Eileen Morrissey, MS, RDH
Does this scenario look familiar? You’ve seated Mrs. Patient, made small talk, updated her medical history, and taken her films. It’s now time to recline her in the dental chair, and as you attempt to do so, her eyes widen and a look of apprehension flashes across her face. The further you lower the chair, the more upset she appears. She pleads, “Please don’t put me back so far!”
Why am I noticing this more and more frequently with patients? I believe it is for a number of reasons. Let’s look at some of the factors that can contribute, as well as potential solutions.
I’m going to focus on nonmedical influences first. I believe that part of this is simply due to control and the fact that some patients likely perceive that we remove much of their control when they enter the dental setting. They lie there in a total state of vulnerability, opening a portion of their bodies to us that almost no one gets so up close and personalwith.
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Never mind that it makes our work more difficult when patients do not wish to comply. In fact, when we share our collective miseries about our aching backs, necks, etc., we are typically not heard. I have found a disturbing trend: more than ever before, patients in today’s world are assertive and demanding. This is their appointment, their insurance, their time, and they will not be inconvenienced in any way.
When up against this attitude, a few strategies are worth trying. One approach is to move the patient back gradually in short increments. Using a pillow roll (or something that can be substituted as such) is also a good tactic. The patient can be positioned further back, but his or her head is still somewhat upright. It’s not great, but it can work.
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I know an RDH who places patients in a position that is almost the Trendelenburg (supine with legs raised 15–20 degrees above the head). This is an extreme that is obviously not needed for her to work effectively. Her patients are often relieved when raised a bit so that they are supine—precisely where she needs them to be!
Verbally, some RDHs have success by saying to the patient, “I can keep you up further, but it increases the risk of making your scaling more uncomfortable because of the compromised positioning. I won’t be able to see as well or get the best angle on my instrumentation.” In some cases, the patient’s fear of scaling discomfort may supersede the perceived need to be more upright in the chair. Warning: this puts patients in defensive mode. Read on for a superior approach.
Linda Hirce, RDH, a practicing dental hygienist in Colorado, has these words of advice: “I never had a problem with putting people back. I may start with complainers a little more upright, but slowly while going around the mouth, I would tell them, ‘I need to lower you just a bit to better see this lower left side.’ Always I would touch their shoulder, bib of course, as I said it. In fact, I would give what I call a comfort touch on the shoulder any time I lowered the patient.”1 For the record, I think that Linda’s approach to patient management here is superb! She gains trust early on. Once achieved, if a change in position is indicated, she requests it as needed. Win-win!
Another challenge is the patient who is fine with reclining in the chair until the ultrasonic is going to be used. Some, particularly elders, may feel as though they are drowning in this position. This can be a big challenge since most of us do not have a staff person available to suction for us. Since I do not wish to sacrifice my use of the ultrasonic on patients with mouths that will truly benefit, I keep the patient upright and stand to do my work. I’m not crazy about it, but I do it. I also know RDHs who have learned to use the ultrasonic in one hand and the high-speed suction in the other. They do not use a mirror and are able to minimize the volume of water. Also, there are numerous other products available that can help to control water flow if one is so fortunate as to work in a practice that will allow the use of these technologies.
What about patients who truly have issues with dizziness and vertigo? This is a trend I’ve seen increase. I questioned an ear, nose, and throat (ENT) specialist (a patient!) who practices in Lawrenceville, New Jersey, for his take on why so many more patients are experiencing vertigo. He stated (preferring anonymity) that more people are being diagnosed with benign paroxysmal positional vertigo (BPPV).2
BPPV is a condition common in older women. Given the aging of the baby boomer population and the fact that women are living longer, it’s inevitable that we are going to see more patients who are affected by this. While the symptoms of BPPV are unpleasant, the cause is benign. The symptoms are triggered by certain positions of the head and often reoccur. The person might feel as if she is moving, although she is not, or unsteady, akin to being on a ship. Nausea can occur, although usually people do not vomit.
The dizziness associated with BPPV is generally thought to be due to debris (known as otoconia) that has collected within a part of the inner ear. Imagine calculus-like particles found in the utricle, a structure within the ear. For whatever reason, they become disengaged from the gelatinous material that normally houses them, and end up, abnormally, in the canals that perceive the head’s rotation. There, they clump together, potentially causing a heavy load that sinks to the lowest segment of the inner ear. Now, the nerve receptors are stimulated abnormally as the head moves. This is not good because the inner-ear fluid then sloshes around, which results in the individual feeling as though she is still moving despite not doing so.3
Vertigo is the consequence of this abnormal stimulation. It is not always clear why the crystals become disengaged. It is thought that traumatic head injuries can be a cause. Those who suffer from migraines can be subject to recurrent episodes; both conditions are more likely in younger patients. However, since parts of the inner ear begin to deteriorate with aging, BPPV can strike the older population as part of this process. The average age for BPPV is 51.4
Unfortunately, there is no known “cure” for BPPV. The good news is that it often simply disappears after several weeks or months. (I know more patients who achieved this positive outcome than patients who did not.) Others may find relief with treatments known as canalith repositioning maneuvers. The goal of these is to move the particles from the inner ear into a vestibule where they can be more easily reabsorbed.5 While an ENT specialist can help with this, I’ve also known people who have self-treated by viewing videos on YouTube that demonstrate said maneuvers.Disclaimer: This is not advocacy for self-treatment of any medical condition.
What activities can precipitate symptoms? These vary, but the common culprit is when the head changes position in a manner implicated by gravity—for example, when the person simply rolls over or rises from her bed.6
Being aware of BPPV and these triggers can help us understand why patients are so fearful about being reclined in the dental chair. I have had clients report that they were worried about needing to turn their heads toward me in a clinical session, in addition to the initial fear of the chair being tilted back. I admit I did not realize the potential impact until a 67-year-old close friend was recently diagnosed. She went through a horrendous time and reported that there was no way she would undergo a dental visit while enduring this.
I have found that what works well in helping patients with active BPPV is to move the chair back first to a position that approximates where you want the person to be during treatment. Then allow her to lower herself back to that position. I also try to minimize how much I ask the patient to turn toward or away from me. “Since falling can be a direct consequence of dizziness and vertigo, and the risk is compounded in elderly persons with other neurologic deficits and chronic medical problems,” safety in getting the patient out of the chair at the close of the appointment is extremely important.7
Recently, I had a patient who experienced his first episode of vertigo in my treatment chair. As I raised him, he told me that the room was spinning. I waited as he sat for a few moments until things appeared to normalize and it seemed safe to escort him to the front.
Having more awareness about this syndrome is useful in helping patients with vertigo to be comfortable, and it can only serve to enhance patients’ positive perceptions about their dental hygiene visits. Strategies to help practicing RDHs counteract patient control issues help us all—a win for all parties.
References
1. Email exchange with Linda Hirce, RDH. Broomfield, CO. July 15, 2018.
2. Dialogue with Anonymous ENT, MD. Lawrenceville, NJ. July 20, 2018.
3. What is benign paroxysmal positional vertigo? WebMD website. https://www.webmd.com/brain/benign-paroxysmal-positional-vertigo#1.
4. Li JC. Neurologic manifestations of benign positional vertigo. Medscape website. https://emedicine.medscape.com/article/1158940-overview. Updated July 23, 2018.
5. Benign paroxysmal positional vertigo (BPPV). Mayo Clinic website. https://www.mayoclinic.org/diseases-conditions/vertigo/diagnosis-treatment/drc-20370060.
6. Hain TC. Benign paroxysmal positional vertigo. Dizziness-and-balance.com website. https://www.dizziness-and-balance.com/disorders/bppv/bppv.html. Updated September 4, 2017.
7. Samy HM, Hamid MA, Friedman M. Dizziness, vertigo, and imbalance. Medscape website. https://emedicine.medscape.com/article/2149881-overview. Updated March 13, 2017.
Additional sources
• Xing G, Chen Z, Bu X. Diagnosis and treatment of horizontal canal benign paroxysmal positional vertigo. Zhonghua Er Bi Yan Hou Ke Za Zhi. 2001;36(1):28-30.
• Britt CJ, Ward BK, Owusu Y, Friedland D, Russell JO, Weinreich HM. Assessment of a statistical algorithm for the prediction of benign paroxysmal positional vertigo. JAMA Otolaryngol Head Neck Surg. 2018;144(10):883-886.
• Bhattacharyya N, Hollingsworth DB, Mahoney K, O’Connor S. Plain Language Summary: Benign Paroxysmal Positional Vertigo. Otolaryngol Head Neck Surg. 2017;156(3):417-425.
Eileen Morrissey, MS, RDH, is a practicing clinician, educator, speaker, and writer. She is an adjunct dental hygiene faculty member at Rowan College at Burlington County. Eileen lectures nationally. Contact her at [email protected] or (609) 259-8008. Visit her website at eileenmorrissey.com.
