Asking sensitive questions

March 1, 2005
It happens in dental offices every day. Patients come in announcing, “I really don’t want to be here.

It happens in dental offices every day. Patients come in announcing, “I really don’t want to be here.” Other variations are “I hate having my teeth cleaned,” or “My teeth are really sensitive; can you just hurry up?” Each one of these phrases may evoke a sick feeling in your stomach, but each episode gives us a perfect opportunity to really help patients and set the stage to develop a very positive relationship.

So often, these negative statements are perpetuated by one short sentence: “That’s okay, I (or Suzy Q Hygienist) will just get you in and out.” There are two things wrong with this approach. First, it tells the patient that you really don’t know or care what is bothering him or her. Secondly, it makes sure that you will never find out what the real problem is. So, the problems just go on and on, appointment after appointment.

There is a very good chance that we can turn these negative thoughts into positive ones if we start asking the right questions, even if the questions are sensitive. For example, how about starting out by acknowledging that there are other patients that do not want to come for dental appointments? It’s nice to let them know that others share the very same sentiment and that you are genuinely interested in helping them overcome their anxiety or resistance to dental treatment.

You can then redirect the conversation into a more positive direction, letting your patients know that dentistry has many new alternatives and treatment options. In other words, today’s dentistry and dental hygiene appointments can be a far cry from their preconceived notions about the visit. In order to address their concerns, you will need to know what bothers them. Ask patients to describe what they are worried about. Let them know you are willing to do things differently to help them be more comfortable, but you need more information in order to make changes.

The perfect example is patients who hate having their teeth cleaned. What are they really telling you? Are their teeth sensitive to touch, or to cold air or water? Are they concerned about sore gingivae, bleeding, or post-treatment sensitivity? Are you dealing with patients who relive horrible dental experiences every time they walk through your door? Or are they financially strapped and don’t see the long-term value of your services? Many people think that dentistry is still practiced the same way it was 50 years ago. We know that’s not true, but their lack of information or the replay of old emotional tapes are all they know.

Let’s tackle cold sensitivity. In today’s world, there is no reason a patient should have to endure thermal discomfort during an appointment. If the issue is dentinal hypersensitivity, there is an ever-increasing number of very effective products that can be applied to teeth prior to scaling. They come in the form of various types of fluoride preparations, desensitizing prophy paste, bonded resins, potassium nitrate, and other professionally applied materials. Patients can also be instructed to use various forms of desensitizing toothpastes or fluorides following the dental visit to keep their teeth desensitized.

Cold water can be a thing of the past as well. Many ultrasonic scalers have self-contained irrigation systems, which means that the irrigating fluid can be warmed prior to scaling. Many of today’s automatically tuned scalers have extended low power ranges, which means less water is required to cool the working tip. Manually tuned magnetostrictive units require much less fluid, so the irrigating medium is warm. Piezo electric units can also be used with much less water spray.

Tactile sensitivity is an issue as well. There are a lot of patients who do not like the sound or the feel of hand instruments. While desensitizing medicaments can help control or eliminate discomfort, advancements in ultra-

sonic scalers can contribute to patient comfort as well. The key is using smaller diameter tips that can slip gently into the sulcus at lower power settings. With today’s new designs, patients often are not aware exactly which tooth surface is being instrumented.

Soft tissue discomfort is very real to some. While the type of instrument and the skill of the clinician play a big role in comfort, some patients just have sensitive gingivae. Even though not all of us are licensed to provide injectible anesthesia, it should be an option for the patient. There are also a number of effective topical anesthetics on the market. They can be applied with a cotton-tipped applicator, sprayed into the oral cavity, swished in the mouth, or applied in site-specific areas via a small application syringe. A small bead of topical anesthetic applied in the vestibule can really aid in the accurate placement of an X-ray film holder.

Discomfort can come from saliva ejectors as well. Most are hard at the end and dig into the soft tissue. One type is manufactured with a soft pad on the end. Saliva ejectors can also be retrofitted with small spongy tips that can be added to a traditional model. Curled designs or molded tongue retractors will also not dig into the soft tissue.

If the real reason for hating the dental appointment is polishing, then don’t! There is no law or science that says polishing is therapeutic. The science supports biofilm destruction, and that is what we do with our ultrasonic scaler. We can also remove stains with the same device. Another approach is to use a very fine prophy paste, toothpaste, or a paste that is self-adjusting to form a polish, since there are patients who want their teeth polished but hate the gritty feeling. There are even patients who don’t want their teeth flossed. Will they perform that little chore later? Perhaps not, but it is not fatal if we don’t do it.

Patients who gag are in a group by themselves. They feel embarrassed that they are at a loss to control this reflex, so they avoid any procedures that elicit gagging. X-rays and impressions are the worst. Here are a few tricks that work. Ask patients to rinse with a strong-flavored mouthwash or sprinkle some salt on their tongue. These strong flavors confuse the senses. Seat patients up straight and, with the head stabilized against the headrest, have them lower their chin to their chest. It is nearly impossible to gag with the head in this position.

Finally, if the problem is anxiety or a loss of control and the above strategies have not worked, then eliciting a dialogue with the patient can help dispel these destructive emotions. Patients who have had an unfortunate dental experience in the past may find it very hard to verbalize their anxiety. Take it slowly. Let them know you are interested in helping them have a better appointment.

Offer to let them control the time limits. Suggest breaking the procedure down into a series of appointments, or maybe doing more treatment in one longer session. How about taking a break every 20 minutes or so? Nitrous oxide sedation, having a trusted friend or loved one in the treatment room, premedication, headphones with music of their choice, virtual reality machines, massage pads on the dental chair, or ceiling-mounted televisions are other possibilities.

Working effectively with patients who do not want to be in our chairs is one of the ultimate challenges for every practicing dental hygienist. A mixture of psychology and science is the key ingredient to making these appointments successful for all. When we help patients create their comfort zone in our dental practices, we have made friends for life - friends that will sing our praises, appreciate our skills, accept needed treatment, and help build our practices.

What a nice way to spend the day ... helping people help themselves.

Anne Nugent Guignon, RDH, MPH, is an international speaker, has published numerous articles, and authored several textbook chapters. Her popular programs include ergonomics, patient comfort, burnout, and advanced diagnostics and therapeutics. Recipient of the 2004 Mentor of the Year Award, Anne is an ADHA member and has practiced clinical dental hygiene in Houston, Texas, since 1971. You can reach her at [email protected] or (713) 974-4540 and her Web site is