Dental students are taught to treat teeth but people decide upon the proposed treatment

The following sections are written for pre-clinical dental school students who are just about to begin clinical treatment of patients. It is also a worthwhile review for students who are already treating patients. Interpersonal skills are a critically important component of patient care.

Teeth…and People

     In school, dental students are taught to treat teeth. In the real world, it is the people attached to the teeth who will either agree or disagree with the proposed treatment. If they agree with the proposed treatment that’s great; but what if they don’t? In private practice those patients will typically never return.

     How can we help patients want what we know they need? First, we must attempt to give them what they want. Then, we attempt to teach them to want what they need.

     Unfortunately, this concept contradicts traditional dental education where every patient is similarly treated. Dental school attempts to standardize dentistry in order to make it comprehensible and repeatable for students. This is a fine academic approach but the recent dental school graduate in private practice will quickly learn that people are not similar. The school teacher and the investment banker, the actress and the housewife, the store owner and the assistant store manager, may all have the same dental problem but may want it treated with a different technique and with differing interpersonal skills.

     There are four main skills which differentiate master clinicians from typical general dentists: diagnosis, treatment planning, case presentation and actual treatment. The ability to master this unique set of skills will be one of the most important determinants of success, or failure, in private practice.

Greeting the Dental Patient

     It may seem silly to have to say it but say ‘hi’ to your patient. And look them in the eyes while doing so. Extend your hand to shake hands while introducing yourself. I prefer to say, “Hi, I’m Jeff” or “Hi, I’m Jeffrey Dorfman.” I prefer to avoid the distance created by saying, “Hi, I’m Dr. Dorfman.” Be enthusiastic and warm. If you are rather youthful-looking and are concerned that a patient might confuse you with support staff then you might try, “Hi, I’m Dr. Dorfman. Everyone calls me Jeff.” Make the patient feel welcome and that you are genuinely happy they are there. I will always refer to a patient by their first name. You cannot just point a patient to a chair and start working.

     You must feel confident in yourself and project that feeling to your patient. You must feel and act happy to take care of your patient. Patients will sense your anxiety and will notice a frown because people are frightened enough when they walk in and are hyper-alert. They are looking for verbal and nonverbal clues about what to expect. It is critically important that your words and behavior make them feel comfortable.

     Why are patients so afraid of dentists? I understand that the two most anatomically sensitive parts of the human body are the teeth and the genitals. The genitals are extremely sensitive so that reproduction occurs. The teeth are also extremely sensitive because this sense of touch, along with the senses of smell and taste, help people differentiate food from non-food which was especially important before they developed the cognitive ability to do so. So, you combine a particularly sensitive part of the human body with possibly a few bad prior experiences and the result is a patient who greets you and clings to every potential clue about whether you will hurt them.

     I strongly suggest that dental students form groups and role play dentist and patient with other students as observers. Watch non-verbal clues and listen to verbal ones that may affect the patient’s experience. These groups could also pretend, or actually perform, dental procedures with the intention of specifically focusing on all the interpersonal skills involved with the patient visit.

Seating the Dental Patient

     Though seating is merely an extension of greeting the patient it is still important in setting up your performance as their doctor. I don’t mean performance negatively as in fake. I mean the manner in which you maintain your happy, confident demeanor throughout the visit. Notice that I am referring to the patient’s visit not the patient’s procedure. The distinction is important. Most dental students, and I am sure a lot of practicing dentists, focus on the procedure they will provide. However the patient’s experience of the procedure begins the moment they walk in the dental school clinic (or dental office) to the moment they leave (or thereafter if they have post-operative pain). Your job, which is equally important as your clinical skills, is to make the entire visit as reasonably pleasant as possible.

     Be gentle when seating the patient and placing the napkin around their neck. You may gently touch them on the wrist or shoulder while making a point in conversation (as cultural prohibitions allow). Patients will experience a gentle touch on the wrist or shoulder as how gentle you will be with them intraorally.

     After the patient is seated give them a moment to take a breath. Don’t rush over and say ‘open.’ Do they look nervous or relaxed? How rapid is their respiration? Are they making eye contact with you? Are they seated half out of the dental chair? Do they have to be somewhere in a half hour?

     I have seen social workers write up fabulous reports about a patient’s social history within the context of a medical record. You need to do the same. Perhaps one can actually ask a social worker within a hospital/university setting to give a lecture on the subject. The point is to understand your patient as you understand their teeth.

     Who is the person attached to the teeth seated before you? How well educated are they? What might be their level of comprehension? Should you avoid the use of SAT words or technical dental jargon in conversation? How might their age affect their desire for treatment? Some older patients feel they are too old to invest in dental work for themselves. Why? How might their ethnic, religious, or cultural background affect what dental treatment they seek? How can you inform a patient about an ideal dental treatment if they don’t fully comprehend it? Is the patient a busy professional who can give you 4.5 minutes for a procedure or a carpenter who says ‘take as long as you need, doc.’ Does the patient live on Fifth Avenue or in the South Bronx? What does their clothing, hair, makeup and/or accessories say about them? How intelligibly was their medical history filled out? How significant is their medical history? Did they present for an emergency and exhibit a mouthful of broken teeth or did they present for a cleaning and a check up?

     I am not suggesting stereotyping patients and offering them differing levels of care. To the contrary, I am suggesting understanding the human being who comes to you for dental care so that you will be able to offer them, and have them accept, the most ideal dentistry possible. I personally find it disturbing that many patients of lesser means are offered less ideal treatment options based upon cost without a full disclosure of the benefits of more ideal, more expensive alternatives.

     A dental students perception of a patient’s ability to pay for dentistry does not relieve them of the obligation to inform all patients of all treatment alternatives and the benefits and risks associated with each. Only the manner in which this information is presented to the patient may vary based upon the individual’s wants, needs and level of understanding.

     Ideal dentistry must be offered to all people. To not do so means the patient was not provided with adequate informed consent which could be argued is malpractice.

     Then why don’t dental students offer all patients multiple treatment options from ideal treatment on down? This is because diagnosis, treatment planning and case presentation for multiple treatment options often requires a mastery of dentistry beyond the skills of most students. Yet it is attainable to a significant degree even while in school if the student is willing to make the effort. Thereafter, honing this skill can become a source of pride for the practitioner.

     Diagnosis is the specific description of the presenting dental problem. Treatment planning involves offering multiple treatment options from ideal dentistry on down, usually varying based upon fee and treatment time. Case presentation is the communication of both the diagnosis and treatment plans in a manner a patient can understand so that they are able to personally chose what is best for them.

     I think that the patient is now comfortably seated.

Listen to the Chief Complaint in Dentistry

     The biggest complaint patients have about their doctors, other than the cost of service, is the lack of communication with their doctor. I understand this is also a common complaint among many married couples. You must be a good listener if you want to become a good doctor.

     After the patient is seated and schmoozed I always look a new patient in the eyes and ask, “Why are you here?” I then write down their response, making a list if necessary. I have never heard a patient reply, “I’m here for a full mouth series of radiographs, study models, head and neck exam, periodontal probings, charting of decayed, missing and filled teeth and then to be checked off by possibly five different instructors.” They usually reply, “I broke a tooth in the back,” or “I’m here for a check-up.” Patients are happy to see me listening, and writing down, why they came.

     The first component of record-making will focus on whether the concern is functional, cosmetic and/or painful. I will also discuss the patient’s medical history and make notations in the chart, “PMH (past medical history)-discussed” and then list any medical conditions. I prefer to write “discussed” because it is inadequate medico-legally to just review a patient’s medical history without actually discussing it with them to ensure they understand the questions. Notice again how important it is that patient’s actually understand all that you are doing.

     I then ask the patient when they last went to the dentist and for what reason. I may note in the record, for example, “PDH (past dental history)-2 years for a prophy” and then inquire why they did not return to their prior dentist and are now visiting me. This can give you a lot of insight into the patient’s emotional needs.

     Sometimes a patient may tell me that they have not been to the dentist for many years or I can see they are agitated sitting in the chair. If I notice this I usually sit back in my chair and in a supportive manner I tell patients about the most common reasons patients do not frequent the dentist: lack of time, lack of money, indifference, or fear.

     It is very common among people to get so caught up with work and family leaving little time to complete their necessary dental work. I will complete their dental work quickly and with a high level of skill. I just need to know the time-frame in which they are working.

     “A lot of people ignore the need for dental work without understanding that by ignoring a problem they usually create the need for more complex, costlier work later. Taking care of any problem earlier will always save money in the end.” I prefer to avoid the use of the word “patients” because patients think of themselves as people, not patients. “If a lack of money is a barrier to receiving proper dental care we may discuss this when we discuss treatment options.”

     “It is also not uncommon for someone not to go to the dentist because they don’t have any pain so they reason they must be healthy.” I then discuss how many diseases like heart disease, high blood pressure (don’t use “hypertension”), diabetes, or cancer don’t typically cause pain. The intention is not to suggest that dental disease is comparable to those diseases but just that most disease is not painful until it is in a later stage so that someone should never use the presence, or absence, of pain with any diagnostic certainty.

     Then I get to the big issue, fear. Without suggesting that the patient before me is actually “afraid” I generally discuss how fear is frequently a large component of why people don’t seek dental care. I discuss the anatomic basis for fear as discussed in “greeting the patient.” I then say, “I have found that the more powerful an individual is, either physically or professionally, the more uncomfortable they are going to a dentist. Though initially ironic, this is actually quite logical. A little, old lady is rarely afraid of dentistry because they are usually relatively powerless (I don’t mean this negatively) in controlling their outside environment. On the other hand, a physically strong athletic type or successful executive might have gotten used to sensing a certain level of control over their environment. These people have the most difficulty giving up control and therefore experience the most fear of dentistry. Therefore, if fear may be (not “is”) a component of why you have not been to the dentist recently you actually probably feel powerful in your daily life.”

     “The way we help fearful patients cope with their dental work is by giving them control. We give them control over what we do, when we do it, how we do it, how much it will cost, what it will look like and how it will function. We also give them control over the potential of pain with a variety of medications (to be discussed later) both during and after any procedures.” (I credit the concept to Martin Seligman’s work on helplessness and depression that I learned at Penn.)

     I do not typically go over these four main reasons people don’t frequent a dentist. If the patient replied, for example, that their last dental visit was eight months ago in San Diego just before they moved to New York then the whole conversation above would have been a waste of time. If, however, you begin to sense that fear may be a significant barrier to the patient receiving proper dental care, then the time is well worth the effort. After such a conversation you may tell a patient, “Okay, now you can take a deep breath since now you know you’re concerns are pretty common.”

     Getting back to the actual chief complaint, determine whether it is functional, cosmetic and/or painful. One needs to also learn the degree of this concern, e.g. how painful is the tooth.

     Next determine to what extent the patient’s medical history and past dental history will impact treatment. Then determine what you must accomplish during this first visit to adequately (not necessarily completely, nor permanently) treat the patient’s chief complaint. Lastly, make the appropriate records for treating the chief complaint only.

     Imagine going to a store to purchase a new shirt. While shopping, the salesperson commented that your pants are pretty ragged too and you really should buy new pants.

     Actually, your shirt is not so bad but your shoes are incredibly ugly. So buy new pants and shoes and come back next year for a new shirt. What would you do?

     I am not equating the significance of seeking dental treatment with that of buying clothes but seek to inform you that the emotional significance may be similar to some degree. In the example above, the salesperson could have provided you with a new shirt and emotionally supported how good you looked. Then he could have informed you that clothes for the new season will arrive in a few weeks. After seeing how much you love your new shirt, come back to see some really fabulous outfits.

     We must first give our patients what they want. Then, we attempt to teach them to want what they need. Before I begin making records, I repeat from my written notes the patient. s chief complaint and confirm that I understand specifically why they came.