Noncompliant patients

May 1, 2010
Today, I am really frustrated! I just finished another patient with absolutely terrible oral hygiene.

by Dianne Glasscoe Watterson, RDH, BS, MBA
[email protected]

Dear Dianne,

Today, I am really frustrated! I just finished another patient with absolutely terrible oral hygiene. Most of these noncompliant patients are regulars in the practice whom I have seen numerous times. It seems that no matter what I say, nothing changes with regard to their oral hygiene habits. It almost makes me angry, because I feel they are not listening to me. Then, after they leave, I feel like a failure since I have not been able to get them to improve their home care.

Maybe I need to change my approach. Maybe I need an attitude adjustment. I’m teachable. Can you help?

Just sign me,
Drowning in CRUD

Dear Drowning,

Your post brought to mind a male patient I will never forget. Every time he came in for his appointment with me, he looked as if he had brushed his teeth with a doughnut. Really. The first time I saw him, I nearly gagged. A little self-talk helped: OK, Dianne, calm down. He’s just an old man who has a hard time standing near his toothbrush. I gently went through the home-care spiel and felt good about my efforts. Six months later, nothing had changed. I could feel indignation rising, and I wanted to get in his face and say, Didn’t you hear anything I said last time? How dare you come to me looking like this! I didn’t say it, but I thought it! OK, Dianne, try again. He’ll do better next time. Fast forward six months, and replay the tape. Nothing ever changed about this man’s home care. I talked myself BLUE in the face, and nothing changed. Over the 10 years that this man was my patient, I was unable to get him to brush his teeth any better. And when I read his obituary in the local paper, I knew this pleasant, 83-year-old man went to his grave with crud-caked teeth. Bless his heart.

Thinking back, though, something did change — me. I moved from seeing the patient as someone who resisted me to someone who needed me desperately. I slowly came to the realization that “not very good” was the best he would ever do with his home care. I met him where he was and became his friend. He loved to talk about his grandchildren and deceased wife. I accepted the fact that I could not change him, but I could help him sans the sermons. The interesting thing about this particular patient is that he did not have periodontal disease. He always had some gingivitis, but no pocketing. We tend to put a very high priority on individual home care and erroneously believe that everybody who has poor oral hygiene will eventually develop periodontitis.

It is probably time to update your approach as well. Here are some tips to help you improve your home-care education skills:

1) Nobody will ever change anything about their home-care routine without first developing self-efficacy. Self-efficacy is defined as people’s beliefs about their capabilities to produce designated levels of performance that exercise influence over events that affect their lives. They have to believe in themselves that they can actually do what you are asking them to do. You can help people develop self-efficacy by not asking them to adopt or master too many new behaviors in a short time. For example, your patient is more likely to develop self-efficacy if you teach one skill in an appointment, rather than expecting him or her to master flossing and brushing in the same visit. When teaching flossing, why not master just one quadrant, rather than the whole mouth? The same thing goes for teaching brushing with power brushes. Have your patient master one quadrant first, and then expand to other quadrants as he or she progresses.

2) If the patient cannot or will not floss, forget it. In fact, it is estimated that in the average practice, the number of patients who floss daily and correctly is about 15%. There are other methods for interdental cleaning that might be easier than floss. I really like the GUM BrushPiks.

3) People do not floss or brush their teeth while lying on their backs. Yet hygienists insist on teaching these skills with the patient in a supine position. For better learning transference, have the patient sit upright for any and all home-care instructions.

4) Do not use weak verbal skills, such as “You might want to think about flossing ... seeing a specialist ... getting this tooth crowned. Delete this phrase from your professional vocabulary. It is the equivalent of the “wet fish” handshake. Please understand people do not want to think about anything that is going to inconvenience them, cause pain (physical or financial), or make them do something outside their little routine. When we make statements like this, the message the patient gets is: It’s not all that important, really, if they just want me to “think” about it. Do you really just want them to think about something? Why even bring it up if that’s all we want them to do? In all fairness, I understand why we make such statements. We hate to give people bad news, so we try to soften the message by padding our words with bubble-wrap phrases.

Consider the difference between these two statements to a patient with gingivitis: “I’d really like for you to think about cleaning between your teeth with floss.” Or ... “Wow, look at this bleeding and inflammation! You have GOT to start cleaning between your teeth with something. You have a chronic inflammation that could even cause you to lose teeth if this continues. There are several things available, so let’s find out what works best for you.” It might be floss; it might be interdental cleaners.

5) Proper use of a good intraoral camera makes a good communicator become a great communicator. If you have an intraoral camera, use it often. If you do not have one, talk with the doctor about purchasing one. When patients actually see what you are talking about, it becomes easier to motivate them.

6) Please do not wait until the end of the appointment to teach home care. Reposition home-care instructions before scaling to give it the proper place of importance in the appointment sequence. This is especially true in periodontal patients. When you set the chair upright after completing a lengthy debridement procedure, the patient is more interested in how soon he or she can leave than listening to you drone on and on about home care.

Hygienists come out of hygiene school traumatized into the thinking that every patient has to reach some preconceived level of oral hygiene, or else the hygienist has failed. It’s time to stop beating yourself up. “Not very good” is the best some people will ever do with their hygiene.

Please do not take it personally when patients do not comply with your requests to change their home-care behavior. Understand that you provide a valuable service to people who trust their care to you. It is your privilege to have people with all levels of home-care mastery in your chair. If everyone were squeaky clean, they wouldn’t need you. Just think how boring your day would be! (Well, OK, we can dream.)

Best wishes,


About the Author

Dianne Glasscoe Watterson, RDH, BS, MBA, is a professional speaker, writer, and consultant to dental practices across the United States. She is CEO of Professional Dental Management, based in Frederick, Md. To contact Glasscoe Watterson for speaking or consulting, call (301) 874-5240 or e-mail [email protected]. Visit her Web site at

More RDH Articles