Paediatric Dentistry – Communication and Prevention Part 1 – PDP023

Jaz’s Introduction: Hello everyone and welcome to another episode of Protrusive Dental podcast. I’m your host Jaz Gulati, it’s going to be an epic two part episode with Dr. Libi Almuzian, who is just one of the nicest people in dentistry. She is a fantastic pediatric dentist, and she has some great gems to share with us all. In the first episode, we talk about real world clinical dilemmas for GDPs. Because seeing children is not everyone’s forte, let’s admit it, some of us are better than others at seeing children. So I think what Libi, Dr Libi shares with us will really help everyone not only those who already love seeing children, because she has some great little tips and tricks that she shares, which allows you to build better report with the child and the parents. But also it gives you if you’re not, you know, fond of children or you don’t like seeing children in practice, but you have to see children, how can you make your visit better? How can you make the patient experience for the child in front of you better and for their parent. So we’re going to talk clinical and also very much non clinical, cooperation, communication, we’re going to talk about how to manage the patient, the child patient with multiple caries lesions, and how to actually more importantly, for me, I found it difficult not to manage the actual dentistry. But actually managed the parent, the lot of time you take bitewings the first time, and you may find significant amounts of tooth decay, which the parent had no idea about, and try and break that news to a switched on parent can be quite difficult. And sometimes you’re managing the parents’ emotions, and not just the child. So we’re going to talk about that. Do you have a way in which you communicate caries with your child patient? Do you just say ‘Oh, it’s a whole, it’s a cavity’, ‘You have bugs on your teeth and they ate your enamel away’? I mean, how do you actually communicate caries to a child, right? Well, I think this is the biggest takeaway amongst many takeaways from this two part episode. And this is Dr. Libi’s sugar bug story. So if you struggle, or you want to a better way to communicate caries to a child and a parent in a playful manner. Then I love what Dr. Libi has shared with us about the sugar bug story. So I’m excited for you to hear it. In terms of Protrusive Dental pearl, I have to do a shout out to one of my listeners who messaged me, I believe they live in Edinburgh. I don’t know their name, but they kindly message me and gave me a tip. The Instagram handle is [B gravities]. The tip they have which is relevant to mounting children is that they have a small Lego man, somewhere in the surgery, somewhere where the parents and the child can find it. And you tell the child and the parent that I want you to try and find this Lego man that’s hidden somewhere. And what it allows is for, allows for, in their own worlds, two minutes of peace and quiet while the child and the parents are having this little game around the dental room, around your surgery where they’re looking for this little Lego man. And it actually is, it works really well for them. And I think it’s a great little pearl. So I think you know buy a little toy or a little Lego man, stick it somewhere, slightly hidden but you can still see it from where you want the dental surgery in the dental chair and play a little game so it gives you some peace and quiet and give them something to do so they’re not all going to loud and rowdy in your dental chair. So thank you so much for sharing that little Protrusive Dental pearl with the listeners I really appreciate you reaching out for that. Guys, enjoy the episode in the two part episode myself and Libi. I’ll do another intro for for the second episode. It was you know, just a man of value that Dr. Libi was providing. I had to split it in two episodes. So lots of great content in there. I do realize that by the time you’re listening to this episode, it will probably be the peak of COVID-19 I hope it peaks and the peak finishes ASAP. I just hope wherever you are, wherever you’re listening to this from you are safe, your family is safe and well. And you try and stay positive, stay distracted away from all the terrible things happening in the news and I wish you and your family all the best. Enjoy the episode. I hope you learned something from it.

Main Interview: [Jaz] Dr. Libi Almuzian. Thanks so much for coming on the Protrusive Dental podcast. You are a dear friend of mine and my wife. Obviously you and Dr Mo Almuzian who came on you know which episode it was must in episode four or five, the orthodontic one. So you’re going to do very kindly, the peads version, Peads 101, Peads 201. We’re going to really, the aim of this episode, Libi is to help GDPs become better at managing the child patient. I’m going to give you my crappy introduction and then I’m gonna let you do a better one. So to me, you are someone who is a an amazing pediatric dentist. You share so much on your Facebook and Instagram channels, helping GDPs. You’re also helping a lot of orthodontists in terms of managing the ortho pediatric cases. And I feel as though you’re supermom, I know you’re super Mom, I’ve met your three lovely daughters. So that’s my crappy introduction for you. Please, Libi, can you tell the world who’s listening because actually now I can tell my listeners that 94 countries listened to my podcast as it’s done. So can you tell the world, can you tell them a little bit about yourself.

[Libi]
So it’s a pleasure to be on your podcast. Thank you very much. I’m a pediatric dentist, I recently completed a clinical doctorate in clinical dentistry, in pediatric dentistry. And I’m just really passionate about Pediatric Dentistry and everything about it. And I just want to make everyone better at treating children for the greater good. So I think it’s something that can be done really well. And it just needs you know, a few hints and tricks and tips for dentists to be able to do a great job. So I’m really excited to share what I can today to help everyone really, and that’s the purpose of my pages, really. On Instagram and Facebook are just bring to light all the information that parents are maybe missing and really be misled in the media at the moment. And from, you know, a consumer point of view, lots of the advertising is in towards parents, and it kind of guilts them into buying things that maybe have hidden dangers, to just raising lots of awareness is our role as dentists, really.

[Jaz]
Brilliant. And as you’re speaking, I’m making notes, because every time you say something like that, and I think of other questions to ask you along the way. So tell us about where you work at the moment. What kind of setting? What are the kind of children that you treat at the moment?

[Libi]
Yeah, so at the moment, I’m working at the Berkeley clinic in Glasgow, and it’s a private clinic, the kind of children that I see are ones who are anxious, maybe considered too young to be treated. And some of them have some medical complications, some of them have some mental complications. So just people with special needs, and just anybody who maybe hasn’t gotten along with their general dentist, not for reasons, not because the general dentist isn’t good enough. But it’s just that their needs sort of out with that. And that’s why people specialize as pediatric dentist, because they’re, you know, we’ve done three years of training. And in those three years, you learn so much, and you just realize just how much more you can do for children. So that’s my role. I really enjoy using inhalation sedation, which is one of the tools that maybe isn’t available to general dentists. And I found it to be a good sort of stepping stone sort of, between actually just having treatment on the chair, or having to go for a general anesthetic, there’s that little bit in between, where you can use inhalation sedation. And if it works, fantastic, that child doesn’t have to go for general anaesthetic, which is, you know, it’s not that I’m against general anesthetic. It’s just I think that teaching a child who’s really anxious to be able to cope with dental treatment is an investment in their future because nobody can avoid dental treatment their whole lives. So being able to overcome those fears is actually helping them more than putting them to sleep and just dealing with the oral health issues. So it’s a more holistic approach, really.

[Jaz]
And also, when children are put under, you know, GA, the treatment plan becomes far more aggressive.

[Libi]
And the reason for that is we don’t want to have children going for a second general anesthetic. And this is, you know, we’re evidence based dentists in the UK. And you know, we, it’s shown that when you’re not drastic in these approaches, you do end up going for a second general anaesthetic and you don’t want to put that child at risk of infection. After you’ve you know, he’s undergone a general anaesthetic and general anaesthetic is not without risk. And it’s also very stressful and traumatic events for the child and for the parents. So you do want to try and avoid it, if you can.

[Jaz]
Well, there’s two things worth mentioning there, one for perhaps students, because I remember being invited as a student, and one of the questions was, What are the signs with a child that there may be neglect at home going on, or things that you are worried about the child’s sort of general well being and one of them is actually if they’ve been to a second GA you really should be looking at what kind of care they’re getting at home. So I remember that being a viable question. And the other thing is that which I’m sure all dentists in the UK know, but for those in the world listening, unfortunately, we have a situation in the UK where and correct me if I’m wrong and my stats are not up to date, but one in three of GA admissions with children is because of a dental reason.

[Libi]
Correct. So it is quite a high figure. I mean, considering all the GAs that are happening for kids, yes, most of the, third of them are for dental issues. And while you can’t, you have to take that with a pinch of salt, because some children are going in because they have buried teeth, you know, they’ve got impacted teeth that need to be taken out, they’ve got other issues, like, it is a kinder option when you’ve got a child who’s 9 or 10 years old and needs all four of his adult molars out. Yes, it’s kinder to send them in for GA because that’s quite a lot to cope with at the age of, you know, 9 or 10. So that’s maybe in the case of NIH or something like that. So it’s not to say that these, you know, that it’s unreasonable that we’re sending all these children for GA. Previously, these children may have had everything done on chair and it might have ended up, you know, being more traumatizing to them. But at the same time, when we’re talking about decayed teeth, and very young children, that’s the GAs that we’re trying to avoid?

[Jaz]
Absolutely. Well, let’s just dive right in because my podcast is very clinically focused, and I want the, you know, the people on the front line, the GDP to really gain value. And that’s what we’re going to talk about. So let’s start with managing a child with multiple caries lesions? How do you manage the child? And how do you manage the patient? manage the parent even? So I know, it’s quite a broad question. And there’s so many factors involved. So for example, I imagine the patient’s age has a significant bearing, what their diets like, what the education levels like, but where, At what point do you think, Okay, this level of caries is should be dealt in primary care, and this is the way it should be dealt? Or what level is that okay, you need to now refer. And just any sort of gems that you can do. I know, it’s too broad of a question, I can narrow it down if you want me to. But just managing the biggest problem that we see is caries in children. And I’m going to come on to later whether when we’re managing caries in general practice, should we use LA? Should we not use LA? that sort of stuff. But if you just start with a general overview of management of caries.

[Libi]
So overall, when you get a child and if they’re cooperative, and the parent is on board, because you have to remember when you’re dealing with children, it’s not the same as dealing with an adult when they come in to be treated, you have to take into account the dynamic. So there’s a new dynamic that’s between you, the parent and the child. So the parent has to be on board with your plan, and the child has to be working for the plan, and you have to win both of them over. The biggest thing you need to think of is just emphaty. So firstly, when you get a patient in, you need to empathize with the parents, and, you know, make them understand that, you know, everybody can find themselves in this situation where the child has caries in their teeth. And that your job as a dentist is to actually help them identify the reasons why we’ve gotten to where we are, and how to move forward. Okay, so no guilt, and no blame.

[Jaz]
Can I add something to that, Libi? Because I think that’s a great starting point. So what I say to adult patients, and to the parents of my child patients is I always say, look, in this practice, where we have a policy of no shame, no blame, we just want to help fix this and prevent it. And we said that from the start, and I just find that everyone just breathe a sigh of relief. Yeah. And everyone’s so much more relaxed. Because if you don’t say that one line or put it across in the message that you’ve just said, then all the while. That’s what the parents are thinking that I’m a terrible Mother, I’m a terrible father. And they’re not really absorbing information you’re giving. So such a great starting point, empathize, and then let them off the hook. Because you know what’s happening. If they’ve got the right attitude, it may not happen again.

[Libi]
Exactly. And it’s just that this, they’re become less defensive and more open to your suggestion. And that’s what you want. That’s for the benefit of the child and parents. And once you get the parent on board, so if your parent is not on board, the parent of the child, you will never succeed in treating that child. Because no matter what the child will feel that that parent doesn’t trust the dentist and they will not trust you. So it’s really important to gain the trust of the family. That’s first thing you need to do so you can motivate them. What I think some GDPs fall into the trap of is treating the tooth which is worst first, which I don’t think is usually the way to go. Because what you’re going to do is you’re, if you’ve got, you know, a pain, a carious tooth, it has the biggest hole it needs, the most amount of treatment that’s going to be quite taxing on the child and you haven’t had a chance to build a relationship with them. And you haven’t had have the chance to actually gain their trust. And it’s a lot about trust, because you’re going into a really personal space of a child, their mouth, not many people are allowed to touch that area of their face. So usually, it’s only their parent or primary carer who will be touching that area. And so for them to allow you to do things that have different smells, different tastes, sounds is really difficult for them. So what you need to do is to build the trust, I would say, when you assess a patient, let them play. So by let them play, I give them the high volume, low volume suction and let them suck out some water from a cup, to show them that they’re allowed to touch these things when I say so you’re still being quite strict with them. So that you’re setting boundaries that you know, and you can say, ‘Right, that’s enough, we’re not going to play any more we’ve finished for today, next time, once we’ve done x, y, z, then we will have another play’, that gives them a bit of a reward system, but also familiarizes them with all the tools that you’re going to use. So if you grab the suction and put it straight in their mouth, and that’s what you would need to do, if you’re doing you know, if you’re using the high speed, you know, you need to get in there with the suction. And so for them to allow you to do that, if you’ve let them already hold the suction and put it in their mouth themselves. That’s like you’ve cut down the time that you have to explain to them and convince them to let you do that. And they won’t jump up and chop.

[Jaz]
Awesome. I want to highlight that as a tip. So put the suction, let them put the suction in the cup full of water, right?

[Libi]
Yeah. And you just introduce and say, ‘Oh, he’s so thirsty, likes to drink? Oh let’s give it a drink.’ And then later you say, ‘Oh, look how funny it feels on your hand.’ ‘Oh, let’s Hoover your nose.’ ‘Oh, actually, why don’t you stick out your tongue, I’ll tickle your tongue’ and you get them to put the suction into their mouth. That’s it, you’ve crossed that barrier. They’re not scared of it anymore.

[Jaz]
That is fantastic. That is really, really good. Because what I do at the moment, and some dentists do this, I give them the mirror, I let them put the mirror in the mouth, I make a little balloon using the glove. But that’s actually one I’ve never come across. And I think that can suction the sound it makes me quite scary. And some of these suctions can be really strong. So I’m definitely implemented that Monday morning. Thank you so much. So we’re gonna have a little play and you’ve set the boundaries. I like how you set boundaries. Okay, playtime is over. Brilliant.

[Libi]
Yeah. So it’s all about, you know, you have to be kind of strict with them. Otherwise, you know, they tend to oversell it or like push boundaries, that’s what they like to do. So it’s just making sure that you’re, you know, firm that, yes, okay, we’re gonna play now, but we’re only going to do two more times. So if they say, ‘Can we do it again?, we say, ‘Okay, we’re gonna do just one more time.’ But you’ve got to make sure that you follow through. So even if they get a little bit upset, when you say that it, it’s over, you distract them, then with something out there, but you make sure you don’t go back on your work, because that will be key to being able to do some treatment for that child. And so I always start with prevention, I’m going to, when I look at a full mouth of caries, if that child has their sixes through, but their baby molar, you know, deciduous molars are carious, the first thing I’m going to address, I’m going to seal those adult molars. Okay, the reason why is first, they are most important, I need them to stick around for the longest. And second, it’s a good, it’s an easy procedure, easy enough procedure that will help them build trust. And you know, I introduce it as ‘Oh, it’s just like getting your nails painted. Have you seen everybody gets gel nails? and you put the special light on this is exactly the same.’ And you can

[Jaz]
That’s the Gem. That is so good. That is you’re gonna, I’m sure gonna make a whole list of analogies after this episode. So that’s another one the gel note, I love that.

[Libi]
It’s actually really funny when I started working in this practice, the nurse had to, my nurse Chloe is fantastic. And that’s another thing having the same nurse. I know that it’s supposed to be rotated and everything. But actually in pediatric dentistry, there’s a huge benefit from having a familiar face that that patient to come in and see the same nurse each time and see the same dentist. There is a big value to that. So if you can do that, that’s ideal. So anyway, my nurse, Chloe had to learn all the language that I use. It’s a different language. So I won’t call things by their names. I wouldn’t say pass me that high speed. I won’t say pass me, you know, long tapered fissured bur.’ I would say, ‘Oh pass me the ice cream cone one,’ just like I didn’t want to

[Jaz]
Can you give us a favor and like at the end if you got like a maybe a list of 15 things like to translate to help the GDP. So for example, I call the fast handpiece, the buzzy bee, but you might call it something else. I call the suction the Henry Hoover, but I think they could probably do best in that cuz some kids might not know what Henry Hoover is. So if you can give us like 10 to 15 things we’d really love that.

[Libi]
Oh, that’d be great. I don’t mind doing that. You can all join me in the craziness. So anyway, back to what we would do first. We do the prevention first. And I have actually downloaded an app, which helps and allows you to make a social story. And social stories are used for children with autism. But I found that using them with any child helps so much. So what it is, is I have taken photos of my own daughter coming into the dental clinic, sitting in the reception, lying on a dental chair with the suction in her mouth, sunglasses on, the light on. The next picture is neat, examining her teeth, then cleaning her teeth with a slow speed handpiece and brush, and then the steps for having the fissure sealant. So showing the blue shampoo, which is the etchant, ‘So we’re going to put blue magic, Tooth Fairy blue shampoo on your teeth, and it makes it really nice and clean, but then we have to wash it away, it doesn’t taste nice. So we’re gonna Hoover it away, so you can’t taste it,’ And explaining to them why you need to put cotton wool rolls. ‘So I’ll keep it dry.’ Explain to them why you need to use the Hoover ‘so you can Hoover away and you don’t have to taste it,’ you explain to them, ‘you need to dry it because you can’t paint your nails when they’re wet. It’s the same thing with teeth, we can’t paint your teeth when they’re wet. So we need to dry it with the air.’ And I use the 3 in 1 and I always want to introduce the 3 in 1. I spray their hair first I say ‘Oh, I’m just gonna dry your hair, you come in to get your hair done, that gets the giggles,’ You’re just all the time trying to do playful, or ‘Oh no, I’ll draw your ear so you can hear me’ ‘Wait a second, I’ll just draw your snotty nose.’ That one is just like even if they haven’t laughed at the first two, they’re like, Oh, this is so funny. And then finally you get it into the mouth. So it’s just building up that you know, ‘And I’ll tickle on your neck for that,’ to just gain them to feel like these things are non threatening. And also, when you give a child a reason for you doing something says that ‘I’m just I’m going to dry your tooth. Or I’m going to use the suction.’ If you say ‘I’m using the Hoover so that you don’t have to taste it because it doesn’t taste very nice. So I don’t you know, I want you to be comfortable.’ You’re making them feel as if you care. And that is the bottom line. When they feel that you care about them and you’re doing things to help them, they will trust you and the treatment can go so much smoother. So using the social story is such a game changer for me. So if I have a patient who next time I’m going to do fissure sealants for and I send them this story of what it looks like, what the things look like, and what the steps are. And they go home and read that with their parents once or twice. And they read it the night before and they come in and know what to expect.

[Jaz]
They read on their parents phone?

[Libi]
I email it to them, it’s in a PDF format, you can print it out, it’s fantastic. So you can make your own story. And you can actually go back and personalize it. So you can see you know, and you could even do it if you wanted to with the actual child and say, ;Right, let’s take a picture of you on the chair. And we’ll put that in the story.’ Okay. And what it does is, it makes them familiar. So kids are always scared of things that are new, they’re, once something is familiar, it becomes much easier. So just knowing, familiarizing them with the steps that are needed to do something just makes it so much smoother when they come in. And even at the beginning of the appointment, I will summarize I will say ‘Do you remember what we’re going to do? It’s really easy, we’re going to do, we’re going to put in the tooth pillows.’ Not cotton wool rolls. ‘We’re going to put tooth pillows so your tooth can have a rest and keep it dry, we’re going to wash your teeth with the blue shampoo. And then we’re going to wash it and dry it and with the Hoover. And then we’re going to paint it to make it super strong. And we’re going to put the Bluetooth very light on it. And then that will be finished.’ Now some children like a challenge. So what I’ll do is I’ll say ‘Usually it takes me 80 seconds to do each. Do you think we could do it faster? Let’s see how fast we can do it.’ And you get them to count in their head. And when you finished one tooth say ‘How long was that?’ And they’ll say ‘That was 76.’ ‘I think we can do better. Let’s do the next one. Let’s see how long that one.’ So all the time they’re distracted by the counting. They’re excited because they want you to be, to win. And another challenge I say is ‘Oh this is a competition. How many things can I fit into your mouth at once? Let’s count. ‘ And while I’m doing the procedure, I’ll be doing the steps that at the same time going ‘Oh my goodness, I fit the cotton roll in, I fit the tooth pillow in, I’ve got my fingers in, I’ve got the hoover in. How many things is that? Let’s count them.’ So all the time you’re distracting, you’re being playful, you’re being fun with them, and they start to trust you. So building trust is really essential. Now if a child was really really anxious, actually, I wouldn’t even start with fissure sealants. I would just put fluoride on. I would just do an appointment where I put fluoride on and I let them have a play with the chair. And then I say ‘Well done. You were amazing. How cool is it coming here. Come back next time. We’re going to make your teeth super strong.’

[Jaz]
At an appointment, you can then I’m assuming your protocol now those nervous patients where you only place fluoride is you start that whole social story as well, you might take a photo of that. I mean, that is amazing. I think anyone who’s serious in the world about using their own practice branding, their own selves, so that child is not nervous. So keep these tell us, I’ll put the link on for this app, or is it on like iPhone or iOS? On Android?

[Libi]
I know it’s iPhone, it’s on iPhone, to be able to use to be able to make your own social story on it. It’s like 14 pounds 99. It’s a one off payment. I paid a few years ago, and I designed it

[Jaz]
That’s totally worth it. I mean, that is, I mean, Okay, fair enough. Look, for NHS practice, look, I totally sympathize or empathize my fears, my peers, whereby they might find it difficult to make stories, but the opportunity you get, that’s great. But in private practice, for those seeing children, this is a no brainer, I mean, the amount of, the wow factor in the parents, because they’re going to be at home reinforcing. And then they’re seeing your image and this is magical.

[Libi]
Helping you and reinforcing the message that you’re working together. And do you know what’s even simpler than all like, the simplest thing, even if you can’t do a social story, even, you know, you have restrictions, whatever. And the first thing I do and your patient assessment is to get the child into the chair, I take a Polaroid picture of them sitting in the chair. So I have a Polaroid camera, I’ll take a picture of them sitting in the chair. Now they think, okay, it’s just fun. Actually, that is them seeing themselves sitting in the chair, smiling, and they’re going to take that picture home, and they’re going to look at that, and they’re going to be proud of it. They’re going to show other people and they’re going to feel like it’s so normal for them to sit in that chair and smile. [Jaz] That is so powerful [Libi] It’s just reinforcing that behavior of it’s ‘you can sit in that dental chair’, and I’ve had many anxious patients who you know, at the beginning, when they first come into the appointment, I don’t force them into the chair straight away. I get stuck in with my first question, which is the most important question ever. What’s your favorite Disney movie? Right.

[Jaz]
That’s the most important question for sure. I love it.

[Libi]
Who doesn’t have a favorite Disney movie?

[Jaz]
What’s your favorite Disney movie?

[Libi]
At the moment is frozen 2. I’m not gonna lie. Frozen 2.

[Jaz]
I knew that. I knew that. Toy Story is Disney, right? Toy Story?

[Libi]
Well, DreamWorks, Pixar, all of these movies that I say to them, ‘What’s your favorite movie?’ And that just breaks the ice. Okay, so I’ll talk about that a bit more in my tips for communication, I think we’ve sort of veered off course of [overlapping conversation] [Jaz]
I’m gonna have probably a two part episode. The first bit, let’s make the first bit about managing the child and communication gem. So let’s go with that. And then the second part, I’ll show you my clinical photo, and let’s talk about the nitty gritty about the local anesthetic or not, full crowns, that sort of stuff. So if you tell me, I mean, is this a good point to talk about sugar bugs? Or is that something common to later? Or is that something you wanna talk about?

[Libi]
Oh, that’s something I do in my assessment appointment. So I’ll talk to them. And I’ll say, ‘Do you brush your teeth? So I really ask, do you brush your teeth?’ ‘Yes, I’ll brush my teeth.’ ‘Okay, how many times?’ ‘Oh, maybe once.’ ‘Yeah, try for two,’ you know, and you ask the parents then, ‘Do you help them with brushing?’ Because, you know, we’re trying to push supervise version. I think parents feel under pressure to give their child independence. So it’s like, yes, they can put their coat on by themselves. Yes, they can dress themselves. Yes, they can feed themselves. Yes, they can brush their teeth by themselves. But actually, they don’t. You have to make the parents understand that it, they’re being misled because their child doesn’t have the manual dexterity to do it. So I say well, ‘Can you tie shoe laces?’ ‘Yeah, I can tie shoelaces okay.’ But even I say to them, ‘I’m a dentist and I brush my own daughter’s teeth. So I can see them really well. And I still misplace it.’ I say to them, ‘And this is my other tip for prevention and motivation, disclosing tablet.’ Oh, my God, I love disclosing tablet. And I think there’s so underutilized, okay? And they’re so cheap. And they’re just so easy to use. And it’s something that you give the parents and you gives the child and it’s so visual, they can see exactly what they need to brush and I say to them, and this is another part of the empathy side of it. I say to them, ‘I’m a parent. I’m a dentist, I’m brushing my daughter’s teeth. I give her disclosing tablet to check that I have brushed your teeth perfect.’ So that’s it, you have to always make sure that you’re not being judgey. Can’t be a judgey dentist, nobody likes a judgey dentist. Children, especially a parent about their child. I mean you’re a parent now, Jaz and I think you can feel, you’ll know that if anybody was to say anything about something you were doing for Ishaan I think you’d be very defensive even if you don’t mean to be you can also

[Jaz]
Absolutely. Every emotion is intensified a 100 fold

[Libi]
Exactly that Yeah, and not all of it makes sense. But that’s parethood.

[Jaz]
So I’d like to share like a little personal thing. I mean, the other day, we were doing cold water babies thing, right? And I’m 30 now, and I’ve achieved some cool things in the past, and I’ve really enjoyed it. But the time that he was dipped underwater, and he swam about one meter, and he came back up, proud stole my mind. Everything else was irrelevant. That was a proudest moment of my life. So definitely parenthood has been amazing, which is why I another reason why, when I’m seeing child patients now, I’m always thinking, Okay, this is someone’s child. And what you said communication is so, so important with his parents, you have to like right at the beginning that you said, they should not feel any shame or blame. And everything you say, has to have the right sort of touch to it.

[Libi]
Exactly. So when I’m talking to them, I say, ‘okay, when you brush your teeth, you’re brushing twice a day, okay? Do you know why you need to brush?’ and they say, ‘Well clean your teeth.’ And I’m like, ‘Yeah, but why why. And this is, when I introduced my sugar bug story. Well, the sugar bug story. And I said, you know, you’ve got these sugar bugs, they live in your mouth. And you know, if they’re a bit older, I’ll say, bacteria, and chaos in bacteria, you know, sugar bugs, just so that to make it feel a bit less intimidating, but also to acknowledge that if they’re older, you know that, you know it’s bacteria. And I say to them, you know, when you eat your food, so I said, you know, these sugar bugs are living things like you. And when you eat your food, where does it go? And they kind of look at me, and like, tell me, and then where does it come out? And you know, all children love it humor. They like to hear about snacks and foods and all these things. And, you know, I think from a young age, they think it’s hilarious, even through to the teenagers. They’re like

[Jaz]
It’s like raising the eyebrow and like thinking what, you know, why is my dentist talking about?

[Libi]
Yeah, do you know, I don’t look at the parents at this point. But by the end I had so much feedback, I’ve had so much feedback from parents saying after hearing that story, we’ve had no resistance to brushing, because you can’t, it’s like one of those things that you can’t unsee I say to them, the sugar bugs, they do lose as well. And it’s all over your teeth. And so every time you eat, they stick to your teeth. The more sugar you eat, the harder they stick, and the bigger they get, the bigger bugs they do. So we need to make sure that we are brushing twice a day to get them off your teeth because those bugs and make holes in your teeth, they make your teeth soft, and they make causing yout teeth, so it’s getting them to understand. And it’s sort of you know, we’re not fobbing them off just saying brush your teeth, you know, you have to give a reason in this day and age, everybody wants to know why they’re doing things. When you give them such a plain explanation. And like I said, they can’t unsee it, I actually have a poop emoji on that I have in the clinic, which I put in my big teeth. So I showed them a mouth with teeth with a poop emoji in it. That’s it, you can’t unsee it.

[Jaz]
That’s the two reason why that’s so powerful, one is because it’s the visual, you have the poop emoji in the mouth, but you’ve attached is not you said explanation. But it’s an amazing story. When you add a story to something, it becomes memorable. And I think that’s why you probably had so much success with this with children. I think, since you told me about it a few months ago, I’ve used it in a few children now. I’m still refining how I say I don’t think I’ll do it quite as long as you do. But this is what it’s all about. You have to practice. And it’s a good point mentioning, I suppose that I’m fairly good with children. And I get that from parents Oh, you’re really good with children. They always want to come and see me. But I get it where they’ve seen someone else and the child and the parents seen someone else. And it’s usually a man who doesn’t, isn’t able to relate to the child at their level, it’s just not part of their personality. Does that? Talking in a high pitch tone and become a child. And I want to at some point, just give some tips about if people finding difficult to relate to children, but they’re still seeing children. What can they do? I mean, my best advice would be practice in the mirror, practice with the either, if you don’t have children patch it to other children because you need to be able to relate to children in a playful manner like you’ve advocated.

[Libi]
And the thing is, the more excited you sound, the more excited they get. The more, so if you’re just like, yes, sit in the chair. We’re going to do this and they’re like this boring. They’ll start to look for excuses to get up. They don’t want to do what you’re saying. But if you really like ‘Come on, let’s go. Yeah, this is so fun. You’re amazing. Look at this. Oh my goodness, I love your shoes. How fantastic!’ It’s just picking up little things and the tone of your voice is excited. They get excited. They’re like, Oh my god, I’m so lucky to be here. I’m so you know, I’m so happy to be here. Look how happy she is. I must be happy too. So it’s it. It’s infectious. [Jaz] It’s contagious. [Libi] So Yeah, so that’s what we want. So going back to my sugar bug story, this is when I bring in, this is when I bring in the disclosing tablets, okay, so I’ll say my sugar bug story, I’ll say, you know, this is why we need to brush to get all of your teeth and the sugar bugs which are sticking, they’re really hard. And of course, we don’t want to feed them too much sugar, because they just get bigger and hold on tighter to your teeth, they’re stronger. And I say, and the thing about these sugar bugs and their [inaudible] is that they’re camouflaged. And they are the same color as your teeth, so you can’t see them. And that’s why I give them the disclosing tablets that say, this is really fun, the first time you do it, you’re going to chew it before you’ve brushed, and you’re going to see all the places that you need to brush. And then after that I turned to the parents as they after that, you’re going to do it once or twice a week to check that the brushing has been done thoroughly. And the thing with the disclosing tablets that I use is that there are two tone. So they will show pinkish color for fresh plaque within 12 hours. And then the bits that are being missed, the more frequent, more regularly sort of all the time, they show off in a bluish purple. So I tell the parents that and I say you know, and it’s, again, just making them feel that it’s non threatening thing that I use them, you know, I use them. It’s not something that I’m giving you because you are not a good parent, you are not [overlapping conversation] [Jaz]
It’s not a punishment, it’s a routine thing.

[Libi]
It’s a fun activity. It’s really good for kids, and I say to them, even I say it’s good to motivate your kids to brush because then they can see it visually, why they need to brush they can actually see it when they can’t see it. It doesn’t mean anything to them when they see it in bright pink, they know that that’s what they need to brush away, it just makes it more more rewarding that they brushed it away. And also I find it’s a really good tool for teenagers. Because they kind of think, Oh, you know, my teeth look fine. But then when they can see a bright pink, that’s a different issue. I mean, with my own kids now who brush their own teeth, the older too, I sometimes will say, you know, I’ll hear them going to the bathroom to brush their teeth. And they’ll go in for about 30 seconds you know, when they’re trying to just, you know, say that they brush their teeth, and they’ll come out and I’ll say, I’ll shout, ‘Did you brush your teeth?’ ‘Yeah, I brush my teeth.’ And I’ll say, ‘Okay, then go chew disclosing tablet, I want to see exactly how well you brushed your teeth.’ So I think it’s a very good parenting tool. That’s what I saved.

[Jaz]
My other thing is using, we give away these little timers that you know the sand ones. and children really respond well to that. What do you think about that?

[Libi]
They like those, I think everything with children is about, it’s about finding something new to motivate them. So at the moment, so you will, from my own experience, we will have that timer, we’ll use it for a week, we’ll use it for a second week, by the third week, it’s forgotten, by the fourth week, it’s sort of not exciting anymore. You need to always mix things up, which is why I say you know, getting a new toothbrush. So my daughter has an electric toothbrush. But in occasionally if she sees a toothbrush she likes in the supermarket, which is manual. ‘Oh, mommy, let at look at this. It’s frozen. Look at this, it’s minions. Look at this, you know, oh, I’m into dinosaurs at the moment, it’s a dinosaur today toothbrush.’ I’ll buy it her a couple of pounds, but actually motivate her for the next two or three weeks, she’ll be excited to use that toothbrush. At the moment, there’s other tools like so again, the disclosing tablets do act as a motivator. So that’s why you use them sort of every now and then to motivate these things. Like I always recommend brush DJ, which is an app. And it’s free. And you know, it won the best Innovation Award in dentistry, because it’s

[Jaz]
That’s been around for about eight or nine years. I mean, the guy was on Twitter. I forget the guy who made the app. But I used to speak with him on Twitter about nine years ago. So and that’s been Yeah, used by thousands of the puppy people.

[Libi]
Yeah, so that just plays music for them while they’re brushing. And it’s free. And it gives tips as well. And also for teenagers. It’s good because it’ll pop up reminders on their phone, saying time to brush your teeth. And then that takes out, you know, the element of the parent having to nag. And we all know and I say to parents, we all know that the kids listen to their phone more than they listen to us. If their phone tells them to brush their teeth. They’re gonna go into it, you know? Yeah, so that’s another motivator. What I’ve just found this week, which I was really excited about. I think you might have seen my posts on this. But there’s a new toothpaste which changes color over the course of two minutes. So you start brushing, it’s clear, it’s got some little specks inside it. And then if you keep brushing over the period of two minutes, it changes to blue. So by the time this bright blue, and it’s genius because you have to keep going and that’s what we want. We want them to be brushing for two minutes, because by two minutes, you know, there’s no, Well, More or less you’ve, you’ve made sure you’ve brushed well within

[Jaz]
What’s this toothpaste so that dentists can make the

[Libi]
It’s just the Colgate toothpaste and it’s aimed, I think six to nine years I might actually have a tube just here because I am going to

[Jaz]
Amazing. That’s really clever. I love that.

[Libi]
Yeah, here it is. It’s aimed at six to nine years old. It’s called magic toothpaste

[Jaz]
Magic toothpaste. Fantastic name.

[Libi]
Fantastic name. It isn’t advertised very well, I didn’t, I think you’d have to really complete the packaging to realize what it does. And I

[Jaz]
We have Mr. trickier because that is phenomenal is really, really good to get. Well done

[Libi]
The next thing. So I got really excited when I saw this and I bought a whole box of it. So I just went into the whole box of the shelf. And I’ve been giving it to anyone who will listen, you know, here you go have some magic toothpaste. My kids loved it. I used it. It’s fun, you know and that’s it. So it’s all about changing it up. It’s like okay, for a while me and my daughter were into you know, when frozen first came out, we have a specific song that we brush along to. And it’s just all about constantly keeping them motivated, which is exhausting but that’s what Parenthood is about. I think you’ve realized this.

[Jaz]
Big time. So just to summarize the last bit you said it start off with a non blaming culture be really playful with all the ways with the suction that you said, social stories just sounds phenomenal. Get the child to count on their head 80 seconds see if they can beat the time, using something like a Polaroid picture. Nowadays, you can get something called like a HP sprocket, which I bought my wife once and it’s like a undergo Bluetooth printer. So that’s something that can be used as long as you can make a photo, print a photo and give it to a child. That’s a genius. Obviously using disclosing tablets, which are massively underutilized. Your Sugar bug story has been phenomenal. And I think it will, you know, relating poop to the teeth is just as a story is just going to stick using the app brush DJ and the magic toothpaste. Is there anything else to wrap up communication? Because I mean, we could go on for days, but just to make it useful.

[Libi]
We could go on for days, I’ve made a couple of notes for you said for like a dentist who’s not really good at it, you know, relating to kids. So when I first started pediatric dentistry, my kids were quite young. And so I didn’t feel I was able to communicate with me to the teenagers. And what I found is I just needed to find one topic that they liked, and learn a lot about it. So for example, when fortnite became craze, I sat down somebody likes fortnite and said, Tell me about fortnite. And I just learned the key phrases that I would need to say, to look as if I was into fortnite, I would say ‘Do you play fortnite?’ ‘Yeah, I play fortnite.’ ‘I’ve only won one Battle Royale.’ I have no idea what Battle Royale is. But I’ve learned that ‘I have won one Battle Royale. How many of you won? And they’ll say ‘Oh, no, I just, my tactic is when they throw you I just hide where they land me and stay there until it’s over. And that’s how I won that one. But I’m not good at playing it. And I’m still on the first skin just like a purple bear.’ I have no idea.

[Jaz]
They must be mortified. The parents must be absolutely mortified.

[Libi]
And but do you know it’s just that icebreaker, it’s that child feeling as if you know something that they know it’s like easily. So even something as simple as putting a sticker on your tunic that day. So on your scrubs, put a superhero sticker on your scrubs. All children know the Avengers, all children know Peppa Pig, even if they don’t like that character, you know, Mickey Mouse, you know, they all know these. It’s something familiar. And once they start to connect you to something familiar, that immediately brings down the anxiety in that child. So just and you should have a favorite movie. So like your homework as a dentist is to have one really , one movie that you know so much about that you could sit there and talk to the child for 10 minutes about you know, ‘Oh, I love this song’

[Jaz]
Toy Story. Definitely, Toy Story for me.

[Libi]
Yeah. So even if they don’t like that movie, it’s just about you having a favorite movie that is something child friendly, that you can talk about and that they can kind of say, ‘Oh, no, I really don’t like the act.’ ‘I know oh, this is my favorite. Don’t you like it when this happens?’ And it’s just about it’s distracting them. It’s making them feel comfortable because you’re, it’s something familiar that they know about. So that’s my tip for dentists. So just try and find something that even if it’s the same thing and your nurse will get sick of you talking about the same thing each time, but it is just about making them feel comfortable and giving if you’re in private practice. And you have the opportunity or the funds to be able to give them something other than a sticker. There’s actually studies that have shown that, you know, cooperation and everything improves, when you give them a small prize, it doesn’t even have to be something amazing. Even like a bottle of bubbles, or like a small bouncy ball, or you know, a pencil, just something that is not a sticker. Because stickers these days, children aren’t too fussed with them. [Jaz] Brilliant. Okay, good to know. [Libi] I mean, I have a sticker, which is personalized, and it says, you know, I’ve been to see Dr. Libi today at the Berkeley clinic. So for me, that’s you know, reinforcing that, you know, that they came to see me and you know, I think it just helps them it’s a bit more personal than just a generic sticker. But at the same time, I give them a price so I have a box, a treasure chest. And what I do is when I’m out if I see something you know, on sale, pencils, whatever. Even those sticker cards which are like a pound a pack, you know football cards and frozen stickers and whatever you can pick up in the supermarket and just having those on hand, it gives them that reward at the end of the appointment and it makes them feel good and it does help them to come back because it’s ‘Oh at the end I get this treasure you know to pick from.’ That’s the last thing that sees

[Jaz]
I imagine you actually have, I imagined you actually have a like a brown treasure chest do you? [Libi] It is. [Jaz] Yeah, I expected not less from the Libi. That’s how the doctor Libi’s list, ultimate list for prevention. Shoot.

[Libi]
Okay, so tips for prevention. First thing, fluoride application, always to ask if they’re having fluoride. You know, I think in England, they don’t do it. In Scotland, they do it in schools, but apply fluoride you have nothing to lose if the parent is fine with having the fluoride on their child. Every time you see them every six months, put some fluoride on when you put the fluoride on, make sure that you use a flosser to get it in between the contact. Okay? That’s where does all, Where did all the Lesion start? Interproximally we should be telling parents to floss their children’s teeth. I don’t know why it’s not a normal thing, because that is where all the caries starts. So we need to be telling them to floss. That’s the second promote flossing, especially when you’ve got the six erupted that contacting with the E. That’s really important. Fissure seal. So now the guidelines have changed. You seal every six. It doesn’t matter if the child is high caries risk or low caries risk. You seal those sixes and you check those seals every time they come in to you. Okay?

[Jaz]
Can I just stop you on that one. So fissure seal on the sixes, Isn’t there some evidence suggests that fluoride varnish is just as efficient or efficacy? Is that the word? Of as doing a fissure sealants. So fluoride varnish, fissure sealants, there’s no difference. Am I right?

[Libi]
Yeah. But now there’s newer evidence to say that fissure sealant is actually superior. And that’s why the, we have Scottish guidelines. So the SDCEP guidelines. And those guidelines changed in 2018. To reflect that new evidence. And to say that we actually be need, we need to be sealing, we’re going to seal all sixes, and sometimes in a high risk child. So if I have a child who’s had caries, and they have deep on their Ds and Es remaining ones that aren’t carious have sealed those as well. Because what sealing is just so quick and easy. And it just it means that that tip is easier to clean. And it just gives that, gives the child a better chance. Okay, so fissure sealant, and also something really interesting. So when I went into school, and I gave a talk to one of my daughter’s classes, one of the mums sort of sent me a message later on with a picture of her daughter’s tooth, it was a six and it had to pit on the palatal site. And she only discovered that pit because I had given her disclosing tablet. And she had chewed it and the mom was looking at her teeth and said, Why is there a pink dot you know, that side of her tooth, and it was a powerful pit. So we need to be checking these sixes for palatal pit. Because if you seal them, then you’ve saved that tooth from developing caries because even in the best oral hygiene if you’ve got that there’s a high chance that will become caries just because at the backtrack so looking at so it might it ideally if you can disclose the child’s teeth and have a look at them yourself. That’s pretty cool. And it’s quite you can use it as the motivation and you know, teaching experience for the child and parents. And yeah, so I would actually recommend anybody who has any interest in treating children reads the SDCEP guidelines for caries management in children because it gives a very good comprehensive overview of what to do and it really guides you so well and it’s got visual aids you know, pictures and things. It tells you how to speak to parents, how to motivate families. It’s just a really great guide and it’s easy to read. And I mean, I think it’s an invaluable tool.

[Libi]
Absolutely. And I’m gonna put all these files like the SDCEP and also the social stories app a link to so stories app on my website and also on the Protrusive Dental community Facebook group. So that’s amazing. Do you have any more of those prevention gems?

[Libi]
I think that’s it really for prevention.

[Jaz]
So let’s wrap up. That was part one, let’s say that was part one. Because there was so many so much to learn. I’m glad it went that direction with the communication gems, I think that one will gain so much from that.

Jaz’s Outro: Thank you so much for listening all the way to the end. That’s all we have time for this episode. The second episode will be out very soon. If you found this useful, or if you know someone who sees children they may not enjoy it so much or there are some aspects, clinical or communication aspects which they struggle with. Please do share this podcast episode with them as well as the next one, and I’ll catch you then stay safe. Stay well.