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Boris is ready to see you, but are you ready to see him?

Oct. 29, 2020
We’ve all encountered difficult patients, but it helps to get some tips from others working in the trenches. Kirsten Brancheau, BA, RDH, explains how she handles the gaggers, the ranters, the “don’t recline me” patients, and more.

Your first patient after lunch is Boris. He arrives 10 minutes late. As you enter the reception area to escort him to your operatory, you hear him tell the woman at the front desk, “I hope the girl is ready ’cause I’m on a tight schedule.” Then he sees you and says, “You ready for me, doll, ’cause I’m ready for you,” as his eyes move from your face to your chest. You resist the urge to reply honestly and instead say, “Sure, come on back.”

On the way to your operatory, Boris pokes his head into the dentist’s operatory, where the dentist is busy with a patient, and starts chitchatting with the dentist. Boris then announces that he needs to use the bathroom. By the time Boris is seated in your chair, you are already 15 minutes behind schedule.

Boris is six feet tall and barrel-chested. You will need to recline him fully to be able to see into his mouth, but that’s not going to happen. He tells you not to recline him because he has postnasal drip. He also needs an FMX and is a gagger.

Boris loves to talk, mostly about politics, but he also likes to throw in some off-color jokes and racist comments. You finally get Boris to stop talking and start the prophy. He tightens every muscle in his mouth, frequently closes his mouth, jerks his head every few seconds, and you have to repeatedly remind him to turn toward you.

Of course Boris has terrible oral hygiene and sensitivity, not to mention a large mobile tongue that follows your instruments wherever they go. He has 31 teeth, and the third molars are impossible to access. His only missing tooth is in the exact spot where your saliva ejector wants to go, and his large tongue and fatty buccal mucosa suffocate the saliva ejector, rendering it useless.

Boris already told you that he just ate lunch but didn’t bother to brush because he knew you’d be doing the job for him. He tells you what he had for lunch, but that was unnecessary because you could detect pieces of a tuna fish salad sandwich with onions on soft white bread stuck between every tooth. He didn’t mention that he also had a beer or two, but you knew that too.

As you reach for the ultrasonic scaler, Boris groans and says, “You’re not going to use that water thing, are you? I hate that. And be gentle. Last time you made me bleed and my teeth hurt for a week.”

You are almost finished with one quadrant when Boris asks, “Are you almost done? I’m on a tight schedule.” But when you finally finish the prophy and the dentist comes in for the exam, Boris perks up and starts talking baseball with the doctor...for 10 minutes. They continue talking as Boris exits your operatory without a thank-you or goodbye.

The challenging patient

Have you met Boris? I hope not, because I’m pretty sure he could singlehandedly end a hygienist’s career or sanity...or both. But if he sounds familiar, it’s because he is a composite of the many challenging patients we deal with on a daily basis.

Over the years, hygienists learn ways to deal with difficult patients that dental hygiene school never taught us. We borrow ideas from one another and sometimes accidentally stumble onto something that works for us. After practicing dental hygiene for almost 43 years, I’ve learned to handle most situations without the anxiety that was part of my early career. Do I look forward to dealing with difficult patients? Not really. Do my tips and tricks always work? Unfortunately, no. But they have made life easier for me, and hopefully for my patients as well. I will share some of my favorites in hopes that they might help you too. Let’s take Boris’s difficult attributes and find some possible solutions.

The habitually late patient

This one is pretty easy, and I think most hygienists do one of the following: 1) Tell the patient the appointment is 10 (or 15 or 20) minutes earlier than it actually is. But be careful when confirming the appointment to give them the same fake start time! 2) Add extra time onto the appointment. I also add extra time to appointments with excessively chatty patients.

The inappropriate commenter

In the beginning of my career, I was extremely uncomfortable when patients made sexual innuendos and off-color jokes. I had no clue how to respond, and I’m sure my discomfort brought satisfaction to the offender. I think younger hygienists today are more comfortable with putting the “dirty old man” in his place, but early on I never had a good retort. (Actually, I always had a good retort, but it only came to me an hour after the fact when the patient was already gone.) One younger hygienist told me she would look the patient in the eye after an unwanted advance, give him a stern remark about her sharp instruments, and request that he never do that again. This seemed to do the trick. But for those of us who aren’t so quick with a verbal reply, I came upon a solution by accident that works for me.

I was seeing a patient for the first time. He sat down and said some things that were totally out of line, and I was at a loss for words. I stood there and stared at him as I tried to form a reply, but no adequate words came to mind. As the seconds passed and I still stood there staring at this man trying to come up with something to put him in his place while remaining professional, I noticed him start to twitch in the chair and avert his eyes. He was starting to get uncomfortable with the silence. It was then that I realized I had come up with the perfect response: dead silence and a stony stare. He had tried to make me uncomfortable (and had succeeded), but I also had unknowingly made him uncomfortable with my silence. Since then, I have used this technique multiple times, not only with “dirty old men,” but also for racist and other inappropriate comments.

The nonreclining patient

Some patients have legitimate reasons for not wanting to be reclined. Vertigo, postnasal drip, and difficulty breathing are a few. But sometimes there doesn’t seem to be a medical issue. The instant you begin to recline the chair, the patient startles and says, “Don’t put me down too far!” The patient gives no explanation and you wonder, Does this patient sleep sitting up?

My saddle stool has been helpful with patients who don’t like to be reclined too much. Since I’m sitting in a higher position than with a traditional dental stool, I don’t have to recline the patient as much to be able to see inside the oral cavity. Sometimes I also stand for these patients. I find it can be a nice break from sitting all the time.

Another devious little trick I’ve used when patients insist they can’t be reclined too much is to say, “I’ll just put you back a little. You tell me when to stop.” When they tell me to stop in a position that really doesn’t work for me, I pick up a scaler and begin to do a little on the easiest teeth to access. After a minute or so, I sit them up and ask them to rinse. Then, I recline the chair again, a little lower this time. For some strange reason, patients rarely notice that they are more reclined than before. You can continue doing this in small increments until you have patients where you want them. It doesn’t work all the time, but much of the time it does.

The dreaded gagger

We all have to deal with this problem, often on a daily basis. Many of us have found helpful ways to prevent gagging, but I have yet to find anything that is foolproof. How do you deal with a patient who begins gagging the moment she sees the x-ray sensor in your hand? Some hygienists recommend salt on the back of the tongue. Some recommend spraying the throat with a topical spray. These solutions never appealed to me because I would hate it if someone did them to me. Instead, I use what I call the “antigagging technique.”

Many years ago, I read about this technique. I don’t remember where I read it, but the article gave a scientific explanation for how it works. Unfortunately, I am much more of a pragmatist than a scientist, and I don’t remember anything about the science behind the technique. At first I was skeptical, but in desperation I decided to give it a try. Much to my surprise, it worked!

I think my verbal approach to the patient may help as much as the technique itself. Here’s my pitch: “I know you’re a gagger, so I’m going to show you my antigagging technique. I’m not going to say it works 100% of the time, but it does work about 80% of the time. I read about it in a scientific journal and I forget the reason why it works. All I know is that it does work most of the time.” Then I have the patient turn one hand palm up, and I put my thumb on a spot just beyond the base of the palm. I tell them that they need to put their thumb exactly where mine is and push really hard. Then I remind them to breathe while I take the x-ray. As I put the sensor in the mouth and run out of the room to take the x-ray, I repeat, “Push hard on that spot.”

Although the computer has a set order for taking bitewings, sometimes I’ll take the premolar shot before the molar shot. This tricks the patient into thinking, “Well, that wasn’t too bad,” and they’re more likely to relax when I take the molar shot next.

The political ranter

First and foremost, if you have a TV in the operatory, do not put a news channel on! I generally leave my TV on HGTV. I have listened to, but never watched, every episode of Fixer Upper so many times that I know every time the word “shiplap” is about to be uttered. I am not a TV watcher, but patients have come to expect it. It’s a diversion and masks other sounds in the office. I find that HGTV is OK with most people. But sometimes someone asks for a specific channel. If it’s a sports or food channel, I’m happy. If it’s news, I know I’m in trouble.

The problem with news channels is that for some reason the patient always wants to watch the channel you hate the most. The other problem with news channels is that the news is generally bad and depressing. The patient is in a dental office, for goodness’ sake! Do they really need to add to their stress by watching the news? Apparently, some patients do. I don’t argue with them. I just inwardly sigh, put on the requested station, and hope for the best.

And then it happens...the political rant. Even if I share the patient’s views, I really don’t want to waste time talking about politics. My standard response when a patient gets going on their political opinions is this: “Yeah, it’s crazy.” I don’t care what they’re ranting about. That’s my only reply. Then I quickly switch to teeth talk. Sometimes I have to repeat the routine more than once, but eventually the patient usually calms down.

The sensitive, lip-tightening, large-mobile-tongue patient

I’ve grouped these challenges together because they frequently go hand-in-hand. Most of us have our favorite products that we use and recommend with these patients. There have been many excellent articles written on how to cope with sensitive patients. I just want to share a few little tricks that have helped me. The first one is simply this: Start on the lower right quadrant.

How does this help? Well, first of all, assuming you’re a right-handed hygienist, it is one of the easiest areas to see and access. Secondly, there is usually less calculus there than on the lower anteriors and maxillary molars. If you see recession, don’t touch the buccals; just go very lightly between the teeth or along the linguals. All of this is simply to relax the patient as they feel how light-handed you are. Once they are more relaxed, you can do a little more real scaling in these areas. I always leave areas of recession for last, as they are the most sensitive areas. The trick is to start so lightly in an easily accessible and generally nonsensitive area that the patient thinks you are not going to hurt them, and then they relax. With any luck, they will also stop following you with their tongue and tightening their lips.

I almost always start with the ultrasonic scaler first, and we know that can be sensitive to some patients. I keep it at low power, and sometimes I run it a bit first, telling the patient that it will warm the water and make it more comfortable. The ultrasonic scaler works best with a light touch, and if you go super light at first, you can gradually increase the pressure and the patient often won’t notice.

One quick tip for those of you who are still using the ultrasonic scaler during this pandemic: The ReLeaf hands-free, high-speed suction has not only allowed me to use the ultrasonic scaler (which I can’t live without), but I find that it also helps prevent the suction from getting stuck between the tongue and the cheek if there are missing teeth. I wish I had discovered this years ago!

And finally, with sensitive or nervous patients, I always use my soothing, hypnotic voice, asking them frequently how they’re doing.

Pick your battles

There are many other annoying things about Boris—not brushing his teeth before his appointment, his condescending attitude (referring to the hygienist as “the girl” and “doll”), his leering gaze, his demands to hurry up because he’s in a rush (although he arrived late and still manages to have time to chat with the dentist and use the bathroom), his blaming you for his bleeding gums and sensitivity, and his lack of gratitude and common decency toward you after all you’ve done for him.

We all have unpleasant patients, but part of being a professional means ignoring their unpleasantness and treating them kindly in spite of their behavior. Over time, some of these not-so-nice patients will warm up to you and treat you better.

When we learn how to better deal with challenging patients—be they physically challenging or emotionally challenging—they frequently will request to see only you. Isn’t that great?!

Over time we all find our own ways to deal with difficult patients. What works for one hygienist might not work for another, but I am grateful for the many hygienists who have shared their coping strategies with me. I hope some of my tips are helpful to you. Next time, when Boris calls to schedule his appointment and requests you, you will be as ready as you can be. You can do it! I promise!

More from the author: Musings of an older hygienist

Editor’s note: This article first appeared in Through the Loupes newsletter, a publication of the Endeavor Business Media Dental Group. Read more articles at this link and subscribe here.

Kirsten Brancheau, BA, RDH, has been practicing clinical dental hygiene since 1978. She earned an associate’s degree in applied science in dental hygiene from Union County College in 1977 and a bachelor of arts degree in English literature from Montclair State University in 1988. She is a member of the American Dental Hygienists’ Association. Brancheau is also a freelance proofreader, editor, and writer. She can be reached at [email protected].