selecting toys for a common space, consider the cleansability; toys that are hard to sanitize may prove poor choices during flu season. In addition, wall decals are a useful and variable design feature for the waiting room or a treatment room because they are easy to remove without leaving a mark.
Not every dentist has the facility to mount a monitor above the treatment chair; as a more convenient alternative, a photo or painting on the ceiling will not only fascinate young children but will also help to distract older, anxious patients. Finally, the reception counter often seems enormous to children, so a small stool can make it a little more manageable for curious children to sneak a peek. Air freshener spray should be kept on hand as well to eliminate the typical smells of the dental practice, which can unsettle or frighten some children.
NONVERBAL COMMUNICATION, INDIVIDUAL PERSONAL SPACE, AND PROXIMITY
“You cannot not communicate.”
PAUL WATZLAWICK
Children are particularly sensitive to nonverbal signals communicated by body language, such as gestures and facial expressions.3 Because nonverbal communication is unconsciously controlled by our thoughts, it is important to always have a positive attitude that enables us to communicate authentically and empathetically—especially in the company of children with behavioral problems. Children have a very keen sense of how well physical and verbal signals match each other—if they do not, the intended message will be misunderstood. Thus, the treatment of a child with behavioral issues may fail from the outset if the dentist exhibits antipathy but tries to cover it up. Children are highly sensitive to discrepancies between what is said and what is felt.4
One of the greatest challenges in the practice of pediatric dentistry is controlling the often-unconscious nonverbal signals we send out so that the young patient gets a positive impression. Especially when beginning with pediatric treatment, self-reflection and analysis of these nonverbal (and verbal) signals is key. Important positive signals include an open smile, a calm manner, and nonjerky movements. Equally important is a respect for the individual child’s personal space—the personal space that they need to feel safe and secure. If people invade our personal space against our will, it can result in rejection, aggression, and anxiety, so we should not expect children to react any differently. While we generally think of any violation of this space in terms of physical proximity, personal space can also be breached nonverbally with a look or a gesture.3 Note that anxious children generally require a larger personal space than outgoing children do.
Therefore, it is important for dentists and dental assistants to read, interpret, and respect a child’s signals when interacting with them. At the same time, however, this personal space needs to be shrunk enough to make dental treatment possible. This is often where the real challenge lies. It calls for patience, a slow approach, acceptance, positive nonverbal signals, rituals (eg, similar sequence when greeting patients or going about the treatment), and sometimes even the patient’s stuffed animals or toys to act as neutral mediators. Once comfortable, children will allow the dentist to encroach on their personal space, and a neutral approach can often be adopted. Stuffed animals can also be a great advantage during treatment: They can be used to demonstrate to the child what the dentist is going to do, thereby allaying the child’s fears, or they can reflect the child’s behavior and thus be used to alter that behavior.3 For example, the dentist can use a hand puppet to mimic a child’s resistance (eg, refusing to open their mouth) and then convince the puppet to let itself be examined, rewarding it with praise and maybe even a small prize. This can influence the child’s behavior and often positively change their attitude. It is not uncommon to see young patients reflect the behavior of the stuffed animal (eg, by opening their mouth).
As mentioned initially, these aspects do not only have a bearing when the child sits down in the dentist’s chair but as soon as the child enters the practice. A friendly smile from the dental assistant at reception and greeting the young patient by name while respecting the patient’s personal space will pave the way for a successful start. When greeting or calling a child from the waiting room, it is important to get down to the child’s eye level. Anything else has an intimidating and threatening effect. On first contact in the waiting room, the ideal distance to maintain from the patient is about 1 m (3 ft). The child should be greeted before his or her parents. Personal information that can be obtained from the case history (eg, the name of the stuffed animal or the child’s favorite color) makes it easier to establish contact and create trust. In doing so, it is important to be authentic and empathetic. If it becomes clear that the child is very anxious or agitated, do not tell them that what they are feeling is not necessary. Telling a child that “there’s no reason to be nervous” is well intentioned but will not reassure a child. On the contrary, it creates additional insecurity because children learn that the feelings they are experiencing are wrong. It is better to show empathy by saying, “I can see you’re pretty nervous. I can understand that. I’ll explain everything to you exactly. That’ll help you feel comfortable.”
To maintain this first connection, once established, it is important for the young patient to be accompanied into the treatment room. This can be used as an opportunity to explain what things you might notice along the way (sounds, smells, or images), or the dentist can give an idea of what is going to happen in the treatment room.5 If the dental assistant brings the child into the treatment room, he or she should introduce the dentist and explain to the child what will happen next.
During the treatment, it is an important part of nonverbal communication for dentists or dental assistants to reassure the child with appropriate touch as soon as they have a hand free. An assistant’s hand on the shoulder, tummy, or head (especially the temples), for instance, conveys a feeling of care and protection and may set the child more at ease.6 At the same time, various acupressure points can be massaged during the treatment (see chapter 7). By contrast, stroking is often counterproductive because it may increase a child’s awareness of being touched. Be aware of this nonverbal communication, and if it is clear that the child is uncomfortable with any of this touching, stop it at once.
VERBAL COMMUNICATION: THE RIGHT CHOICE OF WORDS
Even though children are often preconditioned by their family (“If you don’t clean your teeth properly, you’ll have to go to the dentist and he’ll drill them”), we as dentists are responsible for shaping children’s positive experiences with our profession. Generally speaking, voice control is needed when dealing with young patients: different phases of treatment can be accompanied by different tones of voice and/or levels of loudness. For example, while the treatment is going on, the dentist should talk in a monotone voice that is not too loud. If a child tries to touch the syringe, for instance, he or she can be stopped in a friendly way but with a louder voice. If the child is constantly crying or whimpering, a quiet whispering voice can be used, and the child’s curiosity about what is being said may silence the crying.7
Child-appropriate language is another foundation of successful pediatric treatment. This means using simple, short sentences without any complicated or foreign words. Before the age of 5 years, children cannot grasp abstract expressions of time (afterward, then, later, etc), which can easily be a cause of frustration. In addition, it can be very helpful for the dentist to be reasonably familiar with the latest children’s movies or TV series. This can be a way of gaining the young patient’s trust. The dental practitioner must be sensitive and reflect on his or her choice of words, especially when explaining equipment or treatment steps. If a toddler has only ever heard of a drill from daddy’s tool box, it is
