Maintaining control of problem patients
Life is tough enough for a hygienist trying to keep up with technology, accumulate CEUs, maintain a daily schedule, choose the best products, complete paperwork, sharpen instruments – well, you get the picture. Life is tough enough without adding in many hygienists' greatest fear: the problem patient.
Whether it's 4-year-old Tyler, who can scream like a fire whistle; 37-year-old Susanna, who is hypersensitive and deathly afraid of needles; or 56-year-old Ed, whom the assistants call Mr. Passive-Aggressive, the problem patient can ruin a good day at work faster than an electrical outage.
For many such patients, their problems can be distilled into just one word: fear. What kinds of things frighten patients? There's loss of control – that's a big one. When not-very-brave Ed sits in your chair, he knows he will be required to lean back in a vulnerable, open, powerless posture and submit himself to uncomfortable procedures that he may perceive as painful. So what does he do? He huffs and puffs, takes phone calls, texts his secretary, looks at his watch, opens halfway, and keeps his head turned away from you.
Fear of pain is another biggie. Hypersensitive Susanna knows before she sits down that she's in for a world of hurt, so she becomes a problem, too, in her own apologetic way. She constantly jerks and twitches, gasps and fidgets. She's polite, contrite, and helpless, but she's still difficult. If you decide on anesthesia to handle her problem, she reveals a new one. She has needle phobia.
Fear of the unknown is what motivates children like Tyler to misbehave at the dental office. "Will it hurt? What will she do? Will it taste bad? Will it hurt? What will I have to do? Will it hurt, will it hurt, will it HURT!?!"
Fear of embarrassment keeps many people away from the dental office. It might be as simple as not wanting to hear another lecture on dental floss, or as complicated as not wanting to be touched because of past abuse. If you can identify a simple problem like fear of the dental floss lecture, don't give the lecture anymore. Find useful, nonjudgmental alternatives instead, and your patients may be more faithful with appointments. For more complicated problems, intervention by a mental health professional might be indicated.
Dental anxiety and stress
Remembrance of a traumatic dental experience has been called a type of post-traumatic stress disorder (PTSD), and it can be very real. In one particular small town where I worked for several years, patients would repeatedly describe a dentist they'd seen as a child. Apparently his method for handling children was to put his knee on their chest to hold them down as he worked. That one insensitive dentist created a lot of PTSD for the patients in his town. Encouraging patients to articulate their fears can be the first step to desensitization.
Dental anxiety has been widely studied, and can be quantified with various assessment tools. Some of the tools use simple questions that patients rate on a numbered scale; others use pictures of smiling, nonsmiling, or neutral faces that a patient can choose to describe their feelings about dentistry.
The McGill Pain Questionnaire is used to assess patient pain. The widely used Corah's Dental Anxiety Scale (DAS) rates patients' feelings of anxiety toward dental treatment on a scale of one to five, with five being the most anxious choice. DAS scores can range from four to 20. A score higher than 13 usually is considered to indicate severe anxiety. There is also a Dental Anxiety Scale Revised (DAS-R), which adds a question about dental anesthetic. This scale was used in a 1998 study in Michigan.1 The study concluded that dentally anxious people are more likely to be female, with lower levels of income, and with poorer oral health status than average. They have less than favorable attitudes toward dentistry. The study also concluded that age, race, and educational level were not correlated to anxiety.
Whether or not you use an assessment tool to measure a patient's level of anxiety, the question remains: what will you do to alleviate the anxiety? If you don't alleviate it, the patient will probably disappear, not to resurface until they're in severe pain.
Just as problem patients can be described with one word (fear), so the solution to the problem can be described by another single word: communication.
Let's start with Ed, also known as Mr. Passive-Aggressive. He deals with his anxiety by pretending dental care is unimportant – just something to be squeezed into his very important, busy schedule. If he can distract himself with enough other things, he won't have to deal with his fear. That might work for a 4-year-old, but Ed needs serious dental care, and he needs to accept ownership of it.
One of the frequent complaints of hygienists is that they "can't stand it when patients use their phones in the chair." Here's a simple solution to that problem: don't let them. I once saw a sign at a package drop-off store that read, "Please complete your phone call before you approach the counter." I immediately wanted to put a similar sign in my operatory, but instead I just ask for the phone. "Let's put that on the counter until we're finished," I say. No one ever refuses.
Instead of reclining Ed's chair immediately, sitting at his shoulder, and charging ahead with everything that needs to be accomplished during the appointment (while he pointedly ignores you), swing your stool around to face him as he's sitting upright. "Ed," you might say, "I need your complete attention for a moment. Let's discuss what we'll do today, and how we can make it easy for you." Ask if you can put his cell phone and his newspaper on the counter so he won't be distracted, tell him you need his help, and keep up a steady flow of information to compel his attention. Ask questions that he has to think about and answer. Instead of saying, "Have you been flossing?" say, "Ed, what do you use to clean between your teeth?" As you begin your procedures, describe what you're doing, and ask what he thinks, how he feels, what he might try at home. If you make a concerted effort to draw your patient in and involve him in what you're doing, he won't have time to huff and puff and wish for his phone.
Susanna, the very tender patient with needle phobia, might be tougher to control. The first step in a successful appointment for Susanna has to be successful communication. Reassure her that you will do everything in your power to give her a pain-free experience, and remind her you have many tools at your disposal. Don't hesitate to break up her treatment into two or three short appointments to accomplish what you would ordinarily do in one appointment.
If her hypersensitivity can be handled with something like Colgate Sensitive Pro-Relief or Sylc desensitizing powder, the problem is solved. But what if only a local anesthetic will do?
Phobias and genetics
Did you know that needle phobia is genetic? A study done in Pittsburgh last year2 reported that there is a "significant familial psychological component" to needle phobia, showing evidence of inheritance. It is also a learned behavior, of course, and can be triggered by past traumatic experience. Bradycardia, hypotension, unconsciousness, and convulsions can result from a severe phobia. Phobic patients sometimes feel like medical personnel underestimate or ignore their fears, which leads to increased anxiety and avoidance.
A severely phobic patient should be referred to a specialist for behavioral therapy, but simple desensitization techniques can be used for mildly phobic patients.
A case report of desensitization therapy done in 1992 in Nebraska describes a patient in need of dialysis who could not face needle insertion. For one week, he practiced behavioral therapies of exposure and desensitization. First, he was taught techniques to counter syncope and bradycardia, such as sustained and sequential tensing of muscles to prevent peripheral vascular pooling, and thinking of a situation that made him feel angry or insulted in order to raise his blood pressure and pulse. He had three one-hour sessions with a therapist who simulated needle insertion with a pointed needle cap against his skin. When the practice sessions became unbearable, he reverted to the behavioral therapy techniques he'd been taught. He also practiced at home twice a day. By the end of the week, he was able to begin dialysis.3
Practice Without Pressure
These desensitization techniques are similar to those used by an organization called Practice Without Pressure (www.pwpde.com). PWP was founded by a parent who needed a better way to help her Down syndrome son deal with medical and dental appointments. Physicians, dentists, hygienists, a dental assistant, a phlebotomist, and even a hair stylist are on staff to develop ways to help phobic patients cope with clinical and personal care. They use flash cards and practice sessions to familiarize anxious patients with the procedures they will face at the doctor's office, dental office, barber, and hospital. Sessions include using an opened paper clip to simulate needle insertion. PWP accepts Medicare and Medicaid reimbursement as well as most major insurances.
PWP can be a great resource for a parent dealing with a difficult child who can't accept dental treatment, but sometimes all that is needed is – you guessed it – communication. For children, communication is often called tell-show-do, a magic bullet for most nervous children.
Tips for dealing with nervous children
An article in Dentistry Today4 lists five tips for dealing with nervous children:
- Parental involvement
The first of these – information – is the most important. "Tell-show-do" means just what it says. Tell the child, in age-appropriate language, what you intend to do. Show the child exactly what you will do – six times, if necessary. Then do it.
Let's take Tyler, the 4-year-old screamer. The trick is to catch him before he screams. If he's screaming, he can't hear you, and sometimes that's the point, for him. Meet him in the waiting room, get down on his level, and tell him exactly what will happen in the next few minutes. Tell him that it's OK to be nervous, but it's not OK to be bad or rude. Look him right in the eye and say very seriously, "I will not hurt you." Let him know that in two minutes, you'll be back to take him to the chair. As long as he pays attention and listens, you can add that Mommy will stay with him. If he's fussy, Mommy will have to wait in the waiting room. "What will happen if you start screaming? Can Mommy stay with you? No, she can't. What will happen if you're a good boy and listen? Mommy can stay and hold your hand and watch you, can't she? Do you want Mommy to stay with you? Then what do you have to do?"
That two-minute intermission, for some reason, is a great thing. Most children accept the time limit and come to the chair with no problem. You might even use a small kitchen timer. Set it for two minutes. Then, when it rings, everyone knows the time has come, and it's not a surprise. After two minutes are up, you can take Tyler and Mommy to the chair, reminding him of his promise to listen so that Mommy can stay with him. Keep up a constant stream of information, and never let anything be a surprise. Tell him again and again what you are doing, show him how everything works and feels, then take a firm hold and start your treatment with no hesitation.
In eight years of working in pediatric dentistry, I've learned that if a child cringes back and cries, "No, no!" you can ignore him or her. Start anyway. Once the explorer or scaler or prophy angle actually touches a tooth, the child usually calms down because the worst has happened, and it didn't hurt after all. Frequently I'll scale or polish one tooth, then stop and say, "Are you OK? That didn't hurt, did it?"
Relaxation, the second tip, can also work wonders with anxious children. Ask them to take a deep breath. You might even keep a jar of bubbles for children to blow as a relaxation exercise.
Distraction can take many forms. Contingent distraction relies on the child's good behavior. "Tyler, if you hold still and act like a good boy, I'll give you a headset and you can listen to Sponge Bob songs. How's that?" Noncontingent distraction is anything else that will work. I keep two soft, squishy balls in a drawer that children can hold and play with as I work. Usually it keeps their hands down and their attention elsewhere. A favorite toy or doll can also provide good distraction or security. Sometimes I talk about an upcoming birthday or a new sibling or the next school year, projecting the child into the future. If I can get children to think about being a good role model for baby brother or where they might go for a birthday party, they don't have time to worry about how the prophy paste tastes. My boss frequently sings to children – crazy songs that he learned at summer camp, 1960s doo-wop songs, or even a made-up ditty about the child in the chair.
Reinforcement is also important. I like to ask the child to look at their mother. "Is Mommy smiling at you? That's because you're being such a good boy. I'll bet she's going to tell everybody she knows what a big boy you were at the dentist's office today. Maybe you could even call Grandma and tell her what a good job you did." Frequent praise for every small achievement bolsters the child's sense of accomplishment. "Tyler, you're the best spitter I've had all day. I wish everyone could spit as well as you."
Parental involvement can be sticky. Sometimes all parents do is cause problems, and in that case you shouldn't hesitate to ask them to step into the hall or to let you do the talking. Most of the time, though, they provide needed reassurance. They're good hand-holders, if nothing else.
Obviously some patients, such as victims of past abuse, need professional help to deal with dental anxiety, but in many cases the competent hygienist can manage the problem successfully and help the patient control his or her anxiety. Compassion, communication, and caring are the keys to success.
Cathy Hester Seckman, RDH, is a frequent contributor based in Calcutta, Ohio. Besides working in a pediatric dental practice, Seckman is a prolific freelance writer, a book indexer, and a speaker on dental and writing/indexing topics. She can be reached at [email protected].
1. Doerr et al. Factors associated with dental anxiety. J Am Dent Assoc. 129(8):1111.
2. Sokolowski CJ, Giovanniti JA Jr., Boynes SG. Needle phobia: etiology, adverse consequences, and patient management. Dent Clin North Am. Oct. 2010; 54(4):731-44.
3. Praveen P, Fernandes MD. Rapid desensitization for needle phobia: case report. Received Aug. 7, 2002; accepted Oct. 24, 2002.
4. Five tips for managing pediatric dental anxiety. www.dentistrytoday.com/pediatric-dentistry/1576. Accessed 12-23-10.
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