by Anne Nugent Guignon, RDH, MPH
Uh-oh! A quick glance at tomorrow's schedule indicates that your body is in for a day of agony. Bright and early, Barrel-Chested Bob, seven months overdue and full of calculus and stain, will be sitting in your treatment room. You have one hour to complete this appointment and the following hour you will see his wife, Big-Bosomed Bertha. Mrs. Don't-Put-Me-Back-Too-Far follows their two appointments, but any minutes gained will be lost by her frequent need to rinse even though she is relatively plaque- and calculus-free. And finally, before lunch, Genevieve the Gagger is on the schedule for an updated 20-film series of X-rays.
Later in the day, Mr. Completely Tense is scheduled for a full-mouth debridement appointment right after Peggy-The-Picky, who insists that you complete a perfect, pain-free hygiene appointment. She cannot turn her head in your direction and can barely open her mouth more than an inch. She winces in anticipation every time she expects a procedure to produce discomfort and always complains that she has a headache following every dental visit. The crowning glory to the day is Little Johnny Jump-Up, a restless, inquisitive nine-year-old, whose Mom, Penelope Protective, will remain in the treatment room overseeing your every move.
What a day! You are headed down the road toward a very negative, frustrating day. How will you ever make it out the door at 5:30 and not be tied up in knots mentally and physically? Stop and take a deep breath. The patients trust us. They want our care. There are a thousand reasons why they're difficult, but they are here to be cared for, and we have a professional obligation to provide the best care possible.
Every clinical dental hygienist who has practiced for more than five minutes has faced one, if not all, of these types of patients. Sometimes challenging appointments are spaced apart. When they aren't, we wonder who might be annoyed with us. Who would ever expect us to provide excellent clinical care for patients like this back to back?
But hygienists are very resourceful. We are amazing problem solvers. Let's look at some solutions.
First, if possible, let the scheduling staff know that it would be beneficial to have extra time for a particular patient. I urge you to initiate this dialogue. Some hygienists are fortunate to be able to do their own scheduling; others are in practices that respect the hygienist's recommendation for more time, just like a doctor's request for a longer appointment. It is silly for us to expect the scheduler to read our minds and know how much time we need. Remember, if you don't ask, then it can't happen.
OK, let's deal with Barrel-Chested Bob and Big-Bosomed Bertha. They are a wonderful couple, full of laughs and good stories, but you know how difficult it is to scale their teeth and try to maintain proper body posture at the same time. Large-chested patients force your elbows up and away from your body, giving one the appearance of a bird in flight or a Boeing 737. Magnification loupes allow you to work with the patient chair at a lower level because of the enlarged image, increased working distance, and adequate depth of field. However, this still may not solve the problem of trying to work around patients who are thick-chested.
Once the patient is reclined, additional upper-body support, such as a small pillow or even a roll of towels, can be placed under the neck and upper shoulders. Suddenly, the patient's chin rises majestically out of the chest, dramatically improving your access to the oral cavity. Positioning your operator chair directly behind the patient's head is another trick that is particularly helpful for accessing the mandible. The maxilla will be easier to reach from the twelve o'clock position if you have your patient tilt his chin up an inch or two toward the ceiling, similar to the head tilt/chin lift in CPR.
The Don't-Put-Me-Back-Too-Far Group just amazes me. Often, this is the first thing out of the mouth when one of these patients sits down in the dental hygiene chair. While there certainly are patients who find reclining very difficult, like those who suffer from conditions such as congestive heart failure or low-back pain, being reclined may really represent the patient's feeling that he is losing control over the situation.
I cannot recall the last time I heard a patient give a doctor the same type of directive — an unresolved mystery to every dental hygienist. At a recent continuing-education seminar, one clever hygienist shared her little secret with the audience. She recommended reclining the back of the chair slightly before the patient enters the room. The prepositioned chair makes her patients think that they are starting at point zero, rather than in an already reclined position.
Other options include helping the patient understand that it is necessary for you to be able to see in order to do a good job, or telling patients that you have back trouble and cannot work with them in an upright position. If you don't have back trouble, then this ploy can be classified as "stretching the truth"; however, I guarantee that backaches will be in your future if you try to treat patients who are seated in upright or semireclined positions while you are sitting down. The days of treating most patients in an upright position is as long gone as stand-up dentistry.
Standing during the hygiene appointment is a final solution, but today's treatment rooms do not lend themselves to long-term use of this option. One hygienist wears a back support every time she has a patient who is unable to recline. This is a smart practice when transferring wheelchair-bound patients to and from the dental chair.
I almost forgot about the frequent spitters and rinsers. They slow us down, but most of these patients are very sensitive to having excess fluid in their mouths. Many are gaggers, and a gagging patient is not easy to treat. Frequent rinsing with the water syringe and continuous low-volume suction will tame most, especially during polishing or debridement with hand instruments. Some patients feel more in control if they can operate the saliva ejector, which has its good and bad points. If you give patients too much control, they won't let you get anything done. Other patients are satisfied if the saliva ejector can hang comfortably from the corner of their mouth. Using a limited amount of low-grit polish can also improve the situation.
Lunch is on the horizon, but not until you have taken the full series of X-rays on Genevieve the Gagger. She is dreading the appointment and announces that she always has trouble with X-rays. Actually, I feel a bit of a challenge every time a patient says this to me, because I have a secret. Ever since I was little, I have been a gagger. Through the years, the reflex has become less active, but it is still there, so I feel a certain kinship with this group of patients.
First, keep the patient sitting upright. A semireclined patient will have a more sensitive gag reflex. Instruct severe gaggers to tuck their chin into their chest. It is nearly impossible to gag with the chin in this position. Some hygienists find it easier to take X-rays with their patients in a fully prone position. I've noticed, too, that patients who force their tongue against the film are the ones who have the most trouble. Remind them with every film placement not to do this. Finally, most patients notice that the gag reflex is more active in the morning, so an appointment later in the day is advisable.
If all the positioning in the world does not help, it is time to resort to chemical and mechanical warfare! A small packet of table salt is my initial weapon. Sprinkle a pinch or two on the tip of your patient's tongue and instruct him to swallow. One or two doses of salt does the trick nearly every time, even for a complete series of X-rays. Salt can be contraindicated for those on a sodium-restricted diet.
Patients may also rinse with a diluted solution of a water-soluble anesthetic like a generic Dyclonine, which can be made by your local compounding pharmacy. However, the entire mouth is numb far longer than it takes to expose the radiographs. Some patients find the edge of mandibular radiographs uncomfortable. Topical anesthetic applied to the soft tissue under the tongue can ease this discomfort and allow you to take the perfect film. Years ago, a very clever hygienist developed a foam pad called Edge Ease, which is applied to the edge of X-ray film. Other types of foam pads are available. One brand of film now features a rolled plastic edge.
Finally, the lunch hour arrives. There is just enough time to grab a bite to eat and get a bit of mental and physical R&R. It is so important to take a breather, stretch a bit, and even let your mind wander. There is no rule that says your hygiene brain must be on every waking minute. If you treat yourself to a few minutes of letting go, your muscles can relax and you'll be able to approach the rest of the day with a clean slate mentally.
Typically, Mrs. Picky arrives 15 minutes early. Should you cut your lunchtime short? That is one choice. The flip side is that you will probably not be able to recover that time for yourself later in the day. Consider that Mrs. Picky's promptness shows respect for your time. Remember, she wants a perfect job done.
Working with patients who can hardly open their mouth is one of the hardest things we do, but consider how hard it is for them to sit through an hour of dental hygiene treatment. Many go home with an aching temporomandibular joint or, worse, a headache. Can you imagine how hard it is for these patients to willingly make an appointment with us? Many patients benefit from premedicating with some type of nonsteroidal anti-inflammatory medication one hour prior to their appointment to reduce these aches.
Start scaling procedures on the lower arch while the joint is still unstressed. In addition, you can use a child's mouth prop during the scaling and polishing portion of the appointment. Ultrasonic scalers allow clinicians to use a soft-tissue extraoral rest, which does not place much force on the mandible. It is important to use power scalers with a light touch since any unnecessary pressure reduces tip vibration and, therefore, scaling effectiveness.
A number of our older patients have arthritis or other conditions like osteoporosis. This makes it very difficult for them to turn their head or sit comfortably in the patient chair. In these cases, there is no way around twisting our bodies or leaning across the patient to see the entire oral cavity. Good body posture is impossible. Fortunately, this is not the norm, but imagine how hard it is for these folks to maneuver throughout the day. Put yourself in their shoes.
Many patients can reposition their head if necessary. Most have simply never given a thought as to how uncomfortable it might be for us to spend the day working in awkward positions. Generally, patients are willing to accommodate our needs if we explain the necessity of being able to see well and the importance of maintaining good posture throughout the day.
Most headrests do not accommodate individual neck discrepancies very well and some are downright toxic. A small pillow becomes a handy solution. A wide variety of pillows are available to cushion your patient's neck. Some look like the mini-pillows found on airplanes; others are shaped like a small log or a horseshoe. They can be filled with feathers, foam, buckwheat, herbs, memory foam, or polystyrene beads. Some can be heated in the microwave to create an even more soothing experience for your patient. Each of these pillows should be covered with some type of protective barrier.
My personal favorite is called Pillo'Beans. It molds to any neck configuration and can be tossed in the washer and dryer, an act that could lead to the complete demise of buckwheat pillows. Patients love the feeling and support of Pillo'Beans, which gives more comfort when the head is turned.
Pillows also work wonders for patients with back problems. A pillow or small roll of towels placed under a patient's knees can reduce stress on the lower back, and a small pillow strategically placed under the patient's lumbar area can provide welcome support as well.
Mr. Completely Tense is the next patient on your agenda. These people are complex. There is no telling what has caused them to fear dental appointments. Is it fear of losing control, anxiety about real or imagined pain, or having their personal space invaded? Could it be a sore TMJ, a childhood dental nightmare, or a very real negative dental episode buried deep in their psyches? You just never know.
One of my favorite patients married a beautiful, intelligent woman in her mid-thirties. She was terrified to come to our office. Before he made his wife an appointment, he related this story to me. When his wife was a little girl, she and her mom rented a house owned by a dentist in town. At every dental visit, he sexually molested her and then threatened to kick her and her mother out of the house if she told anyone. Her mother never understood why her daughter was so afraid of going for an appointment. What abuse! This twisted, selfish man made this woman a dental cripple. It has taken years for her to be able to receive dental treatment without fear. I sincerely hope that this is an isolated story, but you never know.
There are a number of useful strategies for treating anxious patients. First, it is critical that you remain calm and use a soothing tone of voice. Nothing makes a patient more nervous than a clinician who appears rushed or distracted. Second, if your patient can verbalize his fear or anxiety, then at least you will know the enemy. Perhaps you can work around it.
For example, if your patient's teeth are sensitive to cold, offer to use a desensitizing agent prior to scaling, a desensitizing polishing paste, or use warm water for rinsing. If your patient dislikes mint, opt for a preprocedural rinse or prophy paste with a different flavor. If the patient hates polishing or in-office fluoride treatments, consider skipping these procedures and recommend either a power brush or polishing with a toothpaste to replace conventional polishing procedures. Some patients prefer home fluoride preparation over in-office treatment.
There are a myriad of ways we can help tense patients. Again, pillows are a favorite. A friend of mine warms a small herbal pack and places it over the eyes of tense patients, especially those with elevated blood pressure. On several occasions, she has noted a reduction in blood pressure within 10 minutes. Soothing music, headsets, CD players, and even television help some people disconnect. Earplugs and eyeshades are other choices. How about the patient who is always cold? Cotton thermal blankets are inexpensive, offer soothing relief, and can be laundered after each patient visit.
The most recent addition in my treatment room is a massage pad in the patient chair. At the beginning of each appointment, I ask my patients if they would like the pad turned on. Most women say yes immediately. Men are more hesitant. The vibrations are pleasantly distracting. Patients find it very hard to concentrate on what is being done dentally as their back, shoulders, neck, and legs are treated to a soothing massage.
In addition to those with high anxiety levels, we have a whole group of patients who are frustrated by conditions such as chronic dry mouth, recurrent aphthous ulcers, hypersensitive teeth, and oral malodors. There are a wide variety of products — many of which are available over-the-counter — to help these patients. Do you take time to help your patients solve these problems? Do you offer them samples of products that might help? A small amount of attention and caring goes a long way in developing a stronger professional relationship with these patients.
Kindness and empathy on your part help diffuse anxiety and frustration. When patients see that you really care about their comfort and are willing to come up with concrete solutions, they will open up even more and you will have grateful patients for life.
Little Johnny Jump-Up and Penelope Protective round out the day. Children can be some of our most rewarding patients, but an end-of-day appointment may prove to be a tactical nightmare. It may be the most convenient time of day for the parent/chauffeur, but on the flip side, children can be wound up right after school or just plain tired. This is not an ideal answer for all situations, but it is something to consider.
Children deserve a special relationship with their hygienist. A parent might be invaluable in creating a sense of calm during the appointment when the child is three- or four-years-old, or if it is the child's first visit to your office. Often, the parent assumes the role of interpreter. Since most of you are probably parents, or at least have younger children somewhere in your life, you probably already know how to have a conversation with someone who is able to walk into your treatment room, regardless of their age.
Most children feel very special if they can have their own appointment. After all, they go to school and make it through the day without an interpreter, so why not make a deal with the parent that you will report all of your findings at the end of the appointment? Once you explain the importance of developing a one-on-one relationship with the child, this type of arrangement should be a natural to any parent who understands the importance of singular relationships.
Finally, the day ends. You made it with flying colors. You survived ... and you delivered great care! See, I told you, hygienists are resourceful. But we are not the only winners. The patient wins, the practice wins, and we have kept our promise to deliver our best care. What can be better than that?
Over the past few months, I have treated a number of 30-year-olds who started seeing me when they were toddlers. Most of them have beautiful teeth with few, if any, restorations. Many of the sealants that were placed in the early 1980s are still intact. These patients are not dental phobics. They are easy to treat and appreciate what our office has to offer. They are the direct product of a long, trusting relationship based on respect and our interest in providing optimal dental care. These adults now bring their own children to the office for dental visits.
Late last year, I experienced one of the most frustrating appointments of my career. Janice arrived in a wheelchair for her first visit at my office. She is in her mid-50s and has had severe rheumatoid arthritis for many years. Her hands are so crippled that it is impossible for her to hold a toothbrush. Two decades ago, she had both of her temporomandibular joints replaced. Now, she could barely open her mouth an inch and could not turn her head at all. Her dentist retired several years ago and her caregivers did not have a good understanding of her dental needs.
It was a nightmare to take X-rays, and the scaling was even worse — plaque and calculus were everywhere. I was forced to make some very difficult decisions. She needed premedication, and portability was a serious issue. Full-mouth anesthesia was out of the question. The clock was ticking. I couldn't see what I was doing, and every fiber of my body protested as it assumed the most unnatural physical positions just to be able to slip an ultrasonic scaler into her mouth. Janice's eyes welled with tears. Her mouth had been so neglected that the appointment was a long way from a routine prophy. When the appointment was finally over, I felt like I'd done the worst job in my life. I encouraged Janice to purchase a power-driven toothbrush with a small head and recommended that she schedule an appointment with me every three months.
Two days after her appointment, Janice phoned the office to schedule a dental hygiene visit for her 93-year-old, blind and deaf mother. Apparently, I had managed the appointment with Janice better than I had thought.
When Janice arrived for her three-month visit, she came with a smile. Her teeth were relatively plaque-free and her gingiva was pink. Her caregiver found the power brush easy to use. I never would have expected this outcome! Sometimes when we feel we have failed, we actually have achieved one of our biggest successes.
Too often, we focus on our schedules rather than the person attached to the mouth. Patients trust us to give them the best care we can. Let us celebrate their diversity rather than complain about how difficult they may be to treat. Trust, respect, patience, caring, and open communication are the secrets to surviving the day with our most diverse and challenging patients.
Anne Nugent Guignon, RDH, MPH, practices clinical dental hygiene in Houston, Texas. She writes, speaks, and presents continuing-education courses on ergonomics and advanced ultrasonic instrumentation through her company, ErgoSonics (www.ergosonics.com). She can be reached by phone at (713) 974-4540 or by email at [email protected].