"I'd like a pediatric dentist to look at her." That's what our family dentist said after seeing possible cavities on the back molars of my 5-year-old daughter. Despite twice-yearly checkups since she was 3, those occasional nights she'd fallen asleep before brushing her teeth had apparently caught up with her. Following his usual practice with patients 5 and under who might need sedation, our dentist referred her to a pediatric dentist.
It wasn't until we arrived at the new practice that I balked. The bland waiting area had the requisite fish tank and out-of-date magazines. But the new dentist's manner was hurried, and when he approached my daughter wearing a surgical mask, I knew this wasn't the place for her.
Or at least not for me. As a child, I recall, I was so terrified of tooth drilling that I once peed in a dentist's chair. For someone who wanted her daughter's experience with dental treatment to be more positive, I was off to a bad start. Why did she need a pediatric dentist anyhow? Clearly I needed more information.
What distinguishes a pediatric dentist is more than chair-side manner, according to the American Academy of Pediatric Dentistry (AAPD). After completing four years of dental school, candidates receive an additional two to three years of training in areas including child psychology, oral pathology, child pharmacology, radiology, sedation, child development and management of oral-facial trauma.
That was reassuring to learn. But when I started asking other parents about their children's dental care, I was quickly struck by how many used pediatric dentists for routine care. Weren't pediatric dentists specialists?
"Yes, but . . . ," was the answer. These dentists would rather be seen as part of the class of doctors who, like OB-GYNs and pediatricians, are also primary care providers, says AAPD president David K. Curtis, a pediatric dentist in Columbus, Mo. According to a government report released a year ago, the nation's 4,100 practicing pediatric dentists provide nearly a third of oral health care services for American children. Lezley P. McIlveen, a pediatric dentist in Herndon, goes so far as to describe practitioners as "pediatricians of the mouth."
But while new parents entertain little doubt about what kind of doctor should perform routine checkups on their babies and when those exams should happen, knowing when and with whom to schedule a first dental visit is less clear. Should you listen to the American Academy of Pediatrics (AAP) and take a child at age 3, or go with the AAPD and wait no later than the child's first birthday? It's not as if the question is wholly academic. While children's oral health has improved over the past few decades, tooth decay is still one of the most common childhood diseases: According to the surgeon general, more than half of children ages 5 to 9 have at least one cavity or filling, and 20 percent of children ages 2 to 5 have untreated dental caries.
Practitioners like McIlveen insist they can improve the situation by "mak[ing] sure that visiting the dentist is a positive and even enjoyable experience" for children of any age. Some parents I talked with, however, were skeptical. Judith Arbacher of Silver Spring stopped taking her daughter to a pediatric dentist when she turned 8. "I can see all the hoopla at age 3," Arbacher muses, "but [at 8] she no longer really needs it. Our generation is so child-centered that I wonder if we are doing [children] a disservice. I don't want them to expect that everything is going to be fun all the time."
On some level, I understand her concern, but my gut told me otherwise. "Positive and even enjoyable." That's what I wanted. Now I just had to find someone who could deliver it -- and hope that I had simply caught the other dentist on a bad day.
Sleepy Juice and Nursery Tales
On the recommendation of some fellow parents, I visited a new pediatric dental practice and knew it was "the one." The bright waiting area was filled with puzzles and children's books. The staff was friendly. They made even a parent with a dental "history" feel comfortable. And if I was comfortable, my daughter would be, too.
The dentist, a young woman with the manner of a preschool teacher but a resume that included perfect scores on her dental board exams, listened to the reason for our visit and then examined Lydia. The verdict: two cavities in need of fillings.
The AAPD Clinical Guideline on Behavior Management outlines numerous techniques to ensure patient comfortat the follow-up appointment I saw several in action. A bolster under Lydia's knees made the dental chair fit better and colorful sunglasses blocked the examination light's glare. Throughout the treatment the dentist explained and then demonstrated the equipment in a soothing, age-appropriate way.
"This is sleepy jelly," she told Lydia about a topical anesthetic gel she applied before injecting her gum with Novocain.
"We're going to put it on your gum to numb the area first. Do you know what 'numb' means? Good. Now you're going to feel lots of wiggles. . . . This is my squirt gun, and I'm going to give you some squirts of sleepy juice."
Pediatric dentists are also trained to use distraction to keep young patients calm. The dentist and her assistant stroked Lydia's forehead and tapped on her hands while unobtrusively passing instruments.They talked while putting on a dental dam: "Okay, sweet pea, I'm going to give your teeth a hug. I'm going to put this blue raincoat on to keep you dry and cut a window for your nose." And they talked through the drilling: "This is my whistler and it's going to sing you a song." The sound of the drill gave me a shudder and I craned my neck to see how Lydia was doing. She was relaxed.
Midway through the treatment, the X-rays arrived and the dentist discovered cavities between Lydia's upper and lower molars on both sides. The tooth adjacent to the one she was working on had decay, and more drilling revealed that it was deeper than anticipated. Lydia would need a pulpotomy (similar to an adult root canal treatment), and a crown to save the tooth.
At this point, I was asked to sit on the chair next to Lydia and start reading aloud. Pediatric dentists often invite parents to hold very young children on their laps; in some cases a body wrap might be used to keep hands away from the mouth.
I grabbed a bookand read. The dentist worked swiftly. Between page turns, I glanced nervously at my daughter's mouth, propped open. Nitrous oxidewas on standby but she didn't need it. Lydia was undergoing what I would consider a major dental procedure with no visible distress.
After readings of "Snow White" and "Cinderella," it was over. "You were wonderful! Mommy's proud and we're proud, too," the dental team enthused. An orange freeze pop materialized. A shiny ring, a beanie animal and a cartoon sticker later, a smiling Lydia emerged from the reception area tonguing her new silver tooth. She said it hadn't hurt at all.
A Pediatric Dentist for All?
I was so impressed that I wondered: Should I, as a conscientious, parent, have been taking my children to a pediatric dentist from the beginning? What was "the beginning"?
My Internet research revealed that both the American Dental Association (ADA) and the AAPD recommend "scheduling a visit to the dentist within six months of the eruption of the first tooth, and no later than the child's first birthday." Who knew? I had followed the AAP guidelines of a first dental checkup at age 3, the earliest age at which my dentist would see a child. When I mentioned my discovery to other parents, they all agreed that the ADA and AAPD guidelines sounded suspiciously self-serving.
However, according to AAPD president Curtis, early dental visits are crucial. He cited as proof the 2000 Surgeon General's Report on Oral Health. "I get a lot of referrals for 3- and 4-year-olds with advanced disease." he says. "If I had seen them at one year, I guarantee I could have prevented it."
A proposal now before the AAP would revise that group's policy, says its author Kevin Hale, who practices pediatric dentistry in Brighton, Mich. The new policy would recommend that all children be assessed for dental risk factors by 6 months of age.Those with significant risk factors would then be urged to see a dentist by age 1. The proposed change is not about drumming up business, insists Hale. "We're finally making the link between good oral health and good overall heath," he said.
The most appropriate candidates for pediatric dental care, he says, are very young children with technically difficult dental problems, children with behavior problems that could interfere with treatment and children who are medically compromised. This would include children undergoing chemotherapy and those with asthma, cleft palates and cardiac, genetic or bleeding conditions. All other children may simply need general dentists who are willing to see children earlier. Some parents say they have found them.
When her son Jason was a baby, Stephanie Elms of Annandale would hold him on her lap during her checkups. She says: "I had planned to look for a pediatric dentist, but when the time came, there was no need for it. My dentist's attitude is wonderful."
Training and attitude are important, but when it comes to choosing a dentist, cost and insurance coverage are often deciding factors.
The ADA's 1999 survey of dental fees shows that fees for preventive care among general dentists and pediatric dentists are comparable. "The perception that pediatric dentists are more expensive is unfounded," says Curtis.
But add insurance reimbursement into the mix and the picture can change. When my husband and I first selected a family dentist for ourselves and our daughters, our choice was largely dictated by our insurance plan at the time, a health maintenance organization (HMO). Under many HMOs, pediatric dentists are considered specialists; families that use one must pay for those visits out-of-pocket. That's not insignificant when an initial visit to a pediatric dentist can cost around $50 and a routine checkup, cleaning and fluoride treatment can cost close to $100. Start at the recommended age of 1, multiply by twice-yearly visits and treatment can get expensive.
Judith Arbacher knows. Like millions of Americans, her family has no dental insurance; as a result, she is changing to a general dentist. "Our [pediatric] dentist has a lot of kid-friendly paraphernalia, but to me it feels a bit like throwing money away. I've only been taking them once a year because I can't afford the out-of-pocket expense." She has shopped around for a low-cost alternative. "At my regular dentist, there's no 'Mr. Thirsty,' no stickers or prizes for being a good patient, and the walls need fresh paint, but a semiannual checkup, cleaning and fluoride treatment is around $58."
My family is now covered by the BlueCross BlueShield Federal Employee Program, which reimburses a fixed sum for specified dental services, regardless of who provides them. For a typical checkup, cleaning and fluoride treatment, for example, the reimbursement is $48. If your pediatric dentist charges much more for these services than a general practitioner, you eat the difference. Direct reimbursement plans give patients more leeway in the choice of providers, by reimbursing them a percentage of dental care dollars spent.
This distinction was brought home to me when I picked up the bill for Lydia's treatment. My cost, after the $78 insurance reimbursement, was an eye-popping $535. This pediatric practice was not one of BlueCross BlueShield's "preferred providers," and I worried that those freeze pops and beanie animals had seduced me. But when I pulled out our insurance plan, I learned that the pulpotomy ($195) and crown ($212) were not covered at all -- no matter where we had them performed. As for the other charges, they were all in line with the usual and customary charges set by BlueCross BlueShield.
Lydia went back to the dentist three more times, for a total cost of $1,169 -- an expensive lesson. As a result I've become much stricter about brushing and flossing. Lydia's older sister has had sealants placed on her permanent molars. And both girls are now seeing the pediatric dentist for routine care despite the additional cost. But for me the real bottom line is knowing that Lydia came through all that dental work with no tears, no fears. Her dentist memories will be decidedly different from mine.
Erica Trafas Burman is a Washington area freelance writer.