"Oh boy…Mrs. Jones is coming in today. She hasn't had a FMX since 2006, she never wants one, she always declines, and she’s probably not gonna do it today, either. I'll see if I can get her to agree to four bitewings, and hopefully she doesn't get mad..."
As hygienists, how many times during our careers have we heard a conversation just like this during a morning meeting? We know the generally accepted standard of care includes periodic full-mouth x-rays. But how do we effectively reach patients who are “resistant” to the care you know you have to deliver?
First and foremost, we are more effective if we believe in what we do as hygienists, plain and simple—wholeheartedly, without apology, and without thinking that we’re delivering "bad news" to our patients when we have to inform and educate them. We need to believe in the standard of care requirements (SOC) that we are bound to uphold, not only for the sake of reducing our liability (and our practice's), but also for the optimal health and proper diagnoses of our patients. This belief has helped me immensely when approaching resistant patient about standards I need to effectively and properly treat them.
Responsibilities vs. rights
Dental professionals understand that these standards were developed to benefit patients, and not holding our patients' care to this level becomes unacceptable to practitioners who agree with this philosophy. We have our own liability, legal responsibilities, and ways in which we cannot veer from what we know is correct and expected.
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From a legal standpoint, hygienists have far more responsibilities than rights, and patient have far more rights than responsibilities. Patients have the right not to know their oral health status if they don't want to. Practitioners don’t have this right—legally, we are responsible for recognizing, codiagnosing, documenting, and reporting to the patient the oral disease process going on in their mouth and body.
The steps to take for compliance
The first step in compliance is not being afraid to talk to the patient. In the hypothetical scenario with “Mrs. Jones,” we’re already predicting the outcome without even attempting to do our best. Alternatively, sitting the patient down in the chair and having a confrontation or ultimatum right off the bat is going to backfire every time. Even if we can persuade the patient with these methods, the results will leave everyone involved feeling deflated.
The second step is taking the time to talk with the patient. This may take a portion of the appointment that's typically for treatment, but adjusting and being flexible to allow for communication will actually save time at future appointments.
You can start the appointment by simply asking the patient how they are, how they’re feeling, and if they have anything to bring up. These questions may open up the subject of, for example, their radiographs all on their own. Let’s say tooth #14 has been bothering them recently; you can then explain how you’ll need a periapical image to see the root's end and surrounding structures. You can also mention that the doctor is going to want to be sure that there is no infection. (I prefer to use lay terms as they help patients feel heard and included.) This is when you can respectfully reference that the subject of needed x-rays (I say "images") came up today with the doctor at the morning meeting. You can even lighten things by joking that their tooth "has good timing today, since the pictures are due anyway.” Such lightheartedness can be useful at times.
Continuing the dialogue
At this time, bring up the older FMX (or your own FMX if they've never had one) and put it up on the monitor to see together. Drag your finger across the bitewings and say something like, "These are the ones we take every year; we call them bitewings, and they are a beautiful survey of the teeth. We can see in between for cavities and check your restorations, and these pictures serve a purpose. But as you can see, the root ends are just ‘chopped off’ in the images because we’re trying to get so many teeth into one picture."
Then drag your finger around the apicies of all the periapicals, explaining how "Every so often we really need to see the root ends of your teeth because this is where an infection or a problem in the bone would lie. Often, these you can have these problems without any symptoms or awareness. We are responsible for you, and these standards are how we take good care of you."
At this point in the conversation, the patient’s ideas against consistent and on-time imaging may already have come up. If not, it's best to not inquire, because then we have to overcome their objections. Asking, "Is it money?" or "Is it radiation?" only brings up the objection. The discussion so far has probably already sufficed, but if there is still resistance, it's appropriate to then bring your doctor into your dialogue with your patient. For example, "I spoke to your dentist this morning, and we did discuss your case. We looked at the fact that your full-mouth series of images is 17 years old, and this caused them great concern. I know that with a tooth bothering you today, they are going to agree images are very needed."
Being clear is very effective, but being threatening or using words like "insist" or "demand" are not going to serve the purpose of guiding our patient to compliance. Setting an expectation can be clear, but kind, at the same time.
The most important aspect is our belief in the full-mouth x-rays. We do not need to apologize for the necessity or the cost of the images; it is well-known that concerns found early on in an image can save the patient so much time, money, and heartache in the long run.
Together with the patient, we can find pathology when it is a controlled situation and not an emergency. A wise person once said, "an ounce of prevention is worth its weight in gold,” and that it certainly does apply to dentistry. When we believe in what we recommend as hygienists, as specialists in our field, our delivery comes across effortlessly and authentically. Patients will respond to steadfastness in our words and confidence.
Erika Flateau, RDH, has been a full-time clinical dental hygienist for 21 years. She developed a relational-based and revolutionary approach to hygiene care. She is regarded by dentists as having an unparalleled ability to connect with and engage patients as they discover their pathway to optimal health. She is effective at confidently educating others and “coaching them up” to a greatest potential.
