METHODS FOR MANAGING FEARFUL AND UNCOOPERATIVE BEHAVIOR

There is no one method or technique to help all children to accept, permit and even like dental treatment.  We strongly believe that one needs to be proficient in the use of a wide variety of approaches for helping children of differing levels of cooperative ability.  Included in such an arsenal of approaches are both communication or conventional (non-pharmacological) strategies, and drug-based approaches (pharmacological) which for some children prove necessary to help the child permit needed treatment. 

CONVENTIONAL (COMMUNICATION) STRATEGIES 

As a pediatric specialist, trained and experienced in treating all aspects of dental problems for children who may be pre-cooperative or lacking in cooperative ability, Dr. Nathan will make every effort to acquaint you with all viable treatment options for your child.  Your input and participation in making decisions as to which strategies are best for your child will always be requested and welcomed. We find most children can readily and successfully accept dental treatment using conventional communication methods.  Speaking in a soft, gentle manner, using language appropriate for a child, and avoiding the use of any and all words and vocabulary that are fear-promoting in nature or context (e.g. "needle, shot, drilling, hurt," etc) goes a long way to successfully introduce a child to our environment.  

Dr. Nathan's personal style and demeanor is directed toward always explaining what will be done and how it will take place by simple explanation and conversation in language your child can understand.  He strongly objects to methods which disregard or bypass the child's attention and ability to understand his/her circumstances. 

PHARMACOLOGICAL APPROACHES 
Nitrous Oxide, Oral Sedation, General Anesthesia

There are essentially three forms of pharmacological assistance to help reduce, overcome, or eliminate childhood dental fearfulness and uncooperative behavior when conventional methods prove inadequate. These are described below: 

NITROUS OXIDE 

Nitrous Oxide , known more commonly as “laughing gas” is inhaled through a nasal mask with oxygen. It is generally useful for only the mildest levels of anxiety. It is rarely effective for young or very young children. Its advantage is it is a short- acting and mild agent; its primary disadvantage is its weak potency to address or overcome moderate levels of anxiety or fearfulness. In Dr. Nathan’s opinion, this is over-used by many dentists for many of their patients. Dr. Nathan, who conducted one of only two longitudinal studies in children in existence, finds it is not particularly more effective than simply talking a young or older child through treatment in a gentle manner. Under these circumstances, he prefers to avoid the use of any drug altogether for children. Nitrous oxide is most commonly used as an adjunct to other more potent pharmacological methods (oral or other forms of sedation). 

IN-OFFICE ORAL SEDATION

Oral Sedation involves the child taking a liquid (or tablet) medication in the office 30 minutes to one hour before one’s appointment time, and is considered a viable option for managing more moderate or severe levels of fearfulness and/or when treatment needs are expected to be more involved or extensive. This method of sedation carries more potency (and risk) (over nitrous oxide) and its dosage or strength is determined by the child’s weight and age, degree of apprehension, resistance anticipated, and the length of the planned treatment. Use of this modality requires extensive knowledge, expertise, experience and judgment of the pediatric dentist. It is not a technique for the novice practitioner. Its primary indication and advantage is that it often, but not always, allows the child and parent to avoid needing a general anesthetic in a hospital or surgical center setting. When anxiety levels are less to moderate, and/or treatment needs are not extensive, this modality can be quite helpful to allow the child to accept treatment in an in-office setting. 

GENERAL ANESTHESIA IN A HOSPITAL OR SURGICAL CENTER

When in-office oral sedation is either inadequate or considered high risk, general anesthesia, administered by a pediatric fellowship trained anesthesiologist, is selected by Dr. Nathan for use in either a hospital or surgical center setting. Use of general anesthesia is usually reserved for children with extensive and invasive treatment needs accompanied by moderate to severe levels of apprehension. The goal of this method is to accomplish all treatment in one visit with the child not being awake for “needles, drilling,” etc., and then to re-introduce the child in six months back into an office setting when treatment needs are neither extensive nor challenging. 

Dr. Nathan insists that parents are fully informed of their options, understand all issues which accompany a particular modality, and are aware of any and all available alternative options. He recognizes the use of general anesthesia as a non-mainstream modality not to be undertaken lightly. While some dentists choose to bring an anesthesiologist into their office to bypass treatment in a hospital setting, Dr. Nathan chooses not to have an anesthesiologist perform general anesthesia in a minimally equipped dental office. When he admits a child for general anesthesia, his cases are treated at Ann & Robert H. Lurie Children's Hospital of Chicago (formerly Children’s Memorial Hospital Medical Center) or their Westchester Out-Patient Surgical Center, Hinsdale Hospital, or Delnor Community Hospital. 

Dr. Nathan is recognized nationally as one of only a few experts in pediatric sedation. As such, he teaches pediatric dentists how to safely and effectively use sedation for children, has been published extensively in this area, and lectures at Ann & Robert H. Lurie Children's Hospital of Chicago, Case Western Rainbow Babies Hospital in Cleveland, Northwestern University Medical School, the University of Alabama, Birmingham, the University of Iowa and numerous other pediatric dental residency training programs and pediatric dentistry organizations throughout the country.

John E. Nathan, DDS, MDS and Associates