I am writing about a concern I have never faced before. I have a patient with moderate to severe gum disease. He has adamantly refused to come in more often than every six months. Over the past three years, he has been very irregular in coming in for care.
However, the real problem is that he will not allow me to scale subgingivally or probe at all. I've explained that just cleaning above the gumline isn't helping, and that his condition won't get better until the calculus is removed from under his gums.
We've offered to use local anesthesia, but he "does not want any shots." We've offered to use nitrous oxide, but he refuses that as well. I have encouraged him to be more thorough with his homecare, but he will not floss because he says it hurts.
Every time I see his name on my schedule, I get a knot in my stomach. I dread seeing him. I know there is so much more I could do to help him - if only he would let me! I actually feel like I am doing him a disservice by only partially cleaning his teeth.
The doctor requires him to sign a form saying that the diagnosed disease, if left untreated, could result in periodontal abscesses and/or tooth loss. Our hope was that the threat of impending pain might nudge him to accept the recommended treatment. However, so far there has been no change in his attitude.
I keep hoping that someday he will allow me to help him have healthy gums and comfortable dental care. Is there something more I can say to get the point across?
Shackled in Charlotte
I can identify with your feelings of frustration over the patient who will not allow you to do your job. Several years ago, I had a female patient with numerous composite restorations on her maxillary anterior teeth. Every time she came to see me, she would point to those teeth and say, "Please do not touch these teeth, because I do not want you to pull my fillings out." I would stifle a groan and say in my sweetest voice, "Why, Mrs. Jones, I wouldn't dream of pulling your fillings out!" As I would start to explore around tooth No. 2 and make my way forward toward the anterior, she would point her finger and grunt, "Uh, uh, uh ..." until I skipped over to No. 11. I could actually see calculus peeking out from the gingival margin. She would never allow me to scale those teeth. The doctor, a quiet and nonconfrontational type, instructed me to do as she wished. He said that when she eventually lost the teeth, he would make her a denture!
The gentleman you describe sounds like a genuine dental phobic. These people don't want to lose their teeth, but they lack the courage to face treatment. They often perceive local anesthesia as a horribly painful experience. Phobics work hard just to garner the courage for an appointment.
Patients often equate a "cleaning" with a simple procedure. This patient still comes to see you because his perception is that a cleaning should not hurt. However, when patients present with periodontal disease, we know they need much more than a routine prophylaxis.
Since pain seems to be the issue and the patient has resisted local anesthetic, you may want to try some of the topical anesthetics. The "Denti-Patch" by Noven gives profound anesthesia to the tissue in areas where you can get it to stick. Ultradent (800-773-6372) sells topical anesthetic in syringes that can be squirted in the sulcus. Also, using a small amount of gel topical anesthetic on the tip of a periodontal probe can be helpful in taking the edge off a procedure. Beutlich Pharmaceuticals manufactures a wonderful dry-handle swab containing a liquid topical. When pressed at the gingival margin, it provides some tissue anesthesia into the sulcus. Beutlich's anesthetic is called Hurricaine (800-238-8542).
Another recommendation is to use your ultrasonic scaler for the major portion of the appointment. If the patient is sensitive, turn the power down to low and debride the sulci thoroughly. If the dentin is sensitive, you may apply a dentin desensitizer, such as HurriSeal (also made by Beutlich) to ease the discomfort. Even if you do not remove all the calculus, the debriding action of the tip will be more beneficial than hand-scaling alone.
Regarding communication with this patient, here is what I recommend. After examining the patient's mouth and doing what he will allow you to do, sit the patient upright. Sit at eye level with him and say: "Mr. Bunker, correct me if I'm wrong, but I believe you are interested in keeping your teeth or you would not be here today. Am I right?"
Patient agrees, possibly reluctantly. You say: "You remember that the doctor and I have found that you have an infection in your gums. Now the funny thing about this infection is that it is usually not painful until the teeth start getting loose or abscesses occur. The good news is that we can help you get this infection under control. The bad news is that this infection is going to continue destroying bone unless it is treated. So now, tell me what you would like for us to do."
Then stop and let the patient talk. If the patient refuses to talk, take that as your answer that he does not wish to proceed with treatment. Keep in mind that you can only do as much as the patient will permit. If he will not permit you to do a more thorough job, don't feel bad about it! Although you may feel that it isn't enough, even a light scaling is better than no scaling at all.
Some doctors seriously consider dismissing such a patient from the practice. Having a patient sign a form stating knowledge of pathology and refusal of treatment may not stand up in court, should the patient force future legal action. No doctor can give permission for negligence. Therefore, be sure to document every conversation with recalcitrant patients.
Phobic patients want and need our help. Showing patience and understanding will go farther than chastisement and frustration. If you can put yourself in your patient's place and imagine the fear he feels, it will be easier in the future to treat him, regardless. Furthermore, if you ever win this man over, he is sure to be one of your most loyal patients!
Dianne Glasscoe, RDH, BS, is an adjunct instructor in clinical hygiene at Guilford Technical Community College. She holds a bachelor's degree in human resource management and is a practice-management consultant, writer, and speaker. She may be contacted by e-mail at [email protected], phone (336) 472-3515, or fax (336) 472-5567. Visit her Web site at http://www.professionalden talmgmt.com