of scissors, if they have pointy little tips, I even take a burr, white stone, and we'll just round those out. They don't look scary. And I'll show a kid and I'll say, you know, this is all I'm going to use. This is just a little tiny pair of scissors like your mom, you know. probably uses if she's sewing or whatever, right? And not only do they not look scary, but with a pointed tip removed, we're not worrying about anything sharp in a little kid's mouth, especially a newborn. And I feel that, you know, with those, I can do a very precise, very nice frenectomy. I'm... Not worried about a kid who's abruptly moving because I've got control. And for me, that's the instrument of choice from littles all the way up. Yeah, great discussion today. Really enjoyed this podcast episode. And I know you lecture because it would be a shame if you didn't because there's a lot you have to say and your insight is really excellent on pediatric dentistry. You do lecture. I do, and I love lecturing because I think that pediatric dentistry is something that should not just be restricted to pediatric dentists. GPs see approximately 70% of the kids in this country, and there is absolutely a place for GPs at the table for treating kids. I couldn't agree with you more on that. And that's one of the major reasons why we had this episode to get more general dentists to get engaged with pediatric dentistry. Thank you so much for your time. Great insight. And we look forward to having you in future programs. Thank you. And I really enjoyed talking to you and I appreciate your time.