From: Mark Dreyer
Sent: Wednesday, May 02, 2007 1:51 PM
To: ROOTS
Subject: [roots] They should pay me double

I always ask myself why I agree to see kids since I don't enjoy it.  So far I've not been able to
convince myself to stop mostly because some of these kids are better than adults.  My issue is how do you gracefully
tell Mom that her kid isn't cooperating and I don't get my jollies out of coercing kids into cooperating, so they'll
have to go elsewhere.  This is never graceful and Moms always become upset and try to convince me to "try one more
time".  I HATE that, so  have toyed with just refusing treatment to kids.

Anyhow, this one was a scared kid, but we made it, with Mom hovering holding the hand for over an hour it took to do
this.  As you can see, we have a few more visits planned, and the other teeth may turn into just fillings.  After I
successfully complete one of these cases, I feel like taking the rest of the day off....and also think I should have
been paid double.  :-))  - Mark Dreyer



Mark, Don't have the first visit be a marathon.  Just numb them, gates out the pulp and maybe get a length.
Pick either the most painful, or easiest to numb tooth first, and make sure you get them numb.

There are several advantages to this:
1) you can promise a pretty short visit, and deliver on that promise...part of the deal.
2) you don't hafta block out a ton of time to do this, so if it doesn't work out, you don't have a 2hr hole in your day.
3) you build trust.
4) you don't wear out the kid
5) you don't wear out yourself.
6) the kid now has realistic expectations and understanding about treatment...

It is understandable that kids freak.
They have a known fear of the unknown.
Let that first visit end easily and happily.
Then next time, you can tell them "The next visit will be just like today...maybe a bit longer.  You did good today.
We both kept our deal, No?" - John A Khademy

One thing I remember GBC saying about ten years ago,  "I don't do kids,  I don't do trauma,  I don't do emergencies."
I don't think I'll ever reach that level,  but I can see the point of view.  Other people were more than able to do
these things while Gary concentrated on what he does best.

I used the Khademi "deal "  a few weeks ago,  it worked really well,  and I do treat quite a lot of kids, especially
trauma cases.  If they don't want to be treated,  then don't treat,  simple as that,  it certainly helped reduce my
stress about the case. - Bill

I struggle with the same thing.  I really don’t enjoy pedo and refer it out whenever I can, but a good cooperative
kid is better than a pia adult.  But you are correct, once you start you’ve kinda committed to the case.  Obviously,
you got your usually high quality result, which you probably should get double for on a regular basis in any event.
Again, very nice. - Gary



Mark,

I am not a pediatric dentist, however about 75% of my patient load is under 12 years old.  I don't sedate kids.  I
will use an anxiolytic dose of Valium or Vistaril and we use a lot of nitrous, but no sedation.  So I still run into
a lot of "can't you please try just one more time."  The way I handle this is to explain to the parent that if I
spend any more time with their child, I will need to charge a behavior management fee.  This fee is $XXX per 15
minutes, usually $100 but sometimes more depending on how badly I don't want to treat the kid, in addition to the
regular fees for dental treatment.  I explain that this is the charge for my TIME and that it must be paid whether we
actually accomplish the dental treatment or not.  Now, I don't usually resort to this until we have already wasted a
full appointment trying to accomplish whatever we were doing.  I am very blunt and tell the parents that I honestly
don't believe we are going to witness a dental miracle with the child suddenly becoming a cooperative patient and
that I think they are probably wasting their money, but that I am willing to try if they are willing to compensate
me.

And if they agree, I give it my best shot.  But when it starts costing them, they are usually willing to accept the
referral.  However, by giving them an option, they rarely are p.o.'d with me when they leave - C Mincy

Dr. Mincy, that is a brilliant way to handle parents.  I think I might steal that one from you.  One question...you
are using valium on children?  I was under the impression that this was dangerous.  What kind of dosage are you
using? - Mohammed Huq

I use more Vistaril than Valium, but when I use it, I dose it at 0.1mg/kg.  This is well below the sedation dose of
0.2-0.4mg/kg but will still achieve relaxation and anxiety reduction in most cases.  I don't use valium at all on any
kid that has ever had a seizure or on kids with ADD/ADHD/or any other psych disorder.

However, the vast majority of my peds get treated with a whole lot of conversation and some laughing gas.  It
probably helps that I'm 5 feet tall with a pony tail and sparkly sneakers--physically, pretty non-threatening.
- Catherine Mincy

Mark  Been there, done that.  When you find out the “nice” way to tell the mom to take their brat somewhere else, let
me know.  Me, I would NEVER allow the mom to stand there holding the kids had while I did any type of restorative or
endo.  Just me -  Terry

Mark, Treating kids can be both draining and not very rewarding.  I look at it like as a challenge. Stropko won't see
kids.

I won't do sedations on kids...except using Niterous.  I probably could with my Conscious sedation license...but in
CA (yes, I live in AZ...but they get their experts from CA commonly), you have to have a special pedo sedation
license if I remember...and I'm not willing to go through the hoops to do it.

Yesterday, we treated this kiddo....this kid didn't cry or even yelp...

I talked to the pediatric dentist PRIOR to Tx who was shocked I wasn't going to do a root canal on this
tooth...almost perterbed that I didn't plan on it.  I tried to explain the progonsis for long term increase with the
amount of root dentin...he seemed shocked I'd consider a deep pulpotomy predictable on a kid like this.  I explained
things for about 20 minutes...so I'll have to wait and see how this turns out so I can use with him as a reference.

Once I got in, it looked like swiss cheese in the defect...so I'm pretty sure it was ECIR.  Vital pulp that we ran
into removing the effected dentin material.  I had to use Terry's dycal trick to make a form to pour in the resins.
Total Tx time was 1.5 hours due to quite a bit of hemorrage from the resorbtion area.  I removed the pulp to the
orfices, put in MTA over it, then because the MTA was so big, placed Optibond on top of a 2-3 mm thickness of MTA and cured, This allowed me to prep the rest of the tooth and create the form needed to restore without saliva and
hemorage needing to be washed away from the MTA...or sure it got onto the optibond cured on the top...but the MTA
didn't wash away when I needed to do a big blast.

I was glad I got to treat the kid...and I've just learned..if they don't cooperate, I'm done - Joseph Dovgan



Ask an anesthesiologist to do the sedation. - Danny
Elegant treatment Dr. JoeyD! - Kendel

Joey, Very nice work on a tough mesial margin.

As for the pedo doc, you'll make a believer out of him after a few cases like this.....unfortunately I can say that
cuz one of my top 10 referring docs is a pedo, and that's why I keep the Versed syrup in the fridge.  :-))

Are you aware of any problems using Ken Reeds recommended dose of .5mg/kg up to 20mg max for conscious sedation on
kids?  Ken's pretty conservative in his recommendations, so I feel comfortable using this does as needed on those
occasional kids that need a little pharmacological help - Mark

NOpe....I'm scared of doing sedation on kids...they aren't like adults...things go south fast. - Joseph Dovgan

And when they do they usually don’t bounce back.  No pedo seds for me either.   That’s what pedodontists are for.
- Arturo

I don’t know why it is always me playing the straight guy, but I’ll bite.  ECIR? - Gary

ECIR = Extra canal invasive resorption - Joseph Dovgan