After you seat the patient, a 42-year-old woman, she turns to you andsays glibly, “Doctor, I don’t like dentists.” How should you respond?Tip: The patient presents with a gross generalization. Distortions and deletions of information need to be explored. Not liking you, the dentist, whom she has never met before, is not a clear representation of what she is trying to say. Start the interview with questioning surprise in your voice as you cause her to reflect by repeating her phrasing, “You don’t like dentists?,” with the expectation that she will elaborate. Probably she has had a bad experience, and by proceeding from the generalization to the specific, communication will advance. It is important to do active listening and to allow the patient who is somewhat belligerent to ventilate her thoughts and feelings. You thereby show that you are different perhaps from a previous dentist who may not have developed listening skills and left the patient with a negative view of all dentists. The goals are to enhance communication, to develop trust and rap port, and to start a new chapter in the patient’s dental experience.

As you prepare to do a root canal on tooth number 9, a 58-year-old man responds, “The last time I had that dam on, I couldn’t catch my breath.  It was horrible.” How should you respond? What may be the significance of his statement?

Tip: The comment, “I couldn’t catch my breath,” requires clarification. Did the patient have an impaired airway with past rubber dam experience, or has some long ago experience been generalized to the present? Does the patient have a gagging problem? A therapeutic interview clarifies, reassures, and allows the patient to be more compliant.

A 36-year-old woman who has not been to the dentist for almost 10 years tells you, “My last dentist said I was allergic to a local anesthetic. I passed out in the dental chair after the injection.” A 55-year-old man is referred for periodontal surgery. During the medical history, he states that he had his tonsils out at age 10 years and since then any work on his mouth frightens him. He feels like gagging. How do you respond?  Tip: In both cases, a remembered traumatic event is generalized to the present situation. Although the feelings of helplessness and fear of the unknown are still experienced, a reassured patient, who knows what is going to happen, can be taught a new set of appropriate coping skills to enable the required dental treatments. The interview fully explores all phases of the events surrounding the past trauma when the fears were first imprinted.

After performing a thorough examination for the chief complaint of recurrent swelling and pain of a lower right first molar, you conclude that, given the 80% bone loss and advanced subosseous furcation decay, the tooth is hopeless. You recommend extraction to prevent further infection and potential involvement of adjacent teeth. Your patient replies, “I don’t want to lose any teeth. Save it!” How do you respond?

Tip: The command to save a hopeless tooth at all costs requires an understanding of the denial process, or the clinician may be doomed to perform treatments with no hope of success and face the likely consequences of a disgruntled patient. The interview should clarify the patient’s feelings, fears, or interpretations regarding tooth loss. It may be a fear of not knowing that a tooth may be replaced, a fear of pain associated with extractions, a fear of confronting disease and its consequences, or even a fear of guilt due to neglect of dental care.  The interview should clarify and inform while creating a sense of concern and compassion.

With each of the above patients, the dentist should be alerted that something is not routine. Each expresses a degree of concern and anxiety. This is clearly the time for the dentist to remove the gloves, lower the mask, and begin a comprehensive interview. Although responses to such situations may vary according to individual style, each clinician should proceed methodically and carefully to gather specific information based on the cues that the patient presents. By understanding each patient’s comments and the feelings related to earlier experiences, the dentist can help the patient to see that change is possible and that coping with dental treatment is easily learned. The following questions and answers provide a framework for conducting a therapeutic interview that increases patient compliance and reduces levels of anxiety.  1. What is the basic goal of the initial patient interview?  To establish a therapeutic dentist-patient relationship in which accurate data are collected, presenting problems are assessed, and effective treatment is suggested.

2. What are the major sources of clinical data derived during the interview?

The clinician should be attentive to what the patient verbalizes (i.e., the chief complaint), the manner of speaking (how things are expressed) and the nonverbal cues that may be related through body language (e.g., posture, gait, facial expression, or movements). While listening carefully to the patient, dentist observes associated gestures, fidgeting movements, excessive perspiration, or patterns of irregular breathing that ma hint of underlying anxiety or emotional problems.

3. What are the common determinants of a patient’s presenting behavior?

1. The patient’s perception and interpretation of the present situation (the reality or view of the present illness)

2. The patient’s past experiences or personal history

3. The patient’s personality and overall view of life

Patients generally present to the dentist for help and are relieved to share personal information with a knowledgeable professional who can assist them.  However, some patients also may feel insecure or emotionally vulnerable because of such disclosures.

4. Discuss the insecurities that patients may encounter while relating their personal histories.

Patients may feel the fear of rejection, criticism, or even humiliation from the dentist because of their neglect of dental care. Confidential disclosures may threaten the patient’s self-esteem. Thus patients may react to the dentist with both rational and irrat1 comments, their behavior may be inappropriate and even puzzling to the dentist. In a severely psychologically limited patient (e.g., psychosis, personality disorders), behaviors may approach extremes. Furthermore, patients who perceive the dentist as judgmental or too evaluative are likely to become defensive, uncommunicative, or even hostile. Anxious patients are more observant of any signs of displeasure or negative reactions by the dentist. The role of effective communication is extremely important with such patients.

5. How can one effectively deal with the patient’s insecurities?  Probably acknowledgment of the basic concepts of empathy and respect gives the most support to patients. Understanding their point of view (empathy) and recognition of their right to their own opinions and feelings (respect), even if different from the dentist’s personal views, help to deal with potential conflicts.

6. Why is it important for dentists to be aware of their own feelings when dealing with patients?

While the dentist tries to maintain an attitude that is attentive, friendly, and even sympathetic toward a patient, he or she needs an appropriate degree of objectivity in relation to patients and their problems. Dentists who find that they are not listening with some degree of emotional neutrality to the patient’s information should be aware of personal feelings of anxiety, sadness, indifference, resentment, or even hostility that may be aroused by the patient. Recognition of any aspects of the patient’s behavior that arouse such emotions helps dentists to understand their own behavior and to prevent possible conflicts in clinical judgment and treatment plan suggestions.

7. List two strategies for the initial patient interview.

1. During the verbal exchange with the patient all of the elements of the medical and dental history relevant to treating the patient’s dental needs are elicited.

2. In the nonverbal exchange between the patient and the dentist, the dentist gathers cues from the patient’s mannerisms while conveying an empathic attitude.

8. What are the major elements of the empathic attitude that a dentist tries to relate to the patient during the interview?

·        Attentiveness and concern for the patient

·        Acceptance of the patient and his or her problems

·        Support for the patient

·        Involvement with the intent to help

9. How are empathic feelings conveyed to the patient? 

Giving full attention while listening demonstrates to the a patient that you are physically present and comprehend what the patient relates. Appropriate physical attending skills enhance this process. Careful analysis of what a patient tells you allows you to respond to each statement with clarification and interpretation of the issues presented. The patient hopefully gains some insight into his or her problem, and rapport is further enhanced.

10. What useful physical attending skills comprise the nonverbal component of communication?

The adept use of face, voice, and body facilitates the classic bedside manner, including the following:

Eye contact. Looking at the patient without overt staring establishes rapport.

Facial expression. A smile or nod of the head to affirm shows warmth, concern, and interest.

Vocal characteristics. The voice is modulated to express meaning and to help the patient to understand important issues.

Body orientation. Facing patients as you stand or sit signals attentiveness. Turning away may seem like rejection.

Forward lean and proximity. Leaning forward tells a patient that you are interested and want to hear more, thus facilitating the patient’s comments.  Proximity infers intimacy, whereas distance signals less attentiveness. In general, 4–6 feet is considered a social, consultative zone.

A verbal message of low empathic value may be altered favorably by maintaining eye contact, forward trunk lean, and appropriate distance and body orientation. However, even a verbal message of high empathic content may be reduced to a lower value when the speaker does not have eye contact, turns away with backward lean, or maintains too far a distance. For example, do not tell the patient that you are concerned while washing your hands with your back to the dental chair.

11. During the interview, what cues alert the dentist to search for more information about a statement made by the patient?

Most people express information that they do not fully understand by using generalizations, deletions, and distortions in their phrasing. For example, the comment, “I am a horrible patient,” does not give much insight into the patient’s intent. By probing further the dentist may discover specific fears or behaviors that the patient has deleted in the opening generalization. As a matter of routine, the dentist should be alert to such cues and use the interview to clarify and work through the patient’s comments. As the interview proceeds, trust and rapport are built as a mutual understanding develops and levels of fear decrease.

12. Why is open-ended questioning useful as an interviewing format? 

Questions that do not have specific yes or no answers give patients more latitude to express themselves. More information allows a better understanding of patients and their problems. The dentist is basically saying , “ Tell me more about it . “ Throughout the interview the clinician listens to any cues that indicate the need to pursue further questioning for more information about expressed fears or concerns. Typical questions of the open-ended format include the following: “What brings you here today?,” “Are you having any problems?,” or “Please tell me more about it.”

13. How can the dentist help the patient to relate more information or to talk about a certain issue in greater depth?

A communication technique called facilitation by reflection is helpful. One simply repeats the last word or phrase that was spoken in a questioning tone of voice. Thus when a patient says, “I am petrified of dentists,” the dentist responds, “Petrified of dentists?” The patient usually elaborates. The goal is to go from generalization to the specific fear to the origin of the fear. The process is therapeutic and allows fears to be reduced or diminished as patients gain insight into their feelings.

14. How should one construct suggestions that help patients to alter their behavior or that influence the outcome of a command? 

Negatives should be avoided in commands. Positive commands are more easily experienced, and compliance is usually greater. To experience a negation, the patient first creates the positive image and then somehow negates it. In experience only positive situations can be realized; language forms negation. For example, to experience the command “Do not run!,” one may visualize oneself sitting, standing, or walking slowly. A more direct command is “Stop!” or “Walk!” Moreover, a negative command may create more resistance to compliance, whether voluntary or not. If you ask someone not to see elephants, he or she tends to see elephants first. Therefore, it may be best to ask patients to keep their mouth open widely rather than to say, “Don’t close,” or perhaps to suggest, “Rest open widely, please.”

A permissive approach and indirect commands also create less resistance and enhance compliance. One may say, “If you stay open widely, I can do my procedure faster and better,” or “By flossing daily, you will experience a fresher breath and a healthier smile.” This style of suggestion is usually better received than a direct command.

Linking phrases—for example, “as,” “while,” or “when”—to join a suggestion with something that is happening in the patient’s immediate experience provides an easier pathway for a patient to follow and further enhances compliance.  Examples include the following: ‘As you lie in the chair, allow your mouth to rest open. While you take another deep breath, allow your body to relax further.” In each example the patient easily identifies with the first experience and thus experiences the additional suggestion more readily.

Providing pathways to achieve a desired end may help patients to accomplish something that they do not know how to do on their own. Patients may not know how to relax on command; it may be more helpful to suggest that while they take in each breath slowly and see a drop of rain rolling off a leaf, they can let their whole body become loose and at ease. Indirect suggestions, positive images, linking pathways, and guided visualizations play a powerful role in helping patients to achieve desired goals.

15. How do the senses influence communication style?

Most people record experience in the auditory, visual, or kinesthetic modes.  They hear, they see, or they feel. Some people use a dominant mode to process information. Language can be chosen to match the modality that best fits the patient. If patients relate their problem in terms of feelings, responses related to how they feel may enhance communication. Similarly, a patient may say, “Doctor, that sounds like a good treatment plan’ or “I see that this disorder is relatively common. Things look less frightening now.” These comments suggest an auditory mode and a visual mode, respectively Responding in similar terms enhances communication.

16. When is reassurance most valuable in the clinical session?

Positive supportive statements to the patient that he or she is going to do well or be all right are an important part of treatment. Everyone at some point may have doubts or fears about the outcome. Reassurance given too early, such as before a thorough examination of the presenting symptoms, may be interpreted by some patients as insincerity or as trivializing their problem.

The best time for reassurance is after the examination, when a tentative diagnosis is reached. The support is best received by the patient at this point.

17. What type of language or phrasing is best avoided in patient communications?

Certain words or descriptions that are routine in the technical terminology of dentistry may be offensive or frightening to patients. Cutting, drilling, bleeding, injecting, or clamping may be anxiety-provoking terms to some patients.  Furthermore, being too technical in conversations with patients may result in poor communication and provoke rather than reduce anxiety. It is beneficial to choose terms that are neutral yet informative. One may prepare a tooth rather than cut it or dry the area rather than suction all of the blood. This approach may be especially important during a teaching session when procedural and technical instructions are given as the patient lies helpless, listening to conversation that seems to exclude his or her presence as a person.

18. What common dental-related fears do patients experience?

·        Pain

·        Drills (e.g., slipping, noise, smell)

·        Needles (deep penetration, tissue injury, numbness)

·        Loss of teeth

·        Surgery

19. List four elements common to all fears.

·        Fear of the unknown

·        Fear of loss of control

·        Fear of physical harm or bodily injury

·        Fear of helplessness and dependency

Understanding the above elements of fear allows effective planning for treatment of fearful and anxious patients.

20. During the clinical interview, how may one address such fears? 

According to the maxim that fear dissolves in a trusting relationship, establishing good rapport with patients is especially important. Secondly, preparatory explanations may deal effectively with fear f the unknown and thus give a sense of control. Allowing patients to signal when they wish to pause or speak further alleviates fears of loss of control. Finally, well-executed dental technique and clinical practices minimize unpleasantness.