Oh Great, I’ve Got This Kid with Oral Pathology … What Do I Do with That?!

By Dr. Ben Curtis

Has this ever happened to you? I know I am not the only one! As a pediatric dentist, this is one area where I use to be nervous and concerned, but I know is an opportunity for my office to shine. I integrated an all-tissue laser into my pediatric practice five years ago and it has been a game changer for my patients and my office.

This case is of a 5-year-old child who has a mucocele, a ruptured salivary gland that has formed a cyst of saliva that persists or gets larger. Fig. 1 is before treatment and Fig. 2 is two weeks post-treatment. These lesions are almost always caused by trauma and are quite common in early childhood. Kids of this age are not known for leaving things alone and they tend to bite and suck on these swellings, which makes them worse. The traditional surgical treatment involves a scalpel, lots of gauze to control hemorrhage and sutures to close the surgical site. Well, that sounds terrifying on a 5-year-old child! Not fun, right?

Fig. 1
Fig. 2
Fig. 3

Then comes the all-tissue laser and changes everything! With an all-tissue laser, we can provide a more minimally invasive surgical approach with minimal bleeding, no sutures and excellent healing … and dare I say, fun for me as the doctor! Could this be a win-win situation for both the patient and the doctor? Yes! I have been able to help countless patients who have these oral pathology lesions with the all-tissue laser in a simple in-office procedure that takes me less than 10 minutes. This procedure has become my most favorite pediatric procedure to preform, and it is all do to the all-tissue lasers help!

Dr. Ben Curtis is an FDC2022 speaker and will be presenting two courses on Thursday, June 23. “Integrating Laser Dentistry into Your Pediatric Care” will be at 9 a.m. and “Lumps and Bumps, Oh My! Successful Removal of Pediatric Soft-tissue Pathology with an All-tissue Laser” will be later that day at 2 p.m. For more information and to register, visit floridadentalconvention.com.

What You May Not Know About Taking Care of Your Child’s Teeth: A Q&A Guide for Parents

February is Children’s Dental Health Month, which aims to educate and engage parents, guardians and kids on keeping kids’ teeth healthy and building good oral health habits for life. To help with this effort, we asked real parents what questions they have or what questions they wished they’d asked sooner as a new parent. With the help of our pediatric member dentists and the American Academy of Pediatric Dentistry, we’ve provided some of the most frequent questions and answers from the experts.

Q: My baby’s teeth haven’t come in yet. What should I be doing to help keep my baby’s mouth healthy?

A: You may be surprised to learn that one of the best ways to keep your baby’s mouth healthy is to make sure that your own mouth is healthy. Untreated dental cavities in your mouth are easily transmissible to your baby via saliva. Yes, cavities are contagious! Keeping your own mouth healthy through good oral health care and regular dental visits will help keep your baby’s mouth healthy.

Also, while your baby’s teeth may not have made their way in yet, it’s a good idea to wipe your baby’s gums and tongue with a wet facecloth daily.

Q: At what age should I start taking my child to see a dentist?

A: The American Academy of Pediatric Dentistry recommends that a child go to the dentist by age 1 or within six months after the first tooth comes in.

Q: What kind of toothbrushes and toothpastes should I be using for my child at different ages?

A: You should be using a soft child-size toothbrush for your child. Picking a toothbrush with their favorite color, superhero or animal also can help get them excited for brushing!

For toothpaste, you should consult with your child’s dentist regarding the type to use and when to begin brushing with toothpaste that contains fluoride.

Q: My child is teething. How can I help with discomfort or pain during tooth brushing?

A: While many children don’t have noticeable difficulties, teething can lead to periods of discomfort, irritability and excess saliva. To help with these symptoms, you can use oral pain relief medication (such as Tylenol ®) and chilled teething rings. Using topical anesthetics, including over-the-counter teething gels, should be avoided due to potential toxicity in infants and very young children.

Q: How well do I need to be brushing my 2-year-old’s teeth?

A: It may be a struggle, but it’s important to be thorough with brushing and ensure that you are reaching all the surfaces of each tooth. This is especially important for bedtime tooth brushing, as it is the most critical brush time of the day.

Q: At what age should flossing start?

A: Every child develops differently. A good rule of thumb is to begin flossing for your child when his or her teeth begin to touch one another, as the bristles of the toothbrush can no longer clean in between the teeth effectively. If you are unsure, it is always best to consult your child’s dentist.

Q: How can I help build healthy teeth habits with my child and make tooth brushing more fun?

A: The following are links to great videos and resources from the American Dental Association (ADA) that can help make tooth brushing a better experience for you and your child.

Q: How should I choose the most appropriate dentist for my child?

A: When you choose an FDA member dentist, you can be assured that your dentist has pledged to uphold the ADA’s highest ethical principles and practice standards.

To learn more about this commitment and find an FDA dentist near you, you can visit http://learn.floridadental.org/find-your-dentist/.

Also, dentists are individuals with their own personalities and styles, so when choosing a dentist, you may want to call or visit more than one dentist to determine if that person is the right match for your family.

Q: What can I expect at my child’s first visit to the dentist, and what do I need to bring?

A: Your first visit is an opportunity to build a relationship with your dentist and establish a dental home for your child. This visit will include a thorough medical and dental history, an oral examination, an age-appropriate tooth and gum cleaning demonstration, and if indicated, a professional fluoride treatment.

This also is a great opportunity to ask questions and encourage a positive relationship with your child and dental visits.

Q: What are some questions I should ask my child’s new dentist or a potential dentist?

A: First and foremost, you are encouraged to ask questions! If you are unsure of or concerned about any issue related to your child’s oral health, you should not hesitate to ask your child’s dentist.

Here are some example questions you may want to ask:

  • When should I start using fluoride toothpaste?
  • Is my child on track in terms of dental growth and development?
  • What insurance do you accept?
  • Do you accept cash/self-pay? If so, is there a discount for doing so?

To find an FDA member dentist near you, visit http://learn.floridadental.org/find-your-dentist/.
For more information on children’s oral health, visit www.mouthhealthy.org.

 

Challenges for Pediatric Dentistry

By Kim Hathaway, MSN, CPHRM, CPHQ, Patient Safety Risk Manager, Department of Patient Safety and Risk Management at The Doctor’s Company

Identifying legal guardianship and the rights of parents can reduce risk prior to treating a minor.

Treatment of a child with parents involved in an acrimonious divorce can present a dentist with unique challenges. When only one parent accompanies a minor patient for dental care, the practice may not anticipate custody issues. Parental disputes may be revealed only after care has been rendered. For example, the other parent might demand a copy of the dental record, object to the care rendered, or refuse payment for services provided without his or her knowledge or consent.

Disputes also can arise when minor patients arrive at the practice with someone other than a parent. A child may attend a dental appointment alone or with a surrogate care provider, such as a stepparent, relative, family friend or older sibling. In any of these circumstances, a practice should always identify the person who can provide consent by proxy.

Scenario 1
A father presented with his 5-year-old child and requested an evaluation to treat dental caries. The child previously had been evaluated by a dentist who recommended a treatment plan to include restoring teeth under IV sedation. The new dentist evaluated the child and advised that the restoration could be safely accomplished with oral sedation in two stages. The first stage was successfully completed and an appointment was made to complete the second stage. In the interim, the dentist received a letter from an attorney who represented the mother of the child and requested a deposition with the dentist. Conflict between the parents resulted in a decision that treatment for the child’s remaining dental restorations and method of sedation would be determined judicially. Because of the hostility and aggression from the mother’s attorney, the dentist was reluctant to provide future care for the child.

Scenario 2
A 10-year-old child had been under the care of an orthodontist for several years and was in the middle of the course of treatment with full orthodontic appliances. After several missed appointments and payments, the office manager called the patient’s home to discuss the issues with a parent. The office manager was informed that the parents were in the process of a divorce and that the father was responsible for the bill. When the office manager called the father to request payment, the father responded that he would not pay for the orthodontic care. The subsequent options for the dental practice were to continue to provide care for the patient without payment, remove the orthodontic appliances prior to the completion of treatment or risk that the patient would not return for treatment.

Scenario 3
An 11-year-old patient and her mother presented to the orthodontist with a complaint that the child’s teeth were crowded and crooked. The treatment plan was discussed with the mother, who signed the proposed plan during the visit. The orthodontist initiated phase one of the treatment, and monitored and managed the orthodontic appliances for several months. A surrogate care provider escorted the child to each office visit. As the development and eruption of the canine teeth progressed, it became necessary to extract the temporary canine teeth. The orthodontist discussed the extraction plan with the surrogate, and the practice called the patient’s mother, who provided permission for the extractions over the phone. Later, when the child’s permanent teeth had not yet appeared, her parents consulted with the orthodontist and expressed concern that the absence of canine teeth would negatively affect her appearance. The orthodontist explained that it might be a year before the teeth fully erupted. Upset by this response, the parents requested a copy of the dental record to present to their attorney. While preparing the record, the dentist realized that the surrogate care provider was the only person who had signed treatment consents. Further review of the dental record revealed that it did not contain documentation giving the surrogate the right to consent for treatment. A parental signature was limited to the treatment and financial plan.

These scenarios illustrate some of the situations that can be encountered when providing treatment to minor patients. Dentists need to understand the rights of parents and the complexities related to the legal consent of minor patients. Many risks can be mitigated through execution of a proper informed consent, and dentists should be familiar with consent laws in their state.

Risk Management Guidelines
The following strategies can help dentists recognize family situations when the individual holding legal consent is difficult to ascertain.

  • Identify the individual who holds legal consent for the minor and document this in the dental record. If this isn’t a parent, find out who has the legal right to consent to treatment.
  • If there is a question regarding custodial rights or minor consent, insist that the parents provide the legal document or court order.
  • Review patient dental records to determine the existence of any documents that establish the status of a custodial parent or legal guardian (divorce decree, restraining orders, etc.) and request a letter from the attorney that describes your legal obligations. Update the information on a regular basis.
  • Develop a “Conditions of Treatment” agreement for parents who are divorced or separating, consider including the following statements on your website, and execute the agreement prior to first visit:
  • The dental care of your child is the first priority.
  • Maintain an open dialogue regarding your child’s dental treatment.
  • The custodial parent has financial responsibility for dental payments.
  • Both of you are entitled to treatment information if you share joint custody.
  • If one parent has exclusive medical decision-making authority, the parent must provide a copy of the court order to the dentist to include in the patient record.
  • If you are not amicable, the dentist can terminate your child’s dental treatment.
  • Require a written consent by proxy when an individual other than the custodial parent or legal guardian accompanies the child. Request updated information on an annual basis regarding individuals who are authorized to accompany the child during treatment visits.
  • If permission or consent is obtained via telephone with a parent or legal guardian, document the communication.

The guidelines suggested here are not rules, do not constitute legal advice and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each health care provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.